Definition and Scope of Addiction Psychiatry
Addiction psychiatry is a subspecialty in the field of psychiatry that deals with individuals with dependencies, for example, to alcohol, drugs, nicotine, and other addictive substances and also to activities like gambling and sexual behavior. This specialty mainly involves the treatment of addicts by using medications and psychological therapeutic approaches. As medical doctors, addiction psychiatrists prescribe the medicines as part of overall therapy. After graduation from medical school, psychiatrists-in-training enter a one-year medical internship, followed by three years of psychiatry residency focusing on all aspects of psychiatry in inpatient, outpatient, and emergency settings. That training includes addiction, but addiction psychiatrists-in-training then undertake a fellowship program in which they concentrate on the diagnosis and treatment of addiction issues. Some addiction psychiatrists are also psychopharmacologists.
Addiction psychiatrists are experts in diagnosing the causes of a person’s addiction. They can identify both the addictive behavior, like substance abuse, and also coexisting psychiatric problems in the addicted person. Addiction, specifically substance use, and other psychiatric disorders have reciprocal, cumulative, and synergistic effects. Hence, addiction psychiatrists are in high demand due to their training in the diagnosis and treatment of both types of conditions.
Over the past 50 years, there has been a dramatic increase in scientific, fact-based knowledge in the field of substance abuse and in the understanding of factors contributing to addictions to certain substances. This rapidly growing knowledge base has been pivotal in developing therapeutic plans for patients with certain substance dependencies. This has been a collective effort by psychopharmacological and neurobiological researchers in combination with psychologic and psychiatric clinicians. The ultimate focus of these therapeutic strategies is to eliminate factors such as depression, anxiety, attentional issues, and other related psychological problems. These factors eventually contribute to a tendency to engage in addictive behaviors.
Addiction medicine is different from addiction psychiatry. The specialty of addiction medicine is rooted in alcoholism. Not always, but addiction medicine physicians are often from the medical subspecialty of gastroenterology; during training, they typically encounter patients with hepatic and other gastroenterological manifestations of addictions, such as liver failure, cirrhosis, esophageal varices, hepatitis, and even nutritional issues.
By contrast, addiction psychiatry has different roots. This subspecialty began in the mid-1980s when an influential group of psychiatrists formed an organization of addiction specialists. They believed they could treat addiction patients more effectively than addiction physicians, particularly patients in recovery. In 1991, this group of psychiatrists successfully convinced the American Board of Medical Specialties (ABMS) that they possess a body of specialized knowledge on addiction, and they gained recognition from the American Board of Psychiatry and Neurology. There is now subspecialty training and certification by the American Board of Psychiatry in Addiction Psychiatry. This recognition gives the field of addiction psychiatry substantial influence over the treatment of addiction. Interestingly, there is no parallel addiction medicine subcertification within the ABMS system either from the American Board of Internal Medicine or elsewhere.
Addiction Psychiatry-Related Medical Specialties
Addiction psychiatry interacts with the following specialties/fields
Addiction medicine
Psychopharmacology
Psychology
Pharmacology
Toxicology
Laboratory Medicine
Forensic psychiatry
Neurology
Hematology
Neurophysiology
Endocrinology
Psychiatry
Emergency Psychiatry
Gastroenterology
Internal Medicine
Medico-Legal Cases in Addiction Psychiatry
Involuntary Commitment:
Statutes exist in federal and state law that govern the involuntary commitment of a patient. Usually, patients may be civilly committed when they have a psychiatric condition or diagnosis that makes them dangerous to others or to themselves. An addictive disorder might rise to the level of requiring inpatient commitment. Most states allow commitment if an addictive disorder can cause danger to self or others.
Civil Competencies:
In many ways, an addiction can affect one’s competency. Impairment of judgment or cognitive function can be due to drug abuse, withdrawal, intoxication and even co-occurring psychiatric diagnosis. Addiction psychiatrists are needed as expert witnesses to determine whether a person is or was competent. Examples include competency to execute documents such as contracts, and wills.
Disability:
The meaning of the term disability varies across the context. In such cases, two things come under focus. First is the eligibility for disability benefits and second is the eligibility for protection under disability law, for example, in the workplace. Addiction psychiatrist experts can parse out the intricacies of the diagnostic criteria, and the requirements for the workplace accommodations and public accommodations.
Employment:
Sometimes, litigation centers on aspects of a person’s ability to function at work. It may be a blue-collar worker alleged to have caused injury due to intoxication or other addiction. That includes DUI. It may be a professional, like a doctor, lawyer, architect, or accountant alleged to be practicing under the influence. Addiction psychiatry experts are needed to address the myriad issues that arise in these cases.
Professional Licensure:
Professional licenses, most typically to practice law or medicine, may be impacted by addiction issues. Whether it is practicing while impaired, stealing trust account monies to pay for drugs or gambling, missing a statute of limitations an addiction psychiatrist expert is the gold standard for assessing and opining about these issues.
Detoxification:
Although addiction medicine experts and addiction psychiatry experts treat addicts, they are not the same. Medical-legal issues involving detoxification typically require addiction psychiatry experts with detoxification experience.
Duty to protect or warn:
Suicidal and homicidal ideation needs to be assessed by all psychiatrists, but addiction adds a complicating overlay. The existence of an addiction diagnosis complicates a psychiatrist’s already complicated legal and medical duties to warn others at risk from the patient’s actions while maintaining patient confidentiality under HIPAA. Addiction psychiatrists should have knowledge about their responsibilities under the law in the jurisdiction in which they practice.
Personal Injury:
Even an apparently mundane personal injury case can require an addiction psychiatry expert witness. Injured plaintiffs, whether previously addicted or not, are susceptible to becoming addicted to pain medication, typically opioids. Attorneys pursuing such cases may require an addiction psychiatry expert to establish a causal relation between the underlying negligent act and the resultant addiction. An addiction psychiatrist is generally the best choice.
Child Custody:
If one or both parents are suffering from substance addiction, child welfare will be affected. Psychiatric evaluation of the alleged parent(s) by a psychiatrist, particularly an addiction psychiatry expert, is required to assess the degree to which the child(ren) will be affected, which is required for a court to act in their best interest.
Addiction Psychiatry Malpractice:
Just as with physicians treating patients for medical diagnoses, an addiction psychiatrist may deviate from standard of care in their diagnosis or treatment. Addiction psychiatry experts are needed in almost every state to evaluate the care rendered by another addiction psychiatrist.
Non-Addiction Psychiatry Malpractice:
In the midst of an unprecedented opioid crisis, physicians in diverse fields, e.g., orthopaedic surgery, pain medicine, family medicine, neurosurgery, physiatry, are alleged to have caused patients to become addicted to opioids. Although such malpractice cases require a medical specialist in the underlying field to determine standard of care and deviation in overprescribing, an addiction psychiatry expert witness is generally needed to establish the connection between the overprescribing and the eventual addiction.
Criminal Matters:
Addiction psychiatry expert witnesses are also needed in criminal cases to evaluate competency to stand trial, sanity and diminished capacity, as well as mens rea in the areas of fetus injury, child abuse, domestic violence, alcohol- and drug-related driving offenses (like DUI), and addiction treatment in jails and prisons. Frequently, suicide and homicide may be alleged to have been caused by a person’s addiction diagnosis or that the addiction diagnosis should be a factor mitigating the mens rea and lead to sentencing reduction. Addiction psychiatry experts are some of the best able practitioners to address these issues.