Introduction to the Special Issue on Substance Use Disorders ...

? 2020 American Psychological Association ISSN: 0735-7028

Professional Psychology: Research and Practice

2020, Vol. 51, No. 1, 1? 4

EDITORIAL

Introduction to the Special Issue on Substance Use Disorders and Addictions

Charles H. Smith

Substance Abuse and Mental Health Services Administration, Rockville, Maryland

Kathi A. Borden

Antioch University New England

This document is copyrighted by the American Psychological Association or one of its allied publishers. Content may be shared at no cost, but any requests to reuse this content in part or whole must go through the American Psychological Association.

Without question, substance use disorders and addiction are major public health issues facing individuals, families, and communities across the United States. The World Health Organization (2018) identified mental and substance use disorders as the leading cause of disability worldwide. According to the National Survey on Drug Use and Health (NSDUH; Substance Abuse and Mental Health Services Administration [SAMHSA], 2019), an estimated 20.3 million Americans struggle with a drug or alcohol problem. Taking a closer look at the NSDUH data, about three out of five people, ages 12 or older (164.8 million people), reported using alcohol and other psychoactive substances (e.g., marijuana, cocaine, heroin) in the past month; 14.8 million people were diagnosed with an alcohol use disorder; and 8.1 million people were diagnosed with a psychoactive substance use disorder (SAMHSA, 2019). Understandably, with the high rates of overdose deaths, national attention is focused on prescription drug use and opioid use disorders (2 million with an opioid use disorder, of which approximately 1.6 million have a prescription pain reliever use disorder and 0.4 million people have a heroin use disorder); however, the most common drug use disorder is marijuana use disorder (4.4 million).

CHARLES H. SMITH received his MS in rehabilitation counseling from New York University and his PhD in counseling psychology from the University of Denver. He is currently the regional administrator of the Substance Abuse and Mental Health Services Administration in the U.S. Department of Health and Human Services in Denver, Colorado. His areas of professional interest include public policy, addiction treatment and recovery supports, suicide prevention, criminal justice, and workforce development.

KATHI A. BORDEN received her PhD from the University of Illinois at Urbana?Champaign. She is currently a professor in the Department of Clinical Psychology at Antioch University New England. Her research and professional interests include child, adolescent, and family issues; social justice, public policy, and legislative advocacy; sexual orientation and gender diversity; psychology in schools; integrated care; and psychology education and training.

CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to Charles H. Smith, Substance Abuse and Mental Health Services Administration, Region VIII, 1961 Stout Street, Room 11-134, Denver, CO 80294. E-mail: charles.smith@samhsa.

The sheer prevalence of substance use disorders is overshadowed by the fact that 95% of people do not see their substance use as problematic, and for those who do, only one out of nine people actually get the care they need (SAMHSA, 2019). This is unacceptable but a reality. Substance use disorders are coupled with enormous shame and many obstacles that prevent patients from accessing vital prevention, treatment, and recovery services. Real barriers include lack of financial resources (e.g., insurance); fear of shame and discrimination; lack of prioritized public health prevention and screening; lack of trained and qualified addictions practitioners; and persistent misunderstanding and stigma among individuals, communities, programs, and health care providers. Examples of this bias are pervasive. Our health care system, for example, continues to classify patient relapse of substance use as a treatment failure, whereas we would never classify an asthma attack or diabetic shock as a treatment failure. Interesting to note, symptom relapse rates of substance use disorders are equal to or lower than for diabetes, hypertension, and asthma (National Institute on Drug Abuse [NIDA], 2018).

These statistics tell only part of the story. Substance use disorders and addiction are serious, complex, chronic illnesses that impact individuals, families, and communities. When substance use disorders and addiction are unrecognized or untreated, the consequences can be long-term and life-shattering: unemployment, arrest and incarceration, homelessness, family separation, social isolation, development of comorbid chronic illnesses, disability, and death. The Deloitte Center for Government Insights compared the opioid epidemic in the United States to an environmental disaster where "it endangers not just one population, but an entire social ecosystem, a community of interconnected individuals and interests" (Bingham, Cooper, & Hough, 2016, p. 3). We need to approach all substance use disorders with this same mind-set and employ comprehensive research, treatment, and policy reforms, as we do with other chronic illnesses such as diabetes, HIV/AIDS, and cancer.

