In a landmark report, Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health (“Report”),1 Vivek Murthy, MD presented for the first time a report by a Surgeon General focused solely on addiction and its consequences. Widely anticipated among members of the substance abuse treatment community, advocates within the recovery movement, and communities and families adversely impacted by alcohol and drugs, Surgeon General Murthy provides a comprehensive review of the neuroscience of addiction. He also summarizes the public health impact of substance use in the US and proposes key recommendations for public mental health policy.
The key findings of the report are discussed in this article, as well as current social norms of alcohol and drug use within the general public and approaches to treatment psychiatrists need to know. Among the recommendations of significance to clinical psychiatrists include:
1) the importance of improving detection of substance use disorders (SUDS) by levering health information technology and models of care such as collaborative care
2) increasing access to effecting treatments through health care reform
3) adopting a public health approach to substance use and SUDs. Much like previous reports, the potential impact is substantial.
The 1964 Surgeon General’s report Smoking and Health: Report of the Advisory Committee of the Surgeon General of the Public Health Service led to changes that revolutionized the views our society has on smoking. Smoking is no longer glamorized in films and television, no longer accepted as a widespread public activity, discouraged among healthcare providers and health facilities, and largely recognized as a substance with significant adverse personal and public health consequences. The history of this shift in public opinion and public policy is well documented.2
Similarly, Mental Health: A Report of the Surgeon General, and the supplemental mental health report on culture, race, and ethnicity in 1999 and 2001 respectively, sparked and continues to fuel discourse and attention to previously neglected public health impacts of unaddressed mental health conditions.3,4
For the past several years, I have been privileged to work under the senior leadership of Dr. David Satcher, the 16th Surgeon General and author of the aforementioned reports on mental health. As Director of the Division of Behavioral Health at the Satcher Health Leadership Institute at Morehouse School of Medicine, I have also worked in close collaboration with the Kennedy Forum. The Kennedy Forum was founded by former Congressman Patrick J. Kennedy in 2013 and has been a leading voice to ensure implementation of the Mental Health Parity and Addiction Equity Act of 2008. Our partnership has worked collectively with diverse stakeholder groups to advance collaborative care and measurement-based care, and convened a State of the Union on Mental Health and Addiction to bring together key influencers to focus national attention on mental health issues that continue to exact a devastating toll in our families, communities, workplaces, and society.5-7
In 2015, nearly a quarter of the adult and adolescent population reported binge drinking in the past month, and the negative economic impact of alcohol misuse is an estimated $249 billion dollars annually.1 The November 2016 Report highlights the immediate direct individual impacts, and it also describes the indirect consequences as well as longer term health and societal impacts of misuse and abuse of alcohol and drugs.
Binge episodes have the potential for producing harm to the user and/ or to those around them, through increases in motor vehicle crashes, violence, and alcohol-poisonings and account for 75% of the costs associated with alcohol use (See Report pages 1-12 for a summary of the cost and impact of substance misuse including binge drinking). Social norms in contexts where alcohol consumption has been shown to influence behavior provide compelling evidence to the dangers of binge drinking. Cullum and colleagues8 call into question accepted social norms in our lives. If you attend a conference dinner, wedding, or fundraiser, have 2 cocktails during the mixer hour, wine with dinner that you allow to be refilled (once for a woman or twice for a man)—you have just completed an episode of binge drinking. How many of us would honestly view this as excessive in the social contexts described?
Despite the enormous deleterious societal impact, a disparity in attention given to this cancer-sized problem, fueled by the persistence of “moral failing,” causal attributions have undermined efforts to implement population-wide cost-effective preventive strategies. The current timing of the Report within a focusing moment created by an escalating opiate addiction epidemic creates an opportunity for public and individual collective action. Much like the previous reports, this one has the potential to catalyze a movement to align efforts and transform public perceptions and behaviors related to addiction.
