AVENUES FOR TREATING ADDICTIONS

Substance Abuse Often Goes Hand-In-Hand With Mental Illness, Psychiatrists Say

NEW YORK - Doctors treating substance abuse are looking to expand their impact.

Abuse of opiate painkillers, such as Vicodin and OxyContin, has risen
substantially in the past five years, making this the nation's
highest-priority drug problem, says Dr. Nora Volkow.

Dr. Volkow, director of the National Institute on Drug Abuse, and other
experts hope that they can better tackle substance abuse by integrating the
latest research on addiction into psychiatric practice. To that end,
addiction-related topics were featured last week at the American
Psychiatric Association's national meeting in New York City.

"To me it is very straightforward," Dr. Volkow said during a news briefing
at the meeting. "I'm a psychiatrist, and one of the things that was very
frustrating to me ... was the realization that most of psychiatric patients
have substance abuse problems. And yet we were not really properly trained
to actually solve these problems."

People might first develop a mental disorder, then an addiction - perhaps
as an attempt to self-medicate, she said. Or kids may first take drugs and
then develop a mental illness. "Could the substance abuse in any way have
made that kid more vulnerable?" she asked, adding that it's a question for
which researchers don't yet know the answer.

The jump in prescription painkiller abuse is relatively new, so there is no
epidemiological data yet to track its source, Dr. Volkow said. The increase
probably has multiple causes, she said, including a relatively new
phenomenon: sale of opiate painkillers on the Internet. Also, legal
prescriptions of the drugs have increased dramatically in recent years.

"One of the things we saw in the '90s was an attempt to improve prescribing
for pain," said Dr. Herbert Kleber, a psychiatrist and researcher at
Columbia University. "And indeed it happened. You had lawsuits about
physicians who did not adequately prescribe enough narcotics for pain."

The increased availability has given not only legitimate patients a chance
to abuse the drugs, but others as well. If you work with teens, Dr. Kleber
said, you find that the first thing many baby sitters do is check the
medicine cabinet.

Painkiller addiction is also a problem among the elderly, who are most
likely to be prescribed opiate drugs, Dr. Volkow said. Sometimes faced with
a number of pills to take, these patients could accidentally misuse them.

"That's a new group of subjects that all of a sudden we're facing," she said.

Female patients have indicated they can find Vicodin or OxyContin by asking
around at their beauty salons, where someone invariably has the drug or
knows how to get it, Dr. Kleber said.

It's not as if doctors and others haven't made progress in the fight
against substance abuse. Illegal drug use among teenagers is down 11
percent, Dr. Volkow noted. And cigarette smoking is at its lowest level in
teens since 1979.

Rates of abuse of stimulants and a class of drugs known as benzodiazepines
(including Valium) have held steady, Dr. Volkow noted, even though
prescriptions for stimulants, mainly to treat
attention-deficit/hyperactivity disorder, roughly double every five years.

Use of the club drug Ecstasy had been going up "exponentially," but has
dropped off recently, Dr. Kleber said. That may have been due in part to an
extensive education campaign about the drug's dangers - and kids seeing
those dangers themselves. Use of GHB (gamma-hydroxybutyrate) and ketamine,
known as date-rape drugs, may also be down slightly, he said.

Estimates about alcohol abuse have held steady for the past decade or so,
said Dr. Shelly Greenfield, chair of the APA's Council on Addiction Psychiatry.

About 14 percent of Americans will have a problem with alcohol sometime in
their lives, she said. However, children - especially girls - are starting
to experiment with it at younger ages.

"The age of initiation of use is now equivalent between boys and girls,"
from 10 to 14, she said. "That goes for many other drugs of abuse as well."

Addiction is a developmental brain disease that starts in adolescence, or
sometimes even earlier, Dr. Volkow said. During adolescence, she said, the
brain is particularly susceptible to the effects of addictive substances.
"You are shattering your life from the beginning," she said. Besides
psychiatrists, Dr. Volkow's agency will press general practitioners -
including pediatricians - to talk to their patients about substance use.

Often, patients are never even asked about a drug or alcohol problem, said
Dr. Greenfield. It's important for doctors to ask the questions and to make
sure they and the patients have the same understanding of the issue, she said.

As many as half of all patients in any kind of doctor's waiting room have a
problem with abuse of alcohol, tobacco or other substances, Dr. Kleber
said. "If you don't ask, if you don't look for it, you're not going to see it."

Psychiatrists and other doctors have an important message to spread, Dr.
Greenfield added: "We have many effective treatments that are both
behavioral and also pharmacologic that we can offer patients."