In 2016, the U.S. surgeon general released the first-ever "Facing Addiction in America: Surgeon General's Report on Alcohol, Drugs, and Health," which specifically called attention to the public health crisis of substance use disorders and addiction (U.S. Department of Health and Human Services, Office of the Surgeon General [HHS], 2016). The report named substance use disorders as a chronic illness; identified the adverse health consequences

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associated with substance misuse and addiction; and acknowledged the breadth of comprehensive evidence-based practices that prevent, treat, and support patients' recovery from substance use disorders and addiction. Overall, the report elevated substance use disorders as clearly preventable and treatable chronic illnesses and called upon communities, health care providers, and policymakers to collectively take action and address this growing epidemic (HHS, 2016).

We know community prevention programs work (e.g., education, harm reduction, and community coalitions); we know clinical treatment is effective (e.g., screening brief intervention and referral to treatment, motivational interviewing, motivational enhancement therapy, cognitive? behavioral therapy, contingency management, and medication assisted treatment); and we know people with substance use disorders and addiction can and do recover (HHS, 2016). Although the research literature is robust, we also know that more research and clinical practice implementation are needed to address this public health problem. Psychologists have large and compulsory roles to play, such as understanding risk and protective factors, developing and implementing effective treatment programs, leading multidisciplinary treatment teams, conducting epidemiological research and program evaluations, and developing health system policy and legislation. Moreover, we have an obligation to educate, train, and supervise all levels of our profession, in core, not elective, competencies of substance use and addiction prevention, treatment, and recovery. Otherwise, we perpetuate the view that substance use disorders and addiction are not serious, life-threatening chronic illnesses and that individuals, families, and communities are not deserving of the same level of commitment, expertise, and care as are those affected by other chronic health conditions.

To emphasize this commitment, the American Psychological Association journals Professional Psychology: Research and Practice (PPRP) and Training and Education in Professional Psychology (TEPP) are releasing coinciding special issues on substance use disorders and addiction. The articles featured in TEPP are provocative and forward-thinking and, most important, call attention to the needs of our education and training systems to (a) elevate foundational research and clinical training in substance use disorder and addiction, (b) ensure students at all levels of education and clinical training and scholarship attain core competencies in substance use disorders and addiction, (c) emphasize the translation and implementation of addiction science in clinical care training settings, and (d) advance development of brief intervention training models in substance use disorder and addictions. Collectively, the TEPP special edition articles make the case that psychology must amplify its commitment to seeing that no psychology student graduates without basic knowledge, skills, and attitudes to recognize and work with patients and their families suffering from substance use disorders and addiction.

The articles in this special issue of PPRP feature a diverse and equally important collection of psychology's professional contributions, both nationally and internationally, in substance use disorder and addiction research and clinical practice. This special issue leads off with articles that highlight the national opioid epidemic. We are pleased to present Arthur Evans's (2020) congressional testimony in June 2019 on the opioid crisis in which he doubles-down on the need for a comprehensive, whole-person public health response grounded in evidence-based prevention,

treatment, and recovery science. One example of an evidencebased, community prevention program is the needle exchange program, also known as syringe services program. Needle exchange programs save lives, combat the nation's opioid crisis, reduce the transmission of HIV and hepatitis C, and support individuals in accessing vital substance use disorder treatment services (Dan, 2019); however, as described by Spaulding and Canady (2020), they are not widely implemented because of limited funding and strong community push-back. Spaulding and Canady surveyed participants of needle exchange programs and uncovered structural barriers (e.g., insufficient locations, restrictive state laws and municipal ordinances, and funding restrictions) and social barriers (e.g., lack of support from law enforcement and community or provider stigma) that reduce participants seeking community-level support. Of interest, Spaulding and Canady identify that individuals who inject drugs but do not participate in needle exchange programs are often labeled by health care providers as disinterested in using clean needles or accessing substance use disorder treatment. Although the authors describe several solutions to counter these real and perceived barriers, it is clear that needle exchange programs need local champions to challenge the community bias toward individuals who inject drugs. Here is an opportunity for psychologists to be community champions, promoting health and well-being, educating stakeholders, and reducing barriers to care.

