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Evidence Based Principles by Research Informed Practices by Dr. Jay Bouldin

The Pros and Cons of Research-Informed Practices in the Treatment of Addiction

In recent years, the healthcare system has been searching for the holy grail of the ideal model for treating addiction. There have been a few models that have come and gone where they have tried to meet the challenges provided by the complex disorder of addiction. We have studied quite a few successful models thus far and there is no doubt this curriculum will be providing more in the coming weeks. The approach to finding effective means of integrated addiction care modals has greatly improved the outcomes and lives of many patients. Some of models may have failed to accommodate the successes in addiction in part because of inadequate capacities, depth, scope and forethought. As time progresses away from these growing pains or progressive failures, the field of addiction treatment has shown and is showing a quick and vacillating evolution where we are observing comprehensive and successful models like the Research Informed Practice Model. Many such patients within office-based care in the research-based model have many advantages. One advantage showing positive results is in the tight regulation and adherence in the continuum of care as well as the patients individualized treatment plan. This is providing proof that proactive oversight and strict compliance activities do help guide a patient effectively with more care and concern than without. When receiving treatment in the research informed office setting, there are more minds and hands on the patients care at more diverse levels of care along the biopsychosocial continuum. One case to outline this point is found in a methadone study where transferring such patients to office-based care research facility offered a higher level of care and tight monitoring for the administration and compliance of methadone to its patients. This research model has led to several thousand patients being successfully treated in an office type settings providing the appropriate management techniques including patient selection, monitoring, pharmacotherapy and behavioral analysis. Early evidence from many other studies of office-based research informed models finds the care of newly entering patients into treatment suggests that such care is more comprehensive. I find the response unsurprising that the patients and families became more involved each in part of a more global setting of care and the long-term outreach in the patient's continued recovery. With the research informed practice, the outcomes appear to be higher in settings without. In my opinion, this model provides a healthier and safer environment for both the patient and the staff. Not only are there more resources available but I am finding the level of knowledge base of staff is at a higher, specialized level and more up to date in turn creating a higher level of care to their patients in the short term and the long term. This approach has positive results and holds a great deal of promise for the future of addiction medicine. One such study example in proof of this approach is found in the APA-PRN Study. It is as follows: OBJECTIVE: The authors describe the APA Practice Research Network (PRN), a national research initiative that ultimately will engage 1,000 practicing psychiatrists in collaborative clinical and services research. The PRN is designed to generate practice-relevant information and to inform future service delivery, policy, and financing decisions pertinent to psychiatry. METHOD: The authors review the relative strengths and limitations of practice-based research compared with other widely used research methods. They also describe the structure of the PRN and its procedures for recruiting network members and for identifying and developing specific network studies. The three primary sources of data for the PRN are 1) the biannual National Survey of Psychiatric Practice, which provides not only a mechanism for randomly recruiting the two-thirds of network participants who are not volunteers but also a baseline for assessing the generalization of PRN findings; 2) separate biannual studies of psychiatric patients and treatments to characterize the network patient/treatment denominator, which is used to monitor trends in psychiatric practice and plan network studies; and 3) specific studies. RESULTS: Pilot data from the PRN have yielded detailed information on the diagnostic and clinical characteristics of 725 patients and on the treatments provided by network psychiatrists. CONCLUSIONS: The APA PRN offers a powerful complement to traditional clinical and health services research approaches. The PRN will help psychiatry improve its ability to meet patients' needs in a context of rapidly evolving scientific and clinical progress and legislative and economic forces affecting health care delivery. (Reference 8) As more knowledge accrues about research informed practice treatment models it becomes clear to me that a more widespread practice of this model will provide a number of positive ripple effects. Maybe the treatment gap will narrow as more patients who live in a variety of locations and have varying needs gain access toward this type of treatment model? As medical and addiction treatment systems reintegrate, not only will medical and psychiatric comorbidities be attended to more fully, but providers may become more willing to address substance use problems as a whole. My belief is that society in general will benefit from this level of care, and we will see more reductions in crime, its associated costs, increased employment from and, possibly, an overall decline in health care expenditures as well. The quest for the perfect model may never be met, but the research informed practice model is moving in the right direction. This model provides proof positive in the combined efforts now available in addiction medicine where many associated disciplines are integrated with other necessary primary care environments. I find emerging implementation of optimal management techniques refreshing and exciting where the union of approaches, modalities, ideologies, philosophies and methodologies will meet to provide the highest level of care possible.

