Healthcare professionals can play a vital role in identifying substance abuse problems and helping patients get the addiction treatment they need. This online discussion will examine efforts to improve training for healthcare professionals in the identification substance addiction.

Suburban Hospital provides an array of comprehensive Behavioral Health Services for individuals with emotional problems, mental illness and addictive diseases, as well as some services designed to foster mental health. Their philosophy of treatment emphasizes respect for patient and family, with a goal to provide care at the least restrictive level possible, and within the local community. Dr. Burbach is one of only a few board-certified addiction psychiatry subspecialists in the Washington area.

Chat Transcript

MODERATOR: Our live Web chat will begin in 5 minutes.

Our host, Dr. Rodney Burbach, is the clinical director of Outpatient Services at Suburban Hospital in Bethesda, MD. Suburban Hospital provides an array of comprehensive behavioral health services for individuals with emotional problems, mental illness, and addictive diseases, as well as some services designed to foster mental health. Their philosophy of treatment emphasizes respect for patient and family, with a goal to provide care at the least restrictive level possible, and within the local community. Dr. Burbach is one of only a few board-certified addiction psychiatry subspecialists in the Washington area.

Please note that the views and opinions expressed by non-CSAT staff members in the Web chats and Webcasts should not be interpreted as official CSAT policy, but, as the views and opinions of the individuals participating in these events.

Now we are ready for the first question. This question was submitted ahead of time.

MODERATOR: How can health care professionals who treat children and adolescents be encouraged to ask those children about problems they may be facing due to addiction in their families?

Dr. Rodney Burbach: I think that pediatricians and other doctors in their continuing education need to be reminded about the importance of at least asking about drug abuse among their young patients. Sometimes the young person might feel free to ask a question or share a concern. There might not be anyone else in their lives that they feel safe asking that question to. We know that doctors can be surprisingly influential in giving information about drug use or smoking. Even a minute or two can make a significant difference.

MODERATOR: Another question that was submitted ahead of time...

My daughter, age 32, is a practicing heroin addict of 5 plus years who has been in and out of various programs including residential treatment, outpatient methadone, etc. She has never been fully professionally evaluated. We do, however suspect that if she were we would uncover a dual diagnosis. In addition to addiction to substance, she has confirmed Hepatitis C and refuses to seek medical treatment for this condition. As her family watches her destroy her life, yet keeping our eye on the future by raising two of her three children, our hands are tied and all efforts to encourage her to get the help she needs in order to live as productive a life as possible have failed. What hope do we have for her future and how can the system help someone who can't and won't help themselves? Thank you for your response.

Dr. Rodney Burbach: We do know that many people with heroin addictions have dual diagnosis, which is to say they have some other psychiatric illness such as depression in addition to their addiction. And treating the other psychiatric illness can make a very important contribution to their staying clean. One of the central goals of a methadone program is to try to give the person enough stability in their life so they can attend to their other life problems. A person who refuses treatment can be of course difficult, but sometimes unpredictably, to the surprise of everyone, a drug-addicted person finally decides he has had enough and so no one should ever give up hope.

MODERATOR: This question was submitted previously...

In speaking with my colleagues about the provision of treatment services to clients, the greatest challenge is serving clients with co-existing disorders. Dollars for treatment remain unequally split between mental health and substance abuse, with much discussion about blended funding while the number of clients identified with co-occurring disorders have reached critical mass. What will it take to attract the revenue to support the identification, training, and treatment that is so desperately needed?

Dr. Rodney Burbach: I agree with the statement that treatment for substance abuse is grossly under funded. I think the political reason for that is that in this era of a shortage of healthcare dollars many other illnesses are thought more worthy of treatment by the majority of the population. On the hopeful side, we know there are many people who are in political positions of influence and have had members of their own families with substance abuse problems. So these politicians often carry with them their personal experience and work when they can for adequate treatment of addiction. A further hopeful note I think is that scientifically in the last 10-15 years we have made wonderful progress understanding addiction. This increasing scientific information strongly supports understanding the addiction and illness as a brain disease and perhaps these scientific advances will lead to more effective treatment.

sara: What can be done for addicts without insurance and without money to pay for treatment? There are several good hospitals in my area, but none of them offer many options for addicts, especially heroin addicts. The hospital patient almost always discharges himself because he doesn't feel like he has any options.

