Evidence-Based Approaches to Substance Use Disorder Treatment

Substance Use Disorder (SUD) (addiction) is a chronic disease that, in the absence of effective treatment, can have a tremendous impact on an individual’s ability to contain cravings for drugs and alcohol, control emotional responses and maintain positive relationships. 

January 09, 2020

Substance Use Disorder (SUD) (addiction) is a chronic disease that, in the absence of effective treatment, can have a tremendous impact on an individual’s ability to contain cravings for drugs and alcohol, control emotional responses and maintain positive relationships. An estimated 7.8% of the U.S. population age 12 or older had SUD related to alcohol and/or illicit drugs in the past year.1 Of particular concern to employers, SUD can have a major impact on worker safety, productivity, retention and health care costs.

Impact of SUD on Employers

  • Over 20.8 million people in the U.S. meet the clinical definition for SUD.1
  • 68.3% of U.S. adults with SUD are employed full- or part-time.2
  • An estimated 20% of deaths in the U.S. are attributable to tobacco, alcohol, and other drug use.2
  • 32.3% of U.S. hospital inpatient costs are attributable to substance use and addiction.2
  • Individuals with addiction have higher rates of absenteeism, decreased work productivity, and higher health care costs.3

Treatment for SUD is complex and ongoing. Individuals with SUD often have comorbid anxiety, depression and/or suicidal thoughts, which further complicates treatment strategies. Only 10% of people with SUD for drugs or alcohol receive treatment for their condition.2 Stigma against seeking treatment remains a major societal and employer concern. Many people still consider SUD to be a sign of a moral failing, rather than a brain disease with many risk factors.4

Several strategies are available to employers to increase the chances their employees and dependents with SUD will receive appropriate, evidence-based treatment and will overcome the disorder. These strategies include the following:

  1. Coordinate with employee assistance programs (EAPs), health plans and other partners to conduct anti-stigma campaigns in the workplace.
  2. Consider conducting peer-support training programs to encourage constructive conversations and the use of behavioral health resources.
  3. Consider first-offense forgiveness policies that, in the case of an SUD-related workplace incident, trigger treatment interventions rather than immediate termination.
  4. Consider requiring out-of-network (OON) inpatient rehabilitation centers (IRCs) to be accredited by the Joint Commission or CARF, and consider excluding facilities from coverage that are not accredited.
  5. Cover medication assisted treatment (MAT), such as methadone and naloxone, for opioid and alcohol addiction.
  6. Work with health plans to promote, or directly contract with, health systems that have integrated behavioral and mental health treatment into primary care, acute care and surgical support programs.
  7. Ensure that care managers, navigator services, decision-support programs and EAP managers are acquainted with resources that plan members can access to receive high-quality care.
  8. Reduce exposure to potentially addictive pain medications (e.g., opioids) by implementing utilization management strategies, such as limiting “first fills,” and covering pain management alternatives.

What is Substance Use Disorder?

SUD is a chronic disease related to brain rewards and motivation with serious consequences, including the following:5

  • Inability to abstain from addictive substances;
  • Impairment of behavioral control;
  • Cravings;
  • Difficulty in maintaining positive interpersonal relationships; and
  • Dysfunctional emotional responses.

As with other chronic diseases, many people with SUD go through cycles of relapse and remission.

Let’s Get Definitional – SUD or Addiction?

 In 2013, the updated Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) changed the way that clinicians diagnose patients who misuse substances. Diagnoses including “substance addiction” and “substance abuse disorder” were wrapped into the current, broader definition of “substance use disorder” (SUD). Someone diagnosed with SUD will fall along a severity spectrum depending on the number of behaviors the person exhibits, such as impaired control using the substance, social impairment, risky use, tolerance and withdrawal. “Addiction” is not a clinical term, but is most often associated with people on the severe end of the SUD spectrum. This guide uses “SUD” throughout.

Risk Factors

According to the American Society of Addiction Medicine, risk factors for SUD include environmental, genetic and biological conditions.5 These can include:

  • Genetic impairments in the brain’s reward circuitry;
  • Emotional trauma or mental health conditions for which someone might use substances to cope (e.g., anxiety and/or depression);
  • Easy access to addictive substances;
  • Peer or family history of excessive substance use;
  • Exposure at an early age to substances while the brain is still developing (pre-21); and
  • Geographical location (see figures, below). A lot is still unknown about differences between the brains

What about Tobacco?

Nicotine is detrimental to health and extremely addictive, but the behavioral consequences of this addiction are relatively mild compared to other substances. This guide will focus on addiction treatment for non-nicotine substances, including alcohol.

Of people with addiction and those without, especially how they are affected over time, which complicates treatment pathways. The Adolescent Brain Cognitive Development study, funded by the National Institutes of Health, is in the process of looking at these differences in 10,000 adolescents, but the results are years away.