As Exampled; The Evidenced-Based Treatments for Addiction

Current emphasis on dissemination and integration of evidenced-based treatments has brought increasing pressure from funding sources to use research findings to improve treatment. To facilitate this effort, it is important for physicians and other healthcare providers in charge of treatment programs to become familiar with some of the complex issues involved in the research-based treatments in addiction therapeutic models. This would include but not be limited to the importance of distinguishing between patient diagnoses, diverse treatment principles and the specific interventions placed within a patients individualized treatment programs. With the inclusion of specific treatments, it is important to appreciate the magnitude of this task. Evidence Based Treatments are only the beginning of the lengthy recovery process that will have to involve many layers of treatments, clinical demonstrations, ongoing clinical supervision, and organized supportive group to be successful. The evidenced based treatment approach should be integrated into the clinician's repertoire and a supportive atmosphere where forthright consultative feedback is ongoing which will further facilitate adoption of new skills and knowledge. Effective treatment programs typically incorporate many components, each directed to a particular aspect of the illness and its consequences. By definition and in practice there are two categories responsible for comprising the evidence-based treatment model. Pharmacotherapy and Behavior Therapy are the cornerstones of the EBT Model where specific pharmacologic and psychosocial treatments are often combined. This may be due to the combined treatments leading to better treatment retention and outcomes providing long term success. There are now three decades of scientific research and clinical practice which have yielded a variety of approaches to the model day architecture of addiction treatment. I found this approach to be most comprehensive and well-founded within my own individualize treatment plan. Furthermore, the EBT model provided me with maximum benefit in my early phases of recovery and continues to resonate in my recovery today. The most effective means in matching assessed patient needs to the most effective services starts with the evidence-based-approaches-to-drug-addiction-treatment. This research suggests it may have the most impact and long-term benefit. Evidence now suggests that substance dependent individuals who report sustained abstinence from their drug of choice have the best long-term outcomes. Not surprisingly, this extensive data subset shows that such treatment is as effective as treatment for most other chronic medical conditions as discusses in the module 10 discussion. Of course, not all drug treatment is equally effective or applied in a standardized way across the continuum. There may even be an obligatory need for this model for its success. The EBT has shown in many cases to overcome inconsistency and variability in treatment plans further improving the fidelity in conceptualized models. It appears to me that it is fair in saying that evidence-based treatment may serve as the starting point and foundation of recovery as a whole. Although this may serve to be a result seen in time, research also has revealed a subset of certain effective but overarching principles that universally characterize the most effective drug addiction treatments and their implementation as seen in current manuals or guides to competent therapeutic modalities. Drug addiction is a complex disorder that can involve virtually every aspect of an individual's functioning in their family, at their work, and within their community. Because of addiction's complexity and pervasive consequences, addiction treatment typically must involve many components beginning with the EBT Model utilizing the pharmacologic and behavioral modalities first. In one sited example, some of the components found within the EBT focused directly on the individual's drug use and its symptomology, whereas others, focused behavioral components on cognitive therapeutics such as self-awareness, coping mechanisms, emotional counseling, competency training and life skills restoration which will all play part in the addicted individual reintegration and productive membership within the family and society. Additionally, the treatment of drug abuse and addiction is delivered in many different settings across a variety of backgrounds using many blends of behavioral and pharmacologic approaches as seen in the EBT Model. In the United States, more than 11,000 specialized drug treatment facilities provide rehabilitation, counseling, behavioral therapy, medication, case management, and other types of services to persons with drug use disorders. Care of individuals utilizing the EBT Model with substance use disorders includes but is not limited to; assessing needs, providing treatment for intoxication, control withdrawal symptoms and developing a specific treatment plan that may consist of referrals to psychosocial care. As presented, the EBT treatment plan is shown to address how the patient will achieve long term abstinence without medical compromise; achieve and maintain abstinence after withdrawal; and gain improvement in functioning within the medical, social, and psychological continuum of care.

Is there a Perfect Treatment Research Model?

