November 21, 2016 Susanna Aiga
Improving the Screening Process for Addiction
Addiction is a difficult topic to discuss. It is one of those possibilities that the average person, as a friend or a family member, would prefer to deny rather than confront, even in the face of overwhelming evidence. Seeing as the average person will typically be untrained, he/she has some leeway as to their inability to recognize an addict, but a professional has a responsibility to properly screen and assess patients to test for addiction. Because this is such a complicated issue, diagnosis is no easy task, and a simple Google search will provide you with multiple articles arguing how clinicians have failed to recognize and address this sector of the population. If this is as prevalent of a problem as it would appear on a typical search engine, then the assessment process must be somehow flawed. So what is so wrong with the screening process for addiction that it is so often cited as being largely misdiagnosed or even ignored?
First, it is important to understand how addiction is screened. According to the National Center for Biotechnology Information (NCBI), a clinician would typically assess their patient in a structured or scripted interview, basing the diagnosis off of their responses to a set of specific questions. Several instruments that are widely used are the Addiction Severity Index, Composite International Diagnostic Interview, and the Structured Clinical Interview for DSM-IV, among many others. The assessments themselves are all highly reliable and valid, and have been designed to be as objective and comprehensive as possible. However, these assessments all differ in their specific clinical targets, so choosing the right instrument for each patient is important. This in itself poses a problem, as the choice becomes a subjective one, based on the judgement of the provider.
Another complication that often arises when a clinician is in the process of analyzing their patients’ symptoms is that the symptoms of addiction are usually similar to other diagnoses. For instance, according to the American Psychological Association (APA), a patient with anxiety, low energy, and self esteem will more likely be diagnosed with a psychological disorder than with some sort of addiction because many common mental health symptoms are similar to those that addicts also experience. This is most common in a mental health setting, which may be a part of the problem; specialized facilities are more equipped to handle these cases, but mental health professionals should at least consider the possibility of addiction in their patients and be able to recognize which symptoms could be the consequence of something other than a mental health disorder.
Misdiagnosis also occurs due to reliance on stereotypes or assumptions. According to the APA, because more men than women are reported to have an alcohol use problem, providers are less likely to discern women as such addicts. Also, the behavioral effects in women are not always the same as those more typically seen in men (e.g. DUIs and arrests). The insured, employed, and Caucasian patients are also less likely to be identified as having an alcohol abuse problem.
Although the assessments themselves are well designed to diagnose addiction, these misdiagnoses reveal that the primary judgement calls made by clinicians are far too subjective to make much progress in diagnosing addicts in multiple situations. It would be beneficial to remove as much potential for a misdiagnosis as possible by utilizing even more objective assessments such as brain scans and genetic testing for addiction in addition to the structured/scripted interviews.
Since addiction has been proven to be a chronic brain disease, brain imaging has been used to reveal causes and effects of drug abuse as well as abusers’ experiences and behaviors according to the NCBI. Different imaging techniques can be used in conjunction to observe how addiction manifests in the brain. Because there is also a genetic component to susceptibility to addiction, genetic testing can also be used for diagnoses. Currently, these tests still need to be further developed in regard to application to addiction assessment, but in the near future, these resources should be utilized for this purpose in addition to the other clinical purposes they serve. Ignoring and misdiagnosing the problem of addiction is not going to make it go away, and more objective testing would only benefit those who need it most as well as supporting friends and families when confronted with such a difficult situation.
References:
Image Source: http://house.wikia.com/wiki/Twenty_Vicodin
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2797097/
https://www.apa.org/education/ce/addiction-screening.pdf
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2851068/