When the U.S. Surgeon General issues a report on substance use, healthcare officials and the medical community are bound to take it very seriously. “Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health,” released Nov. 17, is a 748-page report focused on the most science-based aspects of addiction. But it’s meant for real people, easily readable and searchable.
“Above all, we can never forget that the faces of substance use disorders are real people. They are a beloved family member, a friend, a colleague, and ourselves,” wrote Vivek H. Murthy, MD, Surgeon General, and Vice Admiral with the U.S. Public Health Service, in a preface to the report.
This isn’t expected to be a case of a report that comes out and is put on the shelf, forever to be forgotten. Murthy, who has two more years as Surgeon General, intends to roll this out over time, to audiences such as community organizations and state leaders, says H. Westley Clark, MD, Dean’s Executive Professor of Public Health at Santa Clara University. One of the lead science editors of the report, Clark talked to Addiction Professional on Monday about the document, referring to it as one that “people can digest and use as a springboard for action.” It’s not a textbook, Clark stresses.
With a change of administration, it will be particularly important for there to be a single scientific document about substance use disorders, says Clark. “The Surgeon General can’t dictate to the public health community or other groups,” he says. “But the office can use moral suasion, science, evidence, and reasonable logic.”
There isn’t one “cookie-cutter” approach to treatment, the report makes clear. In addition, it states that treatment is not just medication, in the manner in which medication is often used.
“Personalized medicine doesn’t work that way,” Clark says. “The cookie cutter approach is the easy way out—you offer one thing, and if it doesn’t work, you blame the patient.”
The White House has made significant advances on substance use as the opioid epidemic increased in intensity over the past eight years. Michael Botticelli, heading the Office of National Drug Control Policy, has tirelessly campaigned on behalf of medication-assisted treatment (MAT) for opioid use disorders. But the heft of a Surgeon General’s report would appear to require the government—including President-Elect Donald Trump—to pay attention.
This is the first-ever report on the topic of alcohol and drugs from the Surgeon General. It signals an important shift, not unlike what occurred 50 years ago when the Surgeon General issued a report on the dangers of smoking.
The substances discussed in the report share three characteristics:
“First, many people use and misuse these substances.
Second, individuals can use these substances in a manner that causes harm to the user or those around them.
Third, prolonged, repeated misuse of any of these substances can produce changes to the brain that can lead to a substance use disorder, an independent illness that significantly impairs health and function and may require specialty treatment.”
An addiction is a substance use disorder which is severe and chronic, the report explains.
These definitions are important. The authors, and particularly the report's editors, are the top researchers and experts in the field, and this report can be used as a guideline for anyone searching for the right language. The report uses “misuse” instead of “abuse,” because “substance abuse” sounds shaming. In addition, substance abuse is no longer a diagnostic term in psychiatry. The DSM-5 uses “substance use disorder,” while the earlier DSM-IV used “substance abuse” and “substance dependence.”
The DSM-5 divides substance use disorders into three categories: mild, moderate and severe. The report lists the criteria used to distinguish among the categories:
Using in larger amounts or for longer than intended
Wanting to cut down or stop using, but not managing to
Spending a lot of time to get, use, or recover from use
Inability to manage commitments due to use
Continuing to use, even when it causes problems in relationships
Giving up important activities because of use
Continuing to use, even when it puts you in danger
Continuing to use, even when physical or psychological problems may be made worse by use
(Fewer than 2 symptoms = no disorder; 2-3 = mild disorder; 4-5 = moderate disorder; 6 or more = severe disorder.)
The new diagnostic criteria replace the old reliance on tolerance and withdrawal as the only criteria for “addiction.” Substance use disorder (SUD) includes addiction, but not exclusively.
The report is available for free, in many languages and with assistive technology for those who need it. It is hoped that family members looking for help for their loved ones will make this document, not Google, their first stop. The report states that although substance use disorders often are not treated and covered to the same degree as other chronic illnesses, evidence-based treatments are available. These include behavioral interventions, medications, and social support services.
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