Despite the deep roots of research and public policy driving current substance use disorder screening, brief intervention, and treatment interventions (HHS, 2016; NIDA, 2018), there remain notable opportunities for therapeutic innovation, and gaps in our understanding of the immediate and long-term effects of interventions on vulnerable populations (e.g., women, adolescents and young adults, and individuals from different cultures), settings (e.g., criminal and juvenile justice), and types of substance use disorders or addictions (e.g., alcohol, other psychoactive substances, tobacco, and gambling). DeVargas and Stormshak (2020) examine the therapeutic effectiveness of combining the Young Adult Family Check-Up instrument with motivational interviewing (MI) in positively mediating substance use and high-risk sexual behaviors among young adults. Likewise, Cigrang and colleagues (2020) discuss how the use of MI can improve the social outcomes of women with histories of substance use disorders and sex trafficking who are being released from jail. Although both articles examine the use of MI with unique, special populations, what's intriguing is that the authors are unified in underscoring the importance of clinicians' being well-trained and proficient in MI. DeVargas and Stormshak describe how clinicians who are more comfortable and skillful with and adherent to the principles of MI achieve greater reductions in marijuana use, alcohol use, and high-risk sexual behavior among young adults. Similarly, Cigrang and colleagues emphasize MI as a conversation, an exploratory partnership between the therapist and client that centers on the client's positive health behaviors. In this study, Cigrang and colleagues used MI as a method for helping women with substance use disorders and sex-trafficking histories construct positive prerelease-from-jail plans such as accessing health care; continuing substance use disorder treatment; planning for housing, employment, and family reunification; and integrating MI in the prerelease-from-jail process. Notably, their participants demonstrated significantly lower rates of rearrest. Additionally, the au-

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thors highlight that clinical proficiency in substance use disorder and addictions interventions, such as MI, is achieved not simply by taking an academic class or continuing education course; rather, mastery of MI skills may require ongoing practice and supervision, without which patient outcomes are variable.

Articles in this special issue illuminate the relationships between culture and substance use disorder prevention and treatment and emphasize the importance of improving data on vulnerable subpopulations, implementing culturally relevant strategies to improve treatment access and outcomes, and increasing practitioner cultural awareness and sensitivity. Ahluwalia, Chand, and Suman (2020) introduce us to the substance use disorder treatment needs and therapeutic approaches available to women in India. The overall paucity of specialized treatment for women in India, and related research, is notable, but this article opens the door for therapeutic advancement. Through patient and caregiver interviews and thematic analysis, Ahluwalia et al. confirm the significance of cognitive? behavioral therapy, coping skills training, relapse prevention, emotional regulation, and parenting skills training for Indian women with substance use disorders. What stands out, though, is the important role of significant others for Indian women. Significant others assist women with engaging in substance use disorder treatment and, when needed, can mediate family and community resistance (Ahluwalia et al., 2020).

Similarly, King and her colleagues (2020) and Moreno, Nelson, and Perrin (2020) discuss the influence of culture, language, and religion on substance use behavior and treatment engagement. Among Lao refugees and immigrants and U.S. citizens of Lao decent, gambling is a common social event and is associated with high rates of tobacco use; however, gambling is not associated with alcohol or marijuana use (King et al., 2020). Likewise, Moreno and his colleagues make the case that among Latinx communities, substance use behavior is tied to religious identity, religious activity, and language proficiency, which can be culturally significant factors in substance use disorder treatment outcomes; they may vary across Latinx groups and should be identified and incorporated by practitioners. With the substance use disorder treatment needs of minority communities being disproportionately underserved (HHS, 2016), future work is needed to improve culturally informed data, treatment, and recovery systems and, as emphasized in these studies, significant improvements to the education and training of psychologists.

There is growing concern about the high rate of adolescent use of alcohol, marijuana, and prescription drugs (HHS, 2016), which is typically part of a larger spectrum of behavioral problems, including difficulties in school, social or relational conflicts, and mental illness. Parents and families are searching for help and our health care systems have been slow to respond. Given a societal shift supportive of addiction treatment, business and marketing models are changing and creating more treatment options for parents and families struggling to manage adolescent substance use. Helseth, Escobar, Clark, Spirito, and Becker (2020) surveyed parents of adolescents to identify the most effective ways of engaging adolescents and parents in treatment. Marketing our practice may not be a common skill among all psychologists, Helseth and her colleagues introduce the value of direct-toconsumer marketing (e.g., websites and brochures), partnering with other health care providers and systems that treat adolescents, and opening doors for parents to connect with other parents deal-

ing with adolescent substance use disorders and high-risk behaviors.

Marijuana is the most common psychoactive substance misused (SAMHSA, 2019). With the growing popularity of commercially available cannabis products as well as state policies supporting medical and recreational marijuana, it's not surprising that psychologists are fielding patients' questions about the use of cannabis products. Stuart-Mayer (2020) explains the ethical challenges, dilemmas, and decision points psychologists are forced to confront, often including their own beliefs about self-medication and marijuana or cannabis. Research on the health benefits and risks of cannabis is young, and Stuart-Mayer argues for psychologists to stay current with what we do know about cannabis, to inquire about use behavior of patients, to be sensitive to at-risk populations (e.g., adolescents, pregnant women, and older adults), and to openly communicate the known and unknown risks and benefits of cannabis or marijuana use with patients and families.