I think it is difficult to offer a definitive answer this question. I tend to subscribe that not much in life is as absolute. Similar to the quest in finding perfection in most things, there appears to be true imperfection in the assumption itself. While attempting to find perfection in an imperfect world when it pertains to the human mind and behavior, I find the quest for The Perfect Treatment model to be the holy grail in addiction medicine and could be argued as well as for any field found in healthcare for the most part. The addiction research enterprise has traditionally been separating and distinct from addiction medicine. The ethos has in large part changed in today's Substance Use Disorder Treatment Modalities. Addiction Medicine and associated Research-Based Treatment Programs are become common place and tend to be provided in a paralleled context of addiction treatment as a whole. Although, sometimes limited ways, they might remain separate for ubiquitous reasons like public policies, practices, and laws have worked against this model for the basic provisions of care by clinician. Despite any longstanding barriers or prejudices to the research model in addiction medical care and the risk of prosecution, physicians have recognized a need to provide this type of comprehensive care to addicted individuals. Brief interventions for substance use disorders have been studied long before being adopted and expanded to include evidenced-based research models. It has slowly been found as a necessary process to the whole of treatment and management of addiction patients. More times than not, you find treatment facilities involved in some way, shape or form in the research-based model. I find it to be an integral part to the field and the patient on many levels and submit my experience with it being quite positive and rewarding. I felt part of something bigger than myself with the ideology of my information one day helping others in the future. Additionally, I found the level of care to be higher, more comprehensive than other without a research-based model. Although not absolute, these types of new interventions were intended to facilitate better treatment of patient's settings other than those in just one addiction treatment enterprise I.E., mental health clinics, physician's offices. There is no magic bullet or perfect model of addiction medicine. There are just too many unknowns and overt complexities to overcome. In my opinion, progress rather than perfection holds true in my recovery as well as the ideology of treatments combined in the research-based models.

What to Do When Facing Under- Researched Problem Areas? I am with built with the true belief, “You Can't, Wont and Don't Know Everything!” I think the alternative to this statement is negligent and dangerous. The alternative omnipotent approach is an extremely dangerous place to reside anywhere in live much less healthcare. I believe it is intellectual suicide as well as professional suicide to act in an arrogant fashion especially when others' lives are at stake.

When facing under researched areas I find they should not be shied away from but interred into cautiously. They should be well found and well-funded with the proper abstracts put in place with the resources to support the endeavor. There should be the properly appropriated time, money and staff each component of the problem area. In addition, there needs to be a much stricter area of regulation, compliance and monitoring than with other areas. Due to the very nature of the question, more care, concern and attention should be brought forward and continued along the lines of the endeavor. I think the answer to this question is complex and multi-layered and should be taken on with the highest medical oversights and protections in place in order to protect the patients and secondly the staff. What do I do when faced with a problem area? It is my belief, when you don't know have the courage and tenacity to find out. Ask for Help! I find a few steps helpful when faced with a problem area of any kind, First, recognize you are not going to have all the answers. Second, admit when you don't know something, Third, put in motion the means for finding out what you don't know by asking others. Fourth, do the work and due diligence necessary to find the pathway for the answers to your problem area and see it through until the end. And Fifth, WHEN UNDSURE, REFER! Do You Need to be a Researcher to be A Great Clinician?

Physicians and other addiction professionals who provide research added to their therapeutic model can offer a significant role in supporting and facilitating patients' while contributing to the field of addiction medicine. There are countless advantages in combining the dual discipline methodology. First, they can educate, encourage and persuade patients to enhance their compliance and their long-term participation in many facets to their individualized treatment plan and in large part to heir overall treatment program for long term recovery. It is helpful and advantageous for clinicians to be engaged in a research-based model to provide a multilevel, multidisciplinary level of care to achieve success at the end point of the patient's recovery. Additionally, I find the research-based model obligatory as well to move the field of addiction medicine forward. I also feel that the argument of having more heads and hand involved is a better way to practice healthcare as it pertains to addiction medicine. In the model, the clinician can utilize the deep well of resources acutely to help their patients for maximum benefit. The clinician acts not only as the empathetic healer helping the patient make better decisions in the participating in a research-based model but provide future advancements not yet realized. Many may even influence the power of brief traditional and nontraditional interventions on a patient's drug use and associated behaviors as well whether seen or unseen at the time of its implementation. Furthermore, the combined practice-based research model, a clinician is able to collaborate with group therapists, counselors and physicians about a patients' clinical status or problems with adherence, compliance and participation. Additionally, the clinician may also see a patient more often and more closely for the management of relapse, medication management, and for any co-occurring psychiatric disorders. For example, if the clinician found that the patient was not adhering to their individualized plan by attending actively in group therapy, the clinician can easily make a transition to facilitate a discussion with the group leader or even hold a joint meeting with the patient and group therapist to try to resolve the problem. In so doing, the closer proximity to the patient and their care, the message the patient receives from this collaboration is that the clinician s more engaged, involved and concerned for the overall welfare of the patient. It is my belief, this would send a healthier message and provide a healthier environment for all patients and staff involved. I found this type of patient care more efficacious and beneficial in the therapeutic environment. The research-based group was found to be more intensive and comprehensive to myself and the providers and was important part of the overall treatment plan. The clinician has distinct advantages by adding the research-based practice to their patients. Not only does it add professional credibility, but it more closely monitors the patient's full participation in their comprehensive continuum of care. This modality allows the clinician to identify and resolve any barriers related to the patient's continuum of care and provides a patient with a better understanding in the reasons for care. It may even provide future answers for any possible poor adherence to a patients specific individualized treatment program bringing a better chance of success in the treatment plan as well as their long-term success in recovery.