Implications for psychiatry
For psychiatrists in office-based clinic settings, it is important to stay informed about likely changes in public health policy such as mandatory provider use of prescription drug monitoring programs within your state, and the impacts of recently passed mental health reforms such as the 21st Century Cures Act, the Medicare Access and CHIP Reauthorization Act of 2015, and the Mental Health Reform Act of 2016. In addition, there is an opportunity to reflect on the role of psychiatrists in response to the report’s findings as a professional, citizen, and person of influence within society.
Dr. Wrenn is Associate Professor in the Department of Psychiatry and Behavioral Sciences at Morehouse School of Medicine in Atlanta. She is Director of Behavioral Health at the Satcher Health Leadership Institute and the Satcher Kennedy Center for Mental Health Equity. She is a practicing psychiatrist at the Women’s Center of Excellence for Specialty Care Education at the Atlanta VA Medical Center and provider within Grady Health System. Dr. Wrenn reports no conflicts of interest concerning the subject matter of this article.
1. U.S. Department of Health and Human Services (HHS), Office of the Surgeon General, Facing Addiction in America: The Surgeon General’s Report on Alcohol, Drugs, and Health. Washington, DC: HHS, November 2016. https://addiction.surgeongeneral.gov.
2. U.S. Department of Health and Human Services. The Health Consequences of Smoking—50 Years of Progress: A Report of the Surgeon General. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health, 2014.
3. U.S. Department of Health and Human Services. (1999). Mental health: A report of the surgeon general. Rockville: U.S. Department of Health and Human Services.
4. U.S. Department of Health and Human Services. (2001). Mental Health: Culture, Race, and Ethnicity—A Supplement to Mental Health: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, Substance Abuse and Mental Health Services Administration, Center for Mental Health Services.
5. “Fixing Behavioral Health Care in America: A National Call for Integrating and Coordinating Specialty Behavioral Health Care with the Medical System” Published by The Kennedy Forum In Partnership with Advancing Integrated Mental Health Solutions (AIMS) Center, Department of Psychiatry and Behavioral Sciences, University of Washington and The Kennedy Center for Mental Health Policy and Research, Satcher Health Leadership Institute, Morehouse School of Medicine. http://thekennedyforum-dot-org.s3.amazonaws.com/documents/KennedyForum-BehavioralHealth_FINAL_3.pdf.
6. Fortney J, Sladek R, Unützer J, et al. Fixing Behavioral Health Care in America: A National Call for Measurement Based Care in the Delivery Services of Behavioral Health Services. The Kennedy Forum. 2016. http://thekennedyforum-dot-org.s3.amazonaws.com/documents/KennedyForum-MeasurementBasedCare_2.pdf
7. Wrenn G, Forney J, Kennedy P, et al. A Core Set of Outcome Measures for Behavioral Health Across Service Settings. http://thekennedyforum-dot-org.s3.amazonaws.com/documents/MBC_supplement.pdf. The Kennedy Forum. 2016. Accessed January 17, 2017.
8. Cullum J, O'Grady M, Armeli S, Tennen H. Change and Stability in Active and Passive Social Influence Dynamics during Natural Drinking Events: A Longitudinal Measurement-Burst Study. J Soc Clin Psychol. 2012;31:51–80. http://doi.org/10.1521/jscp.2012.31.1.51
9. Mossman D, Farrell HM. Physician impairment: when should you report? Curr Psychiatr. 2011;10(9):67-71. http://www.mdedge.com/currentpsychiatry/article/64440/physician-impairment-when-should-you-report. Accessed January 17, 2017.
10. Federation of State Physician Health Programs. State Programs. http://www.fsphp.org/state-programs. Accessed January 17, 2017.
11. Kennedy PJ, Fried S. A Common Struggle: A Personal Journey through the past and Future of Mental Illness and Addiction. New York: Blue Rider; 2015.
12. Livingston M, Callinan S. Underreporting in alcohol surveys: whose drinking is underestimated? J Stud Alcohol Drugs. 2015;76:158–167.
13. Oreskovich MR, Shanafelt T, Dyrbye LN, et al. The prevalence of substance use disorders in American physicians. Am J Addict. 2014;24:30-38. http://www.ncbi.nlm.nih.gov/pubmed/25409782