Alcohol and substance use disorders have in one form or another been part of our official psychiatric nomenclature since DSM-I. However, except for the most blatant cases, the notion that psychiatrists needed to be specially trained to diagnose and treat these disorders has only recently received emphasis. There is a tendency to see these disorders as either secondary to "psychiatric" disorders or psychosocia !-psychological problems and to relegate their treatment to either nonmedicai programs (AA) or those few programs where physicians (often nonpsychiatric) specialize in the treatment of alcoholism or drug addictions.
Self-help groups such as AA have been viewed as separate, sometimes even countertherapeutic activities that have little to do with clinical psychiatry. A number of factors have changed this view in recent years. An increasing portfolio of research findings driven principally by the leadership of the National Institute on Alcohol Abuse and Alcoholism and the National Institute on Drug Abuse, recent epidemiological finds demonstrating the high fomorbidity of alcoholism, substance abuse with psychiatric disorders and vice versa, the economics of third-party coverage for inpatient and outpatient treatment services for these disorders, and a heightened emphasis on outcome and cost-effectiveness data to justify health care costs have all converged to produce dramatic changes. While the training of psychiatrists has certainly changed in terms of incorporating knowledge of substance use disorders, many experienced psychiatrists in practice received very little formal training during their residencies.
This comprehensive series of articles edited by Norman Miller, MD, attempts to address the situation. He argues that psychiatry has not traditionally seen substance use disorders as separate in their etiology and course. Training of psychiatrists has not adequately prepared them, in terms of skills and role perception as physicians, to effectively diagnose and treat patients with substance use disorders and those with comorbid substance abuse and diagnosable psychiatric disorders. He and his coauthor Dr. Gold argue that without training and skill necessary to integrate biological, psychosocial, and pharmacological issues in the treatment of these patients, less than effective results are likely to occur.
R. Jeffrey Goldsmith, MD, summarizes the essential features of alcohol and drug treatment. He emphasizes the need to conceptualize alcohol/drug dependence as a biopsychosociocultural disease requiring clinicians to look into their own attitudes toward patients and to understand the strategies and interventions that will successfully engage and retain them.
John Chappel, MD, focuses on the effective use Alcoholics Anonymous and Narcotics Anonymous in treating patients. His article is a virtual primer for the psychiatrist who is not familiar with the philosophy and procedures of the AA model, which he describes in its historical context.
Norman Hoffmann, PhD, along with Dr. Miller, discuss evaluating outcome in the treatment of drug and alcohol dependence. Summarizing some of the methodologie issues of obtaining and evaluating follow-up data, they present outcome data for !arge samples of patients treated in both inpatient and outpatient settings. They accurately qualify the data in terms of the methodotogic issues and demonstrate important treatment effects.
Dr. Weddington's review of the pharmacologie agents in the treatment of addiction gives us an idea of the ongoing research in this area and what is known about the results to elate. Last in this series is an exciting review by Drs. Mark Goid and Miller, looking at the contributions of drug-seeking and withdrawal-avoidance behavior by evaluating the neuroanatomy of drive states and withdrawal. They provide a further glimpse into the understanding of the interaction between learning theory and neurochemistry as a way of understanding the addictive process.
This series illustrates what Dr. Miller maintains at its beginning: the psychiatrist's role is to exert skills and understanding in the compiete integration of tHngnosis and comprehensive treatment, which includes effectively referring our patients to AA, education programs, family involvement as well as individual psychotherapy, and making critical decisions concerning tiie appropriateness of pharmacologie therapy and its risks and benefits. Although the psychiatrist's role in assessing the severity of symptoms such as depression and anxiety in constructing a risk/benefit evaluation of pharmacologie treatment was not explicitly dealt with in this issue, the authors have comprehensively addressed areas of great importance to today's understanding of the psychiatrist's role and responsibility in the treatment of aJcohol/drug-dependent patients. This edition begins to address important needs and we hope it will stimulate further interest in this area. We can differ over how to address these problems; for our patients' sake, we can't afford to ienore them.