1.Siqueland L, Crits-Christoph P. Current developments in psychosocial treatments of alcohol and substance abuse. Curr Psychiatry Rep 1999; 1:179–184.

2. Vaillant GE. A long-term follow-up of male alcohol abuse. Arch Gen Psychiatry 1996; 53:243–249.

3. Vaillant GE. A 60-year follow-up of alcoholic men. Addiction 2003; 98:1043–1051.

4. McLellan AT, O'Brien CP, Lewis DL, et al. Drug addiction as a chronic medical illness: implications for treatment, insurance, and evaluation. JAMA 2000; 284:1689–1695.

5. ASAM PPC-2R. Mee-Lee D, ed. ASAM patient placement criteria for the treatment of substance-related disorders, 2nd edition–revised. Chevy Chase, MD: American Society of Addiction Medicine, 2001.

6.Santa Ana EJ, Wulfert E, Nietert PJ. Efficacy of group motivational interviewing for psychiatric inpatients with chemical dependence. J Consult Clin Psychol 2007;75(5):816–822.

7. Fleming MF, Mundt MP, French MT, et al. Brief physician advice for problem drinkers: long-term efficacy and benefit cost-analysis. Alcohol Clin Exp Res 2002;26(1):36–43.

Handling Ethical Situations During Treatment

When discussing ethical situations during the treatment of addiction, one must have a proper framework of understanding and knowledge of possible scenarios which may arise when treating patients or clients with addiction. Ethical principles are at the core of medical practice and counseling environments. Things to be considered are in ways a counselor or addiction professional must be competent and well versed. It can and will prove most challenging in the areas of screening, assessing, or treating a patient for addictive disorders and may even challenge a professions personal ethics and moral principles. Physicians and addiction professionals may be able to avoid or minimize potential ethical dilemmas if they remain diligent and aware of the sources of potential conflict and how they should be handled. Keeping ethical behavioral principles in mind, the physician-patient relationship must be nurtured and molded carefully paying close attention to any potential conflicts with their patients at the beginning of treatment and must continue with prophylactic steps throughout the treatment plan to reduce any conflicts to a few relatively rare situations.

When discussing of the relationship between patient autonomy, the physician has an obligation to counsel patients about the health risks of substance use first and foremost. It then turns to the concept of informed consent which examines the questions raised when a patient may not be competent to make his or her own decisions or in some cases when a patient is not willing to enter treatment voluntarily. Privacy of information about a patient's addictive disorders and treatment is paramount. Not only is it ethical and moral, it is the law. The confidentiality process begins with a brief discussion of medical information, risks, benefits, treatment options and why it is important. It is always ethical to overview the legal guidelines of the physician-patient relationship and other factors that govern privacy of medical information. There are three specific situations in which the physician or addiction professional can be called on to resolve an ethical dilemma between the binding relationship to maintain confidentiality and the duty to protect the patient and the public at large. Most of the time, ethical principles are congruent and upheld, however, health professionals who screen, assess, or treat patients for addictive disorders sometimes may find themselves in situations where ethical principles are in conflict and must know how to handle them while acting appropriately. There are endless examples of ethical dilemmas or conflicts which may need special care, concern and attention in order to properly handle them for the common good of both the addiction professional and the patients as well. A healthcare provider who suspects a patient has an addictive disorder may face a conflict between an obligation to put the patient's health first and respect for the patient's autonomy.

Furthermore, What about in these situations: What should the physician do and should the they pressure the patient about his or her substance use? Should the physician ask to order medical tests out of concern for the patient's health? Should the physician drop the subject if the patient indicates that he or she does not wish to discuss it out of respect for the patient's autonomy? What should a physician do if the patient's health plan will not pay for the kind of treatment that is needed? Which ethical principles should guide the physician who believes that a patient's addictive disorder poses a danger to the patient's safety: the duty to the patient's health or the duty to protect the patient's privacy? Is the decision-making capacity intact? Is the medical advice coerced? (2)