Dr. Rodney Burbach: A big problem in treating addicts is that they often arrive at treatment having no money and having lost their jobs. People with cocaine addiction may not decide they have a problem until they have run out of money. Some counties and States do offer good quality treatment for new patients and other resources. Although nowhere I think is the funding overgenerous. Also, some people can find their recovery in the 12-step community of Alcoholics Anonymous and Narcotics Anonymous, and those programs of course cost nothing.

MODERATOR: This question was submitted ahead of time...

Our 16-year-old son used methamphetamine over a year ago. We ended up having him in a residential treatment center and he was making great progress. He came home and within a week has been drinking, sometimes a fifth of alcohol day. What can we do to keep him safe and sober? Any recommendations or comments would be appreciated.

Dr. Rodney Burbach: I think the best first step would be to contact the residential program that treated your son and ask for their suggestions. They might suggest that he reenter treatment or they may have suggestions for available outpatient programs. To relapse (return to alcohol or drug abuse) is characteristic of the addictive disease, and by no means implies that all is lost. People can learn from their relapse and get back on a path of recovery.

farra: What healthcare and treatment options are available for people in prison?

Dr. Rodney Burbach: I don't know State by State what is available; I do know several States on the East Coast offer treatment for their prisoners and often those programs are pretty good. Clearly you have a captive group that can't so easily drop out of treatment so although clearly much more can be done and should be done, some treatment is available.

MODERATOR: This question was submitted ahead of time...

MODERATOR: The Association for Medical Education and Research in Substance Abuse (AMERSA) has just issued a strategic plan for interdisciplinary faculty development designed to equip the Nation's health professional workforce to address problems of addiction. The plan includes a set of "core competencies," that is, a list of elements of knowledge, skills, and attitudes health professionals need in order to address problems of addiction. In your opinion, how should these "core competencies" be disseminated?

Dr. Rodney Burbach: Probably the best mechanism for disseminating information is through professional journals and through the continuing education that is required of healthcare professionals. The barriers that have existed to focusing on such care are numerous. One has been that addictions are stigmatized. People don't think very highly of addicts, and not so highly of the people who take care of them. A second barrier is that many people believe that addicts are hopeless and you can't treat them. We know that is simply not true. Treatment of addictions work very well. Lastly, a barrier in medical schools is that the disease of addiction involves several academic departments, psychiatry, internal medicine, surgery, trauma, and infectious diseases. There is often no single department that wants to seize on addiction as its own central focus.

farra: I know a teacher who was concerned about a student's drug use (they were coming to class drunk or stoned). When they approached the student about their concern, and said they wanted to contact their parent, the student got visibly nervous and pleaded with the teacher not to because they said their parents would likely punish them with violence. What should a teacher or any caring adult do in this situation?

Dr. Rodney Burbach: Yes, that is a really difficult decision. Generally the parent should be informed promptly of such a problem. Perhaps in this case, a good next step would be to see the parents in a parent/teacher conference, and in that conference try to judge if it is safe to tell the parents of the drug use. Furthermore, if the student seems at some risk for violence in the family, then child protective services should be notified.

Dexter: Do medical school curriculums adequately address both the diagnosis of substance abuse and conducting brief interventions with patients?

Dr. Rodney Burbach: A simple answer is no. But on the good side, there is certainly much more than there used to be, particularly as we have all become aware of the cost of smoking, alcoholism, and drug abuse to the larger society.

