Substance Abuse

There is no question that substance abuse is a major health concern in the United States and elsewhere. Misuse of alcohol, tobacco, and other drugs and its effects are present throughout society. The human costs of substance use disorders in terms of lives lost, medical and psychiatric morbidity, and social disruption make even the enormous economic costs pale. Traditionally, the “experts” on the issue of substance abuse have been from fields other than General Internal Medicine, such as psychiatry, psychology, sociology, public health and the basic sciences. However, over the past decade we have begun to make our contributions to this important field.

This issue of the Journal is further evidence that General Internal Medicine has “come of age” as a leading discipline in the field of substance abuse. There is other evidence as well. In the recent past, general internists have assumed leadership positions in national societies that focus on substance abuse (external validity); and general internists with academic interests in substance abuse have taken on leadership roles in academic sections of General Internal Medicine (internal validity). One measure of academic success, grant funding from the National Institutes of Health concerning research on alcohol, tobacco, and drug abuse, has been achieved by general internists. Other funders, such as the Robert Wood Johnson Foundation, are increasingly turning to general internists to explore scientific and health policy issues related to substance abuse. The numerous awards given to general internists in the Robert Wood Johnson Foundation Generalist Physician Faculty Scholars Program for substance abuse-related work speak to the increasing attention substance abuse is receiving from talented young academic generalists. Finally, the scientific literature has seen a substantial increase in published research and scholarship in areas related to screening, diagnosis, and treatment of substance use disorders by generalist physicians who are studying patients in their own inpatient and primary care settings. This special issue adds significantly to this literature.

What has motivated our field in the direction of substance abuse research? Similar to other fields in which general internists have made substantial research contributions, substance abuse is a central issue that arises daily in the care of primary care patients. For example, in one study of primary care practices, the prevalence of tobacco use was 27%, the prevalence of illicit drug use was 5%, and 60% of patients used alcohol, of whom 22% had either an “at-risk” pattern of use or actually had an alcohol-related health problem.¹ Even higher rates of substance use disorders are seen in our inpatient settings. Beyond the worrisome statistics and comorbid disorders associated with substance use, these disorders are at the core of what generalism is all about. Dependence on alcohol, tobacco, or other drugs is a chronic disease with a natural history characterized by remissions and exacerbations, which respond to treatment. It can be identified by established screening tests and is associated with well-described comorbidities. It affects patients and families, and can be managed by a combination of counseling and pharmacotherapy. Sound familiar? This could easily characterize chronic lung disease, diabetes, or cancer—all conditions for which we are the first line “experts.” Based on the emerging science in the general medicine literature, including that published in this issue of JGIM, we should become the first line “experts” for substance abuse as well.

The findings of the researchers published in this issue address many of the core areas of substance abuse in general internal medicine practice. They were selected from over 40 submissions for this Special Issue of JGIM. Bradley et al. demonstrate the importance of going beyond screening and the need to give specific advice to patients when “at-risk” drinkers are identified in primary care.² Kraemer et al. demonstrate that when primary care patients who drink at or above “at-risk” levels of consumption are able to decrease their alcohol intake, they may experience important improvements in quality of life and health-related outcomes.³ Merrill et al. use qualitative methods to help us understand the complex and unintended effects resulting from the interactions between drug-using inpatients and their physicians.⁴ O'Toole et al. demonstrate that creative approaches to engaging medical patients into substance abuse treatment can have a positive impact on both placement in ongoing substance abuse treatment and health care utilization.⁵ Similarly, Pollack et al., using a community-based public health intervention, showed that creative models of care can also be effective in reaching injection drug users who are not engaged in the health care system.⁶ In the study performed by Connor et al., another population at risk—the homeless—was examined in a creative manner to better understand their smoking-related behaviors and attitudes and their preference for smoking cessation treatments.⁷ The study by Arnsten et al. identified predictors of adherence to antiretroviral therapy among drug users and demonstrated the need to address ongoing substance abuse in these patients in order to maximize the benefits of HIV medication therapy in this population.⁸ Malcolm et al. provide new data on the pharmacological management of alcohol withdrawal for patients treated in an outpatient setting.⁹ Brienza et al. utilize a new approach for examining gender differences in chronic disease, in this case alcohol use disorders.¹⁰ Wilk et al. and Saitz et al. examine critical issues pertaining to the education of physicians—teaching methods for substance abuse¹¹ and professional satisfaction in caring for substance-using patients.¹² Finally, the Health Policy piece by Merrill demonstrates the central clinical, research, and policy roles that need to be played by general internists at the advent of one of the most exciting substance abuse primary care innovations of our time—office-based treatment of heroin dependence.¹³ Taken all together, most of this work, both the published articles and manuscripts that we were unable to accept, demonstrates that general internists are working at the forefront of the substance abuse field. We believe that this is exactly where we belong.

Policy makers and leading medical bodies have all called upon physicians to take a larger role in the identification and management of patients with substance use disorders.¹⁴ The Society of General Internal Medicine's Substance Abuse Task Force has led the way in bringing our profession to the forefront of this field. SGIM's membership includes leading investigators, educators, and clinicians in the substance abuse field. This special issue is further evidence of SGIM's leadership role in dealing with substance abuse and its many problems. As clinicians, educators and researchers in this field, SGIM and its members have a very bright future.