The scenarios are endless and boundless, but one must put the frameworks in place to make more sense of the ethical architecture in addiction medicine. One might agree that, in order, to better understand ethical situations in addiction treatment, one must review the most common of situations which may occur while in practice. I agree with the ideology that the most commonly occurring situations which one might be exposed to when treating patients must be learned and reinforced. Sixteen of the most common ethical dilemmas and situations to be aware of, have knowledge of as well as be continually assessed in as a future addiction professional are as follows; (Adapted with credit from Principles of Addiction Medicine) Patient Autonomy: Americans attach extraordinary importance to their right to be left alone. We pride ourselves on having perfected a social and political system that limits how far the government and others can intrude on our private lives or control what we do. “The principle of autonomy is enshrined in the Constitution, and the courts repeatedly have affirmed the right of citizens to make their own decisions on fundamental issues.” (3) Medicine places a high value on patient autonomy and patients consult physicians on their own initiative when they decide they have reached a level of discomfort with a particular problem. The physician who is consulted by a patient about a condition such as back pain is expected to outline the causes and suggest possible preventive measures and available treatments. In this case, the physician certainly can make a recommendation, but must recognize that the patient has the right to choose among the recommended treatments or to refuse them altogether. Rarely will a physician consider forcing advice on a patient even if convinced that the patient is making a wrong choice. If and when a patient is in denial about his or her abuse of alcohol or drugs, however, deference to patient autonomy can shift. The principles of autonomy and privacy are critical to the honest communication between physician and patient and may sometimes seem to work against what the physician if he or she sees as the patient's best interests for intervention in the context of drug and alcohol abuse. (4)

Dealing with Denial: Traditionally the respect for the patient's autonomy has made physicians reluctant to ask questions about areas not directly related to the presenting condition particularly if those areas are sensitive like in substance abuse. Until recent years, patients' annual physicals rarely included questions about alcohol consumption, and physicians were even more reluctant to question patients about drug use. However, when a physician screens and assesses a patient for addictive disorders whether by observing the patient, performing laboratory tests, or administering behavioral questionnaires) he or she is seeking information about lifestyle and personal habits that carry a good deal of stigma. So how does a provider deal with this dilemma? Both patient and physician may view such inquiries as intrusions on the patient's autonomy as well as his or her privacy. Nevertheless, when a physician suspects that a patient presents at the office with another presenting complaint as well as drug or alcohol abuse, he or she must take the initiative if the patient does not raise the issue. In such a case, the physician or addiction professional has an ethical and moral duty to act if there is reason to believe that the patient's use of alcohol or drugs is affecting his or her health. Raising the issue is usually not enough since denial is an integral part of addictive disorders. Individuals faced with addiction are most times in denial and fail to recognize or acknowledge their problem. Sometimes addicts find ways to deny or minimize the extent of their alcohol or drug use because they are ambivalent about giving up such use. So what is the proper balance between respect for the principle of autonomy and the physician's responsibility for the patient's health when dealing with a patient in denial? Should the physician raise the issue and then drop it at the slightest hint of resistance on the part of the patient? Should he or she intervene more forcefully by talking with the patient, conducting medical tests, or involving the family? (5)

Talking with the Patient: To fulfill the ethical, moral and professional responsibility to the patient, the physician should do more than simply raise the issue of substance abuse. He or she should provide relevant information then engage the patient in a full discussion of their substance use or abuse. If the patient shows resistance, then he or she should do follow up questions in future visits. How far the physician can intrude on the patient's autonomy will depend a great deal on the strength of the physician-patient relationship. Unless a firm foundation of trust and understanding has been established with each patient the persistent questions or any forceful confrontation can and most likely will backfire, ultimately pushing the patient away. In most cases, it will the individual with the presenting addictive disorder who can and should take action to change his or her behavior. Although the physician can supply information and encouragement, it is the patient who must make the decision to change.

Ordering Laboratory Tests: A physician should obtain the patient's consent before ordering a drug screen. It is most likely that the law does not require the patient's consent. But ordinarily, a physician does not ask a patient to sign a consent form before sending blood or urine for other testing. However, ordering laboratory tests to screen patients for addictive disorders is different and failing to consult the patient can undermine the physician's efforts to induce the patient to acknowledge the problem. The screening urine or blood for drugs is not the routine practice in primary care settings. Patients expect to be screened for blood sugar and cholesterol, but they do not expect their physician to screen them for drug use. A patient confronted with the results of a test he or she did not know about and for which he or she did not give consent may feel betrayed by the physician, which is a shorthand way of saying that he or she will be angry that the physician did not show respect for the patient's autonomy. In this case, the physician runs the risk that such a situation will damage the relationship with the patient. The patient may refuse to participate in any further discussions about alcohol or drug use. Tactically, therefore, the better practice is to obtain the patient's permission for blood or urine tests for alcohol or drugs. Unfortunately, there is a good chance that if the physician consults the patient and asks permission to perform a drug screen, the patient may refuse to agree to the test, but this result may leave the door open to further discussion with the patient about possible drug problems. The patient may even be more likely to appreciate the physician's concern for his or her autonomy and privacy and the result may be more open than would be the case if the physician was perceived as acting behind the patients back therefore not being trusted. Patients are less likely to be surprised that such a test has been ordered with proper rapport and trust where the test results may provide an opening for a healthy conversation about the health effects of alcohol or drug use. (6)

