The Dallas Morning News
NEW YORK - Doctors treating substance abuse are looking to expand their impact.
Abuse of opiate painkillers, such as Vicodin and OxyContin, has risen substantially in the past five years, making this the nation's highest-priority drug problem, said Dr. Nora Volkow, director of the National Institute on Drug Abuse.
Volkow and other experts hope that they can better tackle substance abuse by integrating the latest research on addiction into psychiatric practice. To that end, addiction-related topics were featured last week at the American Psychiatric Association's national meeting in New York City.
"To me it is very straightforward," Volkow said during a news briefing at the meeting. "I'm a psychiatrist, and one of the things that was very frustrating to me ... was the realization that most of psychiatric patients have substance abuse problems. And yet we were not really properly trained to actually solve these problems."
People might first develop a mental disorder, then an addiction - perhaps as an attempt to self-medicate, she said. Or kids may first take drugs and then develop a mental illness. "Could the substance abuse in any way have made that kid more vulnerable?" she asked, adding that it's a question for which researchers don't yet know the answer.
The jump in prescription painkiller abuse is relatively new, so there is no epidemiological data yet to track its source, Volkow said. The increase probably has multiple causes, she said, including a relatively new phenomenon: sale of opiate painkillers on the Internet. Also, legal prescriptions of the drugs have increased dramatically in recent years.
"One of the things we saw in the `90s was an attempt to improve prescribing for pain," said Dr. Herbert Kleber, a psychiatrist and researcher at Columbia University. "And indeed it happened. You had lawsuits about physicians who did not adequately prescribe enough narcotics for pain."
The increased availability has given not only legitimate patients a chance to abuse the drugs, but others as well. If you work with teens, Kleber said, you find that the first thing many baby sitters do is check the medicine cabinet.
Painkiller addiction is also a problem among the elderly, who are most likely to be prescribed opiate drugs, Volkow said. Sometimes faced with a number of pills to take, these patients could accidentally misuse them.
"That's a new group of subjects that all of a sudden we're facing," she said.
Female patients have indicated they can find Vicodin or OxyContin by asking around at their beauty salons, where someone invariably has the drug or knows how to get it, Kleber said.
It's not as if doctors and others haven't made progress in the fight against substance abuse. Illegal drug use among teenagers is down 11 percent, Volkow noted. And cigarette smoking is at its lowest level in teens since 1979.
Rates of abuse of stimulants and a class of drugs known as benzodiazepines (including Valium) have held steady, Volkow noted, even though prescriptions for stimulants, mainly to treat attention-deficit/hyperactivity disorder, roughly double every five years.
Use of the club drug "Ecstasy" had been going up "exponentially," but has dropped off recently, Kleber said. That may have been due in part to an extensive education campaign about the drug's dangers - and kids seeing those dangers themselves. Use of GHB (gamma-hydroxybutyrate) and ketamine, known as date-rape drugs, may also be down slightly, he said.
Estimates about alcohol abuse have held steady for the past decade or so, said Dr. Shelly Greenfield, chair of the APA's Council on Addiction Psychiatry.
About 14 percent of Americans will have a problem with alcohol sometime in their lives, she said. However, children - especially girls - are starting to experiment with it at younger ages.
"The age of initiation of use is now equivalent between boys and girls," from 10 to 14, she said. "That goes for many other drugs of abuse as well."
Addiction is a developmental brain disease that starts in adolescence, or sometimes even earlier, Volkow said. During adolescence, she said, the brain is particularly susceptible to the effects of addictive substances. "You are shattering your life from the beginning," she said.
Besides psychiatrists, Volkow's agency will press general practitioners - including pediatricians - to talk to their patients about substance use.
Often, patients are never even asked about a drug or alcohol problem, said Greenfield. It's important for doctors to ask the questions and to make sure they and the patients have the same understanding of the issue, she said.
As many as half of all patients in any kind of doctor's waiting room have a problem with abuse of alcohol, tobacco or other substances, Kleber said. "If you don't ask, if you don't look for it, you're not going to see it."
Psychiatrists and other doctors have an important message to spread, Greenfield added: "We have many effective treatments that are both behavioral and also pharmacologic that we can offer patients."
(c) 2004, The Dallas Morning News. Distributed by Knight Ridder/Tribune News Service.