Angel: How do you help a close relative who has a substance abuse problem (drugs and alcohol) and appears to be suffering from depression, but refuses to get professional help?

Dr. Rodney Burbach: Sometimes such a person can be persuaded to accept help by doing a "intervention." An "intervention" is a non-angry confrontation of that relative by several other well-meaning family members or friends who have firsthand knowledge of the person's alcoholism or drug abuse. Each of the people in the "intervention" should strongly believe the person needs treatment. The only purpose of the "intervention" is to get the suffering addict into treatment. It is not a forum to unload anger and guilt and recriminations.

lisa: What can a healthcare professional do to encourage a patient to get treatment that clearly resists?

Dr. Rodney Burbach: I think it is important for a healthcare professional who has identified an addiction problem to not put the issue aside even though the person resists treatment. One can in a professional and factual way continue to speak of the addiction illness and the importance of treatment. Such persistent concern and professional attention, which is not antagonistic or does not have a hassling quality, can eventually bring the person to decide they need to seek treatment. People often get well in many small steps.

farra: How can treatment professionals best reach the homeless population? Do you know of any model programs?

Dr. Rodney Burbach: There are around the country some county and city funded programs that reach out to the homeless street people, bringing treatment to them rather than insisting that these homeless people appear at a clinic. Such outreach programs can be quite helpful; unfortunately staffing these programs is expensive.

MODERATOR: This question was submitted previously...

The topic of Recovery month is removing the stigma. Until the disease of addiction is no longer treated as a crime, including imprisonment and job discrimination years after a drug charge, how can the stigma ever be removed? The Government is the biggest offender in this area. The criminal penalties, in many States, for possession of marijuana are often much more severe than manslaughter. How do we remove stigma without first addressing the attitudes/legislation that STILL says addiction is bad behavior, even criminal?

Dr. Rodney Burbach: My hope is that as the advances in neuroscience show that addiction really is a brain disease, as these scientific advances show that addicts have compromised ability to resist drug use, and as data collects that treatment is cost effective and works, my hope is that all of these factors will lead addiction to be less stigmatized. I remember when depression was highly stigmatized. It seems much less stigmatized today. In fact, antidepressant medications are among the most prescribed medications by primary care doctors.

lookingforhelp: What can be done on college campuses, where there is so much unchecked drinking and drug use and students are not as encouraged to see healthcare providers?

Dr. Rodney Burbach: The first point is that there is much more drinking and many more alcohol- and drug-related problems on some campuses than others. So a first step would be to choose a college in which rates of excessive drinking are not high. On campuses that have a tradition and reputation of being a party school, perhaps alumnae or concerned parents can have some input.

Dexter: What is an effective way to emphasize to physicians the importance of looking for signs of substance abuse? Many physicians seem to think that this is better left to the role of mental health caregivers.

Dr. Rodney Burbach: Again, I think we need continuing education to teach physicians that many medical illnesses that appear in their offices are caused or exacerbated by alcohol or drug abuse and therefore attending to the alcoholism and drug abuse is a necessary part of effective healthcare. Problems for the physician are that many patients will deny or minimize their alcohol or drug use and if the physician has no other source of information, he or she may be constrained from pushing the issue further. Many physicians feel they don't know how to treat alcoholism or addictions. Those who feel they don't have that competence and are reluctant to get it, should at least become familiar with other addiction treatment resources in their community.

lookingforhelp: What about the role of the alcohol industry? Do you think they should take more responsibility? Is it okay to accept their funding for educational outreach?

Dr. Rodney Burbach: One of the difficulties of responding to alcohol use in this country is that for the majority of people alcohol brings pleasure to their lives. We know that modest amounts of alcohol have health benefits. We also know that excessive use of alcohol causes enormous social pain and something like 140,000 deaths a year in this country. So it seems wisest to try to focus on alcoholism and alcohol-related problems and not simply try to ban alcohol entirely. As far as accepting alcohol industry money, I am not sure. Certainly it is always hard to turn away money for a good cause. On the other hand, I think it is very easy to be compromised. I think it is evident that the tobacco industry continues to pursue the young smoker despite their protests that they do not.