When the Patient is an Older Adult: The physician who suspects an older adult patient is abusing alcohol or drugs may be especially sensitive. As we age, most of us become more sensitive to perceived threats to our autonomy because of the stigma surrounding addictive disorders. A patient whose physician suggests that he or she may be drinking too much or abusing drugs whether legal or illegal might conclude that the physician is suggesting that the patient's functioning or capacity is diminished. If an older adult thinks that his or her autonomy is being threatened, the patient may be more likely to point to the normal as the infirmities of old age are sometimes the source of the difficult. Most older adults are unaware that the way their bodies metabolize alcohol and drugs which include prescription medications differently. As we age, biological changes occur and the amount of alcohol or drugs consumed without obvious adverse consequences can harm their health and even incapacitate them. Moreover, many older adult patients take multiple prescription drugs to control other ailments like high cholesterol, high blood pressure, diabetes, depression, or anxiety. They may not be aware that their prescription medications can interact with each other and with any alcohol or nonprescription drugs they may consume which would interfere with the therapeutic effects of their medications. This approach emphasizes these issues and provides a better opportunity for a provider to engage an older adult patient in a discussion about addictive disorders without posing a threat to his or her autonomy. (7)

Informed Consent: Autonomy also is at the root of our belief that a patient has the right to decide what treatment he or she will accept, and even whether he or she will accept treatment at all. When a physician asks a patient to sign an “informed consent” agreement, he or she is affirming that the patient has the right to make decisions about his or her medical care. “Informed consent” has two components. First, the patient's decision to undergo a course of treatment must be based on knowledge and competency. The physician must give the patient the kind and amount of information the patient needs to make an intelligent “informed” choice and that the patient must be capable of understanding the information and making a decision. Second, the patient's decision must be voluntary and a product of his or her free will. What happens when one of these conditions cannot be met in cases when the patient is not fully informed or competent to make a decision for himself or when he is coerced into treatment? This is an area of litigation and legislation in nations courts and will continue to be controversial. (1, Capron)

Informed Equals Knowledge Plus Competency:

The physician is obligated to give the patient all the information he or she needs to make a decision as it pertains to their healthcare. This information should include the physician's opinion of the patient's diagnosis as well as an outline of the available treatment alternatives and a description of what each alternative it may involves which should always including the benefits and risks. Additionally, an explanation of any and all of a treatment's consequences should be presented with conversation and responses to any of the patient's questions. Often times, the physician also helps the patient evaluate the treatment alternatives in accordance with the patient's values, hopes, and fears. Unfortunately, with the growth of managed care, physician and patient no longer have an exclusive relationship and managed care organizations have intruded itself into the mechanics of the physician-patient relationship. Additionally, many managed care contracts shift some financial risk from the managed care company to the physician and in some plans, the contract gives physicians whose patients do not use expensive or extensive services a financial bonus. Sadly, this practice is unethical and immoral but not illegal. In other plans, the contract limits the services for which the physician will be reimbursed. In this way, many managed care plans create incentives that can impinge on medical judgment at times. If a physician allows financial incentives or disincentives to influence treatment recommendations or even discharge a patient who has exhausted benefits under the contract, that physician has placed financial interests before his or her obligation to the patient's health which is a clear ethical violation. Because managed care sometimes places covert limits on certain forms of treatment, medical ethicists have begun to suggest that the physician should inform the patient about any and all economic issues that could influence either the physician's recommendation or the patient's decision. This attempt would provide another layer of consent as an “economic informed consent” which would ensure that the patient knows about any limitations the managed care plan or insurer might imposes on treatment before making their decision. (8)

Competence (Decision-Making Capacity): The concept of informed consent is based on the assumption that the patient has a normal or expected decisional capacity. Decisional capacity means that the patient is able to understand the physician's explanation of the diagnosis, prognosis, any treatment alternatives, and likely outcomes if the treatment is refused. The physician should be able to go through the complex process of assessing that information in accordance with his or her personal system of values, beliefs and wishes as well. Most patients who have decisional capacity may ask their physician questions about the treatments and procedures of their medical care but decisional capacity in dealing with two groups like adolescents and older adults is an area of controversy and debate. (8)

