What is the best course of treatment for someone exhibiting symptoms of drug abuse?

Treatment Approach for Drug Abuse

The best course of treatment for someone exhibiting symptoms of drug abuse is a combined approach of pharmacotherapy and behavioral therapy, which has been shown to yield better outcomes for morbidity, mortality, and quality of life than either modality alone. 1

Assessment and Diagnosis

1. Screening and Stratification:

   • Use validated screening tools like the Drug Abuse Screening Test-10 (DAST-10) to identify substance misuse 2
   • Stratify substance use into categories: hazardous use, substance abuse, or substance dependence 2
   • Assess for comorbid psychiatric conditions, which are common in patients with substance use disorders 2

2. Substance-Specific Assessment:

   • Identify the specific substance(s) being used
   • Evaluate the severity and pattern of use
   • Screen for intimate partner violence, which occurs at rates exceeding 50% in some patients with drug use disorders 2

Treatment Algorithm

Step 1: Brief Intervention for Hazardous Use or Substance Abuse

• For cannabis and psychostimulant users, provide a single session of 5-30 minutes incorporating individualized feedback and advice 2
• Use motivational interviewing techniques, which have been shown to decrease the quantity and frequency of drug use 2
• Focus on:
  • Discussing the role and impact of substance use
  • Eliciting diagnostic criteria
  • Providing clear advice about reducing or stopping consumption 2

Step 2: Pharmacotherapy Based on Substance Type

For Opioid Use Disorder:

• Opioid agonist therapies (methadone and buprenorphine) are the most effective pharmacotherapies 1
• Methadone must be dispensed only by certified opioid treatment programs 3
• Naltrexone can be helpful in maintaining abstinence, particularly in motivated populations 2

For Alcohol Use Disorder:

• Offer acamprosate, disulfiram, or naltrexone to reduce relapse 2
• Select medication based on patient preferences, motivation, and availability 2

For Stimulant Use Disorder:

• No specific FDA-approved medications are currently recommended 2
• Dexamphetamine should not be offered for treatment 2
• Focus on behavioral interventions, particularly contingency management 1

For Benzodiazepine Dependence:

• Implement planned withdrawal using gradually tapering doses over 8-12 weeks 2
• Convert to long-acting benzodiazepines rather than short-acting ones 2

Step 3: Behavioral Therapy

• Cognitive Behavioral Therapy (CBT) is effective for targeting cognitive, affective, and environmental risks 1
• Contingency management is particularly effective for stimulant use disorders 1
• Psychosocial support should be routinely offered, especially for alcohol dependence 2
• Consider involving family members in treatment where appropriate 2

Step 4: Referral to Specialized Treatment When Needed

Indications for referral include:

• Failure to respond to brief interventions 2
• Need for medically supervised withdrawal ("detoxification") 2
• Comorbid chronic pain requiring opioid therapy 2
• Co-occurring alcohol or benzodiazepine abuse 2
• Uncontrolled or unstable psychiatric disorder 2

Referral options:

• Outpatient treatment for patients with stable living environments 2
• Residential treatment for patients needing a stable and safe living environment 2
• Mutual help meetings (e.g., Narcotics Anonymous) for ongoing support 2

Special Considerations

Managing Withdrawal

• Withdrawal from cannabis, cocaine, or amphetamines is best undertaken in a supportive environment 2
• Symptomatic medication may be used for relief of symptoms like agitation and sleep disturbance 2
• Monitor for depression or psychosis during withdrawal, which can occur less commonly 2

Addressing Pain in Patients on Opioid Agonist Therapy

• Continue the usual dose of opioid agonist therapy 2
• Use conventional analgesics, including opioids, to aggressively treat painful conditions 2
• Higher opioid analgesic doses at shorter intervals may be necessary due to cross-tolerance 2
• Avoid using mixed agonist and antagonist opioids as they may precipitate withdrawal 2

Harm Reduction

• Facilitate provision of sterile injection equipment for injecting drug users 2
• Educate patients about safe injection practices and proper disposal of syringes 2
• Recommend vaccination against hepatitis A and B 2

Common Pitfalls and How to Avoid Them

1. Undertreatment of withdrawal symptoms

   • Inadequate withdrawal management can lead to patients leaving treatment against medical advice 4
   • Ensure aggressive symptom management, particularly for pain and cravings

2. Stigmatization by healthcare providers

   • Stigma can cause patients to leave treatment prematurely 4
   • Approach patients in a non-judgmental manner and reassure them that their addiction history will not prevent adequate care 2

3. Failure to address comorbid conditions

   • Mental health disorders are common in patients with substance use disorders 2
   • Screen for and treat comorbid psychiatric conditions concurrently 1

4. Overlooking social determinants

   • Address social factors such as housing and employment 1
   • Screen for intimate partner violence 2

By following this comprehensive approach that combines pharmacotherapy with behavioral interventions and addresses comorbidities and social factors, healthcare providers can effectively treat patients exhibiting symptoms of drug abuse and improve their long-term outcomes.