MODERATOR: This question was previously submitted...

It is my understanding that in the year 2000, the law was changed to make it possible for independent physicians to distribute methadone and other related medications for heroin withdrawal. I have not experienced this situation. Is it very difficult for the physicians to qualify to do so? Does it simply promote methadone mills in individual offices? Or are addicts truly being helped in their home or work environs rather than having to return to the locations where they have used in the past?

Dr. Rodney Burbach: I believe the law to which you refer relates to buprenorphine and not methadone. There is discussion about making buprenorphine available for the maintenance treatment of opiate addicts. As far as I know, that law change has not happened.

farra: What are some of the warning signs that healthcare professionals should look for when seeing teens to diagnose if there are any drug/alcohol problems?

Dr. Rodney Burbach: Probably the first signs to look for are a deteriation in various aspects of a young person's life. They may be more irritable and have increased conflicts with their parents. They may do less and less well at school, and seem less interested. A cause of great concern should be for a parent to learn that any of their child's good friends are drug users. Young people who use drugs tend to hang together. Some treatment programs offer a brief sort of educational and evaluation program for young people who are suspected of having a drug or alcohol problem.

Mixplixious: How would one go about trying to increase the med school curricula related to substance abuse issues?

Dr. Rodney Burbach: Probably the easiest and most direct way of increasing medical school interest is to fund that interest. Medical schools are not likely to turn away money for any good cause, so if perhaps if you have money to direct to this effort, it would be well spent. Medical schools these days are under financial pressures, so it will probably be difficult to persuade them to spend more money focusing on addiction treatment unless one can bring some money to that effort.

farra: What organizations and resources are available to help healthcare professionals with recovery efforts?

Dr. Rodney Burbach: Most, perhaps all, medical societies have a special committee often made up of physicians who themselves are recovering. This committee will make treatment recommendations for the healthcare professional of course, but a primary responsibility of such a committee is to protect the public from any para professional. These physician health committees are often intimately familiar with local treatment resources and also familiar with several programs around the country that specialize in treating healthcare professionals.

Dexter: How can a physician foster a relationship with a child patient to the point where the child would feel comfortable to speak freely about parental substance abuse? The amount of time a doctor spends interacting with patients has dropped considerably over the past two decades.

Dr. Rodney Burbach: I agree that it is a very large problem that the time a physician spends with each patient is diminishing. However, I think the physician often stands in a unique role as somebody in the life of a young person that they have seen occasionally for years. And if that person seems knowledgeable and nonjudgmental, and if the young person feels safe, they may well share their concerns about their parent's drinking.

MODERATOR: Our hour has concluded. And now we will have some concluding remarks from Dr. Rodney Burbach.

Dr. Rodney Burbach: There are two points I would like to make that I think are often not appreciated. The first is that cigarettes and alcohol are far and away the largest killers in our society. Alcohol kills over 140,000 people a year. Cigarettes kill over 400,000 people a year. Illicit drugs produce enormous suffering in society, but kill far fewer people, probably less than 10,000 per year. The second point is that addictions to alcohol and other chemicals really do change brain function in such a way that the addict's ability to control the use of or refrain from using alcohol or drugs is compromised. Alcoholics and addicts do have some ability to choose and those of us who treat alcoholics and addicts try to work with that ability to choose to live differently by showing them it is possible and by helping them to learn from other recovering people.

Moderator: For more information, visit CSAT's Recovery Month Web site at http://www.recoverymonth.gov.

We would like to thank our host, Dr. Rodney Burbach, clinical director at Suburban Hospital's Outpatient Treatment Center for his participation in this online event, and thank our participants for their questions. This transcript will be available shortly so that others may benefit from the dialogue.

The chat has now officially ended.