Issues in Dealing with Adolescents and the Elderly: Adolescents do not have the legal same status as full-fledged adults and therefore there are certain decisions that society and the law does not allow them to make. Below a certain age which varies from state to state, adolescents must attend school and cannot drive, marry, or sign binding contracts but some states, but in some states the adolescent's right to consent to medical treatment or to refuse treatment will also differs from an adult's right. In more than half the states, adolescents now have the right to consent on their own to addictive disorder screening, assessment, and treatment while in other states, a parent must be notified and/or consent. In states that deem adolescents competent to consent to an addictive disorder and their treatment do not require parental consent and the physician has no ethical dilemma or situation. He or she can provide whatever treatment is appropriate and to which the adolescent patient consents. It is in those states that require parental consent or notification that the physician sometimes encounters a complex ethical situation. quandary. The difficulty arises when an adolescent who seeks assessment or treatment refuses to permit communication with a parent. If the physician believes that the adolescent does need treatment, he or she has a few choices as presented by the provider. (2,6,8)

Issues in Dealing with Older Adults: Most older adults are fully capable of understanding medical information in most situations. When weighing treatment alternatives and making then articulating decisions a small percentage of older patients are clearly incapable of participating in a decision-making process. In such cases, the older adult may have signed a health care proxy or may have a court-appointed guardian to make such decisions. The real difficulty arises when a physician is screening or assessing an older adult whose mental capacity lies between those two extremes. The patient may have fluctuating capacity of periods of greater or lesser alertness depending on the time of day or number of days where the patient's condition may even be transient or deteriorating. Diminished capacity may affect some parts of his or her ability to comprehend information and make complex decisions but not in others. When this occurs, the caring for an older adult patient whose decisional capacity is less than optimal, the physician must help the patient to understand the information presented and appreciate the implications of each alternative treatment so that they older patient may make a rational or decision, based on the patient's best interests? And what can the physician do if the patient appears to be not competent decision. Although there are no easy answers to these questions, there are several possible approaches listed 1-4 below: (2,6,8) 1.Present Information Carefully: The physician can help the patient who appears to have diminished capacity through a gradual information-gathering and decision-making process. Information should be presented in a way that allows the patient to absorb it gradually, clarify and restate information as necessary, and summarize the issues already covered at regular intervals. Each alternative and its consequences should be laid out and examined separately. Finally, the physician can help the patient identify his or her values and link those values to the alternatives thus helping the patient narrow his or her focus and proceeding step by step, the physician may gain assurance that the patient has understood the choices and acted in his or her own best interests. (9)

2. Enlist the Help of a Health or Mental Health Professional: If helping the patient through a process of gradual information-gathering and decision-making is not working, the physician can suggest that physician and patient jointly consult a mental health professional or a health professional who is familiar with the patient's history and has a better understanding of the obstacles to decision-making. Or the physician could suggest a specialist who can help determine why the patient is having difficulty and whether he or she has the capacity to give informed consent.

3. Enlist the Help of Family or Close Friends: Another approach is for the physician to suggest that the patient call in a family member or close friend who can help organize the information and sort through the alternatives. Asking the patient who would be helpful could gain endorsement of this approach.

4. Consult a Family Member or Friend: If the patient cannot grasp the information or come to a decision, the physician might ask the patient to allow him to consult a family member or close friend. If the patient consents, the physician should lay out the concerns to the family member or friend. It may be that the patient already has planned for the possibility of incapacity and has signed a durable power of attorney or health care proxy.

Guardianship: A guardian is a person appointed by a court to manage some or all aspects of another person's life. Anyone seeking the appointment of a guardian must show proof in the courts that the individual is disabled in some way by disease, illness, or senility. The disability has to prevents that individual from performing the tasks of everyday life which are necessary to manage one or more areas of his or her life. Each state handles guardianship proceedings differently, but some principles apply across the board. First, Guardianship is not an all-or-nothing state. Second, the courts generally require that the person seeking appointment of a guardian prove the individual's incapacity in a variety of tasks or areas. Third, the courts can apply different standards to different life tasks as in, managing money, managing a household, making health care decisions, entering contracts. With those considerations, a person can be found incompetent to make contracts and manage money but competent to make his or her own health care decisions or vice versa and the guardianship will be limited accordingly by a judge. Guardianship limits the older adult's autonomy and is an expensive process and it should be considered only as a last resort. (1,8)

