Addiction is the compulsive, drug-seeking behavior, representing a loss of control that leads a person to continually acquire and use the drug/substance, despite serious medical and/or social consequences.1 In 2009, the National Survey on Drug Use and Health reported an estimated 20.8 million adults were classified with substance use disorders, defined as dependence on or abuse of an illicit drug or alcohol.2 Among those adults with substance use disorders, 42.8% (8.9 million adults) had a co-occurring mental illness.2 The use of illicit drugs was more likely in adults with any mental illness compared to no mental illness (26.5% vs. 11.6%).2 Similarly, adults with mental illness were more likely than those with no mental illness to be binge alcohol users in the past month (29.8% vs. 24.1%, respectively) or to have heavy alcohol use in the past month (9.4% vs. 6.8%, respectively).2 Adults having co-occurring serious mental illness and substance use disorders were more likely to have made suicide plans than those with serious mental illness alone (15.8% vs. 10.2%, respectively) and more likely to have attempted suicide in the past year (8.4% vs. 3.9%, respectively).2 The implications, in terms of pathophysiology and treatment, of co-occurring substance use disorders and mental illness, are not fully understood and remain a mystery.3 In this issue of the Mental Health Clinician, Dr. Christian Teter discusses this very issue in his review of his recent publication in Psychiatry Research on the implications of comorbid bipolar disorder and substance abuse issues on medication adherence and ultimately patient care.

The number of pharmacists addressing or acknowledging substance use disorders in their daily practice appears to be minimal, though the exact statistic is unknown. Pharmacists, considered the “most accessible” healthcare professionals, are well-positioned to address substance use disorders with regards to identification and education.3,4 One potential reason for minimal participation of pharmacists may be lack of training.5,6 Pharmacy students appear to receive little training in addiction, pain, and ADD/ADHD management.4 Lafferty et al. conducted a survey study of pharmacists and found that 67.5% reported involvement in at least 2 hours of addiction/substance abuse education in pharmacy school and that 29.2% had received no substance abuse education. About 45% of pharmacists surveyed had much or very much knowledge regarding intervention and counseling patients about potentially addictive medications, and only 38% of pharmacists thought they had much or very much knowledge about the addiction disease process.

The American Society of Health-System Pharmacists (ASHP) published a statement on the pharmacist's role in addiction medicine in 2003 (reviewed in 2008 and found to still be appropriate by the Council on Pharmacy Practice and Board of Directors) stating “…pharmacists have the unique knowledge, skills, and responsibilities for assuming an important role in substance abuse prevention, education, and assistance”.7 ASHP points out that pharmaceutical care of patients includes evaluating appropriateness of pharmacotherapy and counseling, as well as monitoring outcomes related to medication use.7 

For example, pharmacists may identify pain management patients that may benefit from recommendations for long-acting or extended-release formulations.5 Pharmacists may also identify those displaying signs of substance use disorders and serve as advocates for their treatment by referring patients to appropriate facilities, in addition to informing healthcare providers of patients use.5 In the area of education, recommendations from ASHP include providing information and referral to support groups, providing recommendations regarding appropriate use of mood-altering substances, providing substance abuse education to fellow pharmacists and healthcare professionals, maintaining professional competency in substance abuse prevention, education, and assistance, and conducting research on substance abuse and addiction.7 Pharmacists can educate patients on the role of medication in the treatment of substance use issues in addition to how the medications work.3 

Within this issue of the Mental Health Clinician, one of the areas we investigate is how pharmacists can and are involved with substance use disorders. We will explore the path Dr. Aimee McRae-Clark took to develop a career path in research involving substance use disorders, an area in which she now has over 100 publications. We also delve into the events that occurred in the life of Dr. Merrill Norton as the basis for his innovative practice in substance use disorder treatment and his plans to educate future pharmacists. Dr. Sarah Melton discusses CPNP provided programming regarding pain management of patients with addiction occurring at the 2011 ASHP Midyear Clinical Meeting and 2012 CPNP Annual Meeting. Pain management specialist Dr. Julie Waldfogel shares a patient case involving the management of acute pain of patients with addiction (algorithm included).

This month's MHC also features what we hope will be a useful, long-term tool for you--the MHC Toolbox of Drugs of Abuse. Though not all-inclusive, this toolbox is based on information found through government and drug agency organizations and is meant to provide insight into the effects of many illicit substances including bath salts and spice. This effort was instigated due to the many questions that have been posed on the CPNP Email Discussion List regarding bath salts and spice. Designer drugs, such as bath salts or spice, are agents that have pharmacologic effects similar to controlled substances, but are not under legal control since they are chemically distinct from controlled substances.8 These drugs may be marketed as a “legal high.” The dilemma in controlling designer drugs based on their structural similarity stems from the fact that these designer drugs may also be structurally similar to approved medications for depression or anaphylaxis.8 Designer drugs can also avoid control by being placed in packaging labeled “not for human consumption”, thereby failing to meet all attributes needed to be considered a controlled substance.8 The example previously mentioned, bath salts, have no legitimate use for bathing and are meant to be abused and the same chemical has also been sold as plant food.

September is National Alcohol and Drug Addiction Recovery Month, dedicated to educating Americans on the effectiveness of addiction treatment and mental health services, enabling patients with mental illness(es) and/or substance use disorders to recover and live a healthy and fulfilling life (Recoverymonth.org). Building and using a local list of resources, containing information on drug and alcohol use disorders and treatment centers, can be a good place to start for CPNP members. By building an available list of resources, help can be offered and may be more likely accepted by patients in their time of need.3 As Tommasello states: “a person who expresses a desire for help today may have been unwilling to accept a referral yesterday and by tomorrow the urgency may have passed.3 For more information on how to get involved or bring Recovery month to your facility, see www.recoverymonth.org.

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