Prevalence

According to the U.S. Substance Abuse and Mental Health Services Administration (SAMHSA),over 20 million Americans had SUD in 2015.1 Substance use varies widely by region and age, with regional variations related to the type of substance.6 For example, alcohol use disorder is most prevalent in the Upper Midwest, whereas heroin use is most common in the Northeast.6 SAMHSA publishes a large amount of data on state and regional prevalence for the public.

Impact on Behavioral and Physical Health

The DSM-5 identifies eight categories of substances for which someone could develop an addiction: alcohol, cannabis (marijuana), hallucinogens, inhalants, opioids (prescription or illicit), sedatives (e.g., valium), stimulants and tobacco.

Short-term Physical Effects

Each of these substances will have different short-term physical and mental effects on a person. For example, inhalants (e.g., nitrous oxide) create a brief sense of giddiness or euphoria with associated loss of motor skills, drowsiness, dulled inhibitions and other side effects.7 Conversely, stimulants like cocaine can increase alertness and energy for a short period of time while increasing heart rate and sensitivity to light.8 Withdrawal symptoms present even more challenges, like fatigue and depression. For many addictive substances, an overdose can lead to unconsciousness and death. According to the National Institutes of Health (NIH), in 2015 there were 52,404 deaths in the U.S. due to overdose.9

Comorbid Conditions

Rates of anxiety and mood disorders among people with SUD are twice as high as those for the general population.10 Among people who present to an emergency department for suicidal thoughts, 42.8% have SUD (excluding alcohol) and 29.6% have alcoholuse disorders.11 People with SUD are six times more likely to attempt suicide.12 Causality goes both ways; many people will use addictive substances to cope with symptoms of anxiety or depression, while others may develop a mental health condition as a result of dependency on a substance.

Long-term Physical Effects

Long-term use of most addictive substances greatly increases the likelihood of liver failure, cancer, stroke, among other illnesses and conditions. Long-term use is also associated with increased risk for developing mental health problems (see text box on comorbid conditions).

Behavioral Effects

Although the physical effects of SUD vary depending on the substance, the associated behaviors and the impact of those behaviors on patients is similar across categories. Each of these substances triggers pleasure centers of the brain that, over time, change the normal hierarchy of an individual’s needs and desires.10 Behaviors associated with non-nicotine SUD include:

  • Inability to abstain from addictive substances, including serious withdrawal symptoms when discontinuing use;
  • Impairment of behavioral control;
  • Increased risk-taking like driving under the influence;
  • Disruptive cravings;
  • Difficulty maintaining positive interpersonal relationships; and
  • Dysfunctional emotional responses.

The impact of SUD varies by individual. Some people are not able to hold down a job due to their addiction, alienate friends and family, and experience severe behavioral and physical effects. Others are able to work fulltime and largely conceal their addiction for extended periods of time until a serious adverse event occurs, such as a workplace safety incident.

Impact on Employers

The percentage of U.S. adults with SUD who are employed full- or part-time is 68.3%.2 SUD among employees and their dependents presents several major problems for employers.

Absenteeism, Presenteeism and Retention

Workers with SUD are more likely to have reduced productivity, take short- and long-term disability (LTD) leave of absence, and lose their jobs. Behavioral health conditions, including SUD, account for almost 10% of LTD claims.13 Workers with alcohol dependency are 2.7 times more likely to have injury-related absences.14

Safety Concerns

The absence of inhibitions to risk-taking behavior and the potential impairments related to the direct effects of substance make workers and their peers vulnerable to serious safety events, especially in the health care industry and any worksite where heavy machinery is used. For example, among people presenting in the emergency department with an injury sustained at work, 16% have alcohol in their system.14

Cost of Treatment

Treatment for addiction care in the U.S. costs an estimated $28 billion a year, as of 2010. This is lower than spending for other major health conditions (see Figure 2), but there are signs that spending will increase as the opioid epidemic continues to take more lives and additional focus is put on high quality treatment for SUD.

Why People Don’t Get Care: Stigma

SUD has for decades been considered evidence of a moral failing on the part of an individual, rather than a disease with genetic and environmental risk factors. Stigmatizing these individuals is pervasive across society, including among health care providers, family members of people with SUD, and even health benefit managers.

At a January 2017 Business Group meeting on mental health, 61 large employers were polled on the top barrier to connecting people with high-quality mental health services, and stigma was the number one response.

Stigma is a large reason why only 10% of people with SUD receive care. If someone is worried that their friends, family, boss, and potential future employers will see them as inferior for having a SUD (and fire them!), they are less likely to seek care.

Some employers are working to reduce workplace stigma by:

  • Using c-suite testimonials about personal or family experiences with SUD to promote help-seeking behaviors;
  • Partnering with peer support programs to encourage employees to recognize when a peer may be struggling with a behavioral health condition and help them access treatment resources; and
  • Implementing workplace policies that help connect employees to treatment resources upon revelation of a SUD, rather than immediately terminating an employee.

The National Academy of Sciences, Engineering, and Medicine identifies several evidence-based anti-stigma strategies similar to those listed above, including behavioral health literacy campaigns and programs that connect people with SUD to others who have not experienced it.

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