Voluntary versus Coercion: A growing number of patients in addiction treatment have been forced into such treatment by their families, employers, or the criminal justice system. A spouse may give his or her partner an ultimatum to enter treatment or face consequences or an employer may require treatment as a condition of retaining a job. In the case of the courts, a criminal justice agency may require a defendant to enter treatment as a condition of probation, parole, or suspension of their charges. Critics of the coerced treatment format contend that it is unethical because it violates the principle of autonomy, and some critics say they are particularly concerned when it is the criminal justice system mandating treatment holding out the possibility that a criminal defendant will avoid incarceration. Some critics charge that the power imbalance in such circumstances is especially annihilative to autonomy in most cases. The proponents of coerced treatment counter this with the fact that although such coercion unquestionably impinges on a patient's autonomy, it does not violate it altogether even in the criminal context. The patient may not want to enter treatment, but always has a choice and retains the right to refuse. He or she may not like the consequences as in losing a spouse, losing a job, or being incarcerated on criminal charges, but still retains the autonomy to make the decision for themselves. Proponents for coercion also point out that patients who stay in treatment for at least ninety days have better outcomes than those who leave earlier and speaks to the extent that coercion does in fact raises retention rates where it works to improve the odds that the patient will have a positive outcome. (3,4,13) The possible ethical situation are endless. With the upcoming developments in addiction science and treatment models, there will inevitably be additional ethical issues. The authors in our text point out that concerns about the ethical implications of scientific developments should be a given greater urgency by the stigma and discrimination still attached to addiction as well as the persons who suffer from this medical disorder. Areas in which ethical concerns are likely to develop which may include new approaches to the prevention and treatment of drug addiction like in; vaccinations, the use of genetic data to predict the effects of drugs on individuals and specific vulnerabilities to addiction; the use of neural imaging to identify past, present and potential addiction problems; and the consequences of non-medical use of prescription medications for purposes such as cognitive enhancement (1,8,9 PoA) Special attention will continue to be given to confidentiality and privacy in addicted individuals because questions may continue to be raised about the capacity for informed consent on the part of an addicted patient and their true “voluntariness” of their participation in therapeutic interventions.

As presented, certain ethical principles are central to medical practice especially in the treatment of patients with substance use disorders. Foremost among these situations is the physician's or addiction professionals' obligation to put the patient's interests first. This position is closely monitored and followed in the continuum by respecting the patient's autonomy, which includes the patient's right to make his or her own medical decisions as well as the right to be left alone. A similar foundation should be grounded in the fact that the patient's privacy and confidentiality is paramount to the therapeutic environment. Notwithstanding, the health professional also has a fiduciary duty to protect society when the patient's condition poses a threat to themselves or others.

References: Chapter 107, Principles of Addiction Medicine

1. Capron A. Ethical and human rights issues in research on mental disorders that may affect decision-making capacity. N Engl J Med 1999;340: 1430–1434.

2. Uhl G. Are over-simplified views of addiction neuroscience providing too simplified ethical considerations? Addiction 2003; 98:871–874.

3. Morse S. Medicine and morals, craving and compulsion. Substance Use Misuse 2004; 39:437–460.

4. Husak D. The moral relevance of addiction. Substance Use Misuse 2004;39: 399–436.

5. Ashcroft R, Campbell AV, Capps B. Ethical aspects of developments in neuroscience and drug addiction. Foresight brain science, Addiction and Drugs Project. London, England: Ministry of Health, 2007.

6. Winters KC, ed. Screening and assessment for adolescent substance use (Treatment Improvement Protocol 31). Rockville, MD: Center for Substance Abuse Treatment, 1999.

7. Blow FC. Screening and Assessment for adolescent substance use (Treatment Improvement Protocol 26). Rockville, MD: Center for Substance Abuse Treatment.

8. Winters KC, ed. Treatment of adolescent substance use (Treatment Improvement Protocol 32). Rockville, MD: Center for Substance Abuse Treatment, 1999.

9. Wright A, Weinman J, Marteau T. The impact of learning of a genetic predisposition to nicotine dependence: an analogue study. Tobacco Control 2003; 12:227–230. 10. Murray T. Ethical issues in immunotherapies and depot medications for substance abuse. In: National Research Council and the Institute of Medicine of the National Academies. New treatments for addiction: behavioral, ethical, legal, and social questions. Washington, DC: National Academies Press, 2004:188–212.

11. Hall W, Carter L. Ethical issues in using a cocaine vaccine to treat and prevent cocaine abuse and dependence. J Med Ethics 2004; 30:337–340.

12. Farah M. Emerging ethical issues in neuroscience. Nat Neuroscience 2002;5: 1123–1129.

13. Ridgely M, Iguchi M, Chiesa J. The use of immunotherapies and sustained-release formulations in the treatment of drug addiction: will current law support coercion? In: National Research Council and the Institute of Medicine of the National Academies. New treatments for addiction: behavioral, ethical, legal, and social questions. Washington, DC: National Academies Press, 2004:173–187.


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