Several kits that do not require special training to administer are available for rapid testing in the office. Other tests can be sent out for laboratory analysis. Methods to decrease the likelihood of tampering with urine testing (eg, direct urethral supervision, point-of-care testing, and analysis for adulterants and unreliable samples) have been developed and are available as well.47 Drug testing allows clinicians to identify more individuals with substance use disorders, who may otherwise have their disorders misdiagnosed. For example, within an emergency department, up to 45% of admissions are directly related to drug use, and the prevalence of substance-related admissions increases significantly when alcohol use is also considered.48 As "drugged driving" becomes more problematic, and other substance-related visits continue, substance abuse clinicians will likely be enlisted to provide screening and brief interventions in the emergency department.

Impaired-physician programs

Although up to 90% of addicted persons in the general population experience relapse within 1 year, only 10% to 25% of physicians who attend specialized treatment programs share this outcome.49-52 In addition, those who do relapse typically reenter recovery with booster treatment.53 Various factors may contribute to their success, including high levels of resources (eg, intellectual, financial, social).

However, it is noteworthy that programs for impaired professionals provide the most comprehensive treatment available. They generally use psychoeducational sessions, individual CBT, group therapy, 12-step programs, relapse-prevention, family-based psychotherapy sessions, and contingency management. In addition, physicians generally spend more time in treatment and have access to more intensive/individualized care.54 Follow-up services are more intensive and are characterized by random drug testing with immediate consequences for positive results. Many physicians in recovery cite continued urine testing as a powerful deterrent to drug use, which greatly increases their motivation to remain abstinent.

Although this comprehensive approach is very expensive, the success rate provides support for its implementation on a wider scale. When considering the actual cost of addiction (including health care costs, lost wages, legal fees, mortality risks), paying for high-quality intensive treatment may be a more cost-effective alternative.

Public health interventions

In addition to individual treatment programs, societal interventions can greatly influence drug use in the general population. For example, the implementation of indoor smoking bans significantly decreased rates of tobacco use and secondhand smoke exposure. Similarly, increased taxes on tobacco products serve as a successful prevention strategy, and increased alcohol taxes have been associated with significantly reduced alcohol-related mortality.55,56

Some research has demonstrated preliminary positive effects of television commercials produced by the Partnership for a Drug-Free America in reducing drug use among teenagers.57 Whereas adolescents' self-reported substance use has shown a fairly stable decrease since 1996, deaths related to certain drugs appear to be increasing in some areas.58-60 Reducing prescription misuse, illicit drug use, and their consequences remains a major challenge for our nation, and no long-term effective strategy has been identified. More research is needed to evaluate additional methods of public health prevention and intervention for addiction.

Addiction as a unitary disease

Although drugs of abuse are diverse and affect the brain via different acute mechanisms of action, each influences the reward circuitry of the brain's limbic system by increasing dopamine release in the nucleus accumbens. As suggested by Nestler,61 it is possible that a common molecular pathway underlies all addictions, and perhaps this can be exploited to develop more effective treatments.

Applied research has shown that treatment outcomes for impaired physicians do not differ based on their choice of substance (R. L. DuPont et al, unpublished data, 2008); physicians with addiction to opioids or crack cocaine fare as well as those with alcohol dependence. Given the high prevalence of polysubstance abuse and the fact that the same treatment appears to be effective for alcohol, opioid, marijuana, benzodiazepine, and cocaine dependence, it may be more useful to consider the treatment of addiction disorders rather than attempt to tailor interventions based on a specific drug of abuse.

Behavioral addictions

Research is accumulating regarding the similarities among chemical addictions and other compulsive-behavior disorders.62 For example, researchers have developed an animal model of food addiction (sugar) in rats that closely parallels that seen with drug addiction.63 Imaging studies in humans also point to a shared neurobiological mechanism. Pathological gambling, hypersexual behavior, and compulsive eating are frequently comorbid with drug addiction and share similar neurological patterns.64-66 In each case, alterations in the natural reward pathway appear to be implicated in the tendency to continue the behavior despite negative consequences. Although similar behavioral and pharmacological treatments have shown efficacy with these groups, more research is needed to clarify the process of addiction and determine how and why addiction manifests in various behaviors and substances of abuse. In the meantime, clinicians should be vigilant for signs of "addiction transfer" in patients who are attempting sobriety, because preliminary evidence suggests that these patients may be more vulnerable to symptoms of behavioral addiction and vice versa.67
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