Many well-designed epidemiologic studies have clearly demonstrated that psychiatric disorders, such as depression (bipolar and unipolar), anxiety and stress disorders, to name a few, co-occur with Substance Use Disorder (SUD) far more frequently than would be expected by chance alone. Moreover the correlation is bidirectional. Previous Epidemiologic Catchment Area Studies estimate that 45% of individuals with an alcohol use disorder and 72% of individuals with a drug use disorder have at least one co-occurring psychiatric disorder. More recent smaller studies show higher concordance rates. Yet, there are sparse data on the co-occurrence of medical illness and SUD.
Lagisetty, et al., analyzed data from the National Ambulatory Medical Care Survey (NAMCS), and generated cross-sectional estimates from outpatient visits to primary care providers. For adults seeing a primary care physician between 2009-2011, these data revealed that out of 1.18 billion visits, 17.6 million had a substance use diagnosis, while 1.6 billion did not. Medical illness are common, as might be expected simply on the basis of an aging population and a lack of timely medical or preventative care. Hypertension, hyperlipidemia, chronic lung diseases and arthritis were among the most common, as were anxiety and depressive illnesses. Patients with SUD require medical, neurological and psychiatric evaluation and treatment when necessary.
Why Does This Matter?
Addiction programs are fortunate if they have a full time MD skilled in evaluation, diagnosis and treatment of medical diseases. Most programs, however, lack a psychiatrist with the advanced training and skills to provide a comprehensive evaluation and treatment for patients with co-occurring psychiatric illness or acute symptoms of abuse, trauma or the toxic effects of psychoactive substances, which can and do produce temporary psychosis and severe neurological problems.
Providing a comprehensive medical, psychological and psychiatric assessment in addition to addiction specialists should be common fare in treatment centers for SUD. Sadly, this is not the case. When we overlook or misdiagnose a concurrent medical or psychiatric disorder, we are making the revolving door more likely. The patient suffers, is likely to leave treatment early, begin or return to self-medication, relapse, and incur further pathology.
We can, and we must, do better.