This special issue concludes with a case example of how psychologists can play a leading role in a comprehensive, communitylevel public health response to the opioid crisis. Rural counties of Utah have been particularly impacted by high rates of opioid addiction and overdose deaths. Yaugher, Bench, Meyers, and Voss (2020) describe how the Utah State University Health Extension: Advocacy, Research, and Teaching (HEART) initiative has mobilized community action teams, developed innovative prevention and recovery programs, and expanded access to treatment for individuals with opioid use disorders. The key ingredient here is community collaboration, tackling a public health challenge, like opioid addiction, with participatory leadership. The HEART initiative exemplifies how psychologists have core science, practitioner, and leadership skills that can improve the health and wellbeing of individuals, families, and communities.

We hope this two-journal effort will prompt future research, education, and psychological practice initiatives and advancement. Together the special issues of PPRP and TEPP accentuate our call to action: to advance our knowledge and skills to prevent, treat, and support the recovery of individuals, families, and communities struggling with the chronic illnesses of substance use disorders and addiction.

References

Ahluwalia, H., Chand, P. K., & Suman, L. N. (2020). Therapeutic focus for women with substance use disorders: Views of experts and consumers in a tertiary hospital in India. Professional Psychology: Research and Practice, 51, 34 ?50.

Bingham, K. M., Cooper, T., & Hough, L. M. (2016). Fighting the opioid crisis: An ecosystem approach to a wicked problem. Retrieved from

Cigrang, J. A., Fedynich, A. L., Nichting, E. M. S., Frederick, S. A. L., Schumm, J. A., & Auguste, C. B. (2020). Brief motivational interviewbased intervention for women in jail with history of drug addiction and sex-trading. Professional Psychology: Research and Practice, 51, 25? 33.

Dan, C. (2019). The important role of substance use disorder treatment providers in ending the HCV and HIV epidemics [Weblog]. Retrieved from

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This document is copyrighted by the American Psychological Association or one of its allied publishers. Content may be shared at no cost, but any requests to reuse this content in part or whole must go through the American Psychological Association.

DeVargas, E. C., & Stormshak, E. A. (2020). Motivational interviewing skills as predictors of change in emerging adult risk behavior. Professional Psychology: Research and Practice, 51, 16 ?24. 10.1037/pro0000270

Evans, A. C., Jr. (2020). Testimony on the inadequate federal approach to opioid treatment and the need to expand care. Professional Psychology: Research and Practice, 51, 5?9.

Helseth, S. A., Escobar, K. I., Clark, M. A., Spirito, A., & Becker, S. J. (2020). Marketing therapy to parents concerned about adolescent substance use: Association of adolescent problems and parent preferences for direct-to-consumer marketing. Professional Psychology: Research and Practice, 51, 68 ?76.

King, S. M., Doppler, G. L., Wollmuth, A. K., Wasberg, S. M., Prementine, C. G., & Walls, J. (2020). Gambling, substance use, and help-seeking attitudes in a community-based sample of Lao refugees, immigrants, and U.S.-born citizens. Professional Psychology: Research and Practice, 51, 51? 60.

Moreno, O., Nelson, T., & Perrin, P. B. (2020). Language proficiency, alcohol, and drug use among Latinx groups: A brief report of the role of religious engagement. Professional Psychology: Research and Practice, 51, 61? 67.

National Institute on Drug Abuse. (2018). Principles of drug addiction treatment: A research-based guide (3rd ed.). Rockville, MD: National Institute on Drug Abuse, National Institutes of Health, U.S. Department of Health and Human Services.

Spaulding, S. D., & Canady, B. E. (2020). Barriers to needle return in harm reduction programs. Professional Psychology: Research and Practice, 51, 10 ?15.

Stuart-Mayer, S. L. (2020). Working with clients who self-medicate using cannabis: Ethical and clinical considerations for psychologists. Professional Psychology: Research and Practice, 51, 77? 84. 10.1037/pro0000269

Substance Abuse and Mental Health Services Administration. (2019). Key substance use and mental health indicators in the United States: Results from the 2018 National Survey on Drug Use and Health (HHS Publication No. PEP19-5068, NSDUH Series H-54). Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration.

U.S. Department of Health and Human Services, Office of the Surgeon General. (2016). Facing addiction in America: Surgeon general's report on alcohol, drugs, and health. Washington, DC: Author.

World Health Organization. (2018). Global status report on alcohol and health. Geneva, Switzerland: Author.

Yaugher, A. C., Bench, S. W., Meyers, K. J., & Voss, M. (2020). How psychologists can impact the opioid epidemic. Professional Psychology: Research and Practice, 51, 85?93. pro0000287

Received December 23, 2019 Accepted December 23, 2019

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