The Assessment and Treatment of Addiction: Best Practices in a Direct-to-Consumer Age

Introduction

Addictions are a constellation of complex and chronic illnesses that affect multiple domains in a patient’s life, primarily for the worst. Nosologically, they are defined by use of an addictive agent and effects, rather than process, in contrast to many other diseases that are not defined primarily by chief complaint, but by etiology. As with other recurrent illnesses, multidisciplinary assessment and therapy improve chances of recovery, but perhaps no other diseases pose a greater variety of challenges, are met with more diverse and even opposite therapies, and are more neglected. Increasingly, people are reliant on web-based tools, direct-to-consumer self-help books and websites, and portable electronic devices when seeking solutions for lifestyle-related problems and health problems and risks that lie along a contiuum of risk factor to disease. Here, we propose a medically centered, generalized framework for the treatment of addictions, which can incorporate such new tools to deliver better assessment and interventions. We target multiple domains, which frequently involve severe, complex, and intractable problems that require a multidisciplinary team of expert providers. The treatment team integrates new measures and new interventions—some enabled by new technology and most not—that will hopefully be based on the pathophysiology of addictions. Individuals at risk, users, individuals with use disorder, and recovering patients represent different stages of the disease process, requiring assessments and interventions targeted to the stage. Multiple domains of vulnerability, use, addiction process, and consequence require evaluation and integration into a comprehensive treatment plan. Dramatic progress in the treatment of other chronic diseases for which etiologic-specific treatments are wanting, including cystic fibrosis and diabetes, indicates that a comprehensive approach, expensive though it may be, and incorporating appropriate technologies for at-home testing and intervention, can greatly improve the current prevalence and relapse statistics for addictions, which are diseases whose expense and impact on lives and communities justify the cost.

The Assessment

As with any medical evaluation, a detailed History and Physical (H&P) remains essential. One may ask why. For example, screening questionnaires such as the Fagerstrom (smoking) and Michigan Alcohol Screening Test (MAST) can ascertain most smokers and alcoholics. Furthermore, any heavy user of an addictive agent—be it a drug, gambling, or the Internet—is more than likely addicted and this can be readily ascertained by direct or indirect observation of use, and, for example, a blood alcohol level, or the reading from an electronic monitoring device. A person may enter mood or craving scores into an electronic device, or the information might be directly collected, for example, by recording their movements or changes in facial expression over time. However, such observations are insufficient to define a Diagnostic and Statistical Manual of Mental Disorders , Fifth Edition (DSM-5), Use Disorder, and diagnosis of a DSM-5 Use Disorder represents only a starting point for understanding causes, process, and consequences of a patient’s addiction, and the beginnings of therapeutic engagement—the deep partnership that must be formed between patient and the multidisciplinary team. Fig. 13.1 highlights some of the key domains of addictions that need to be included in an H&P. All should be evaluated during the initial assessment to stage severity. It is important to understand the individual events that led a patient to this point in disease progression. This process will create the full clinical problem list, help to identify resources for recovery, and help to establish for the patient that their problems are of concern. This begins a therapeutic process, which includes the patient appreciating the relationship of their addiction to other causes and consequences. In line with a process-oriented conceptualization of addiction, this scheme includes at-risk individuals, understanding that addiction medicine needs to address its identifiable “precancerous lesions,” which may include escalating use or signs of progression to full disease; for example, in the way that physicians do not disregard infection or metabolic syndrome until a patient is actually septicemic or in renal failure. The complexity of initial assessment will only increase as new tools become available from multiple disciplines ranging from neuroimaging and genetics to electronic monitoring of substance use and emotional state. For example, in the domain of genetics , the heritability of addictions has been well established, suggesting that more clinically useful genetic variants in addition to ALDH2 (alcoholism/flushing/upper gastrointestinal [GI] cancer) and CHRNA5 and CYP2D6 (smoking, lung cancer) will be found. Many people are already receiving such genetic results direct-to-consumer, and websites devoted to the Asian flush , and inappropriate and potentially harmful treatments, have proliferated. For example, in the domain of addiction neuroscience, psychophysiological differences in executive cognition, emotion, and reward are being identified. Such measures offer the prospect of identifying at-risk individuals and offering early interventions. However, and actually as required by the diversity of assessments that may be required following whatever screening methods that may have been used, the true starting point of assessment is not an individual test—be it genetic, neuropsychologic, or behavioral—but the detailed H&P.

The Stages of Addiction

Addictions are chronic relapsing and remitting diseases, and although they are diverse, assessment will vary according to stage.

The Domains