Treatment of Substance Use Disorders
The recommended treatment for individuals with substance use disorder includes a combination of pharmacotherapy and behavioral interventions tailored to the specific substance of abuse, with medication-assisted treatment being the gold standard for opioid use disorder and alcohol use disorder. 1
Initial Assessment and Screening
- Use validated screening tools like the Drug Abuse Screening Test-10 (DAST-10) to identify substance misuse and categorize severity 1
- Assess for comorbid psychiatric conditions, which are common in patients with SUDs 1
- Screen for specific substance(s) of abuse to determine appropriate treatment approach 1
Substance-Specific Treatment Approaches
Opioid Use Disorder
- First-line treatment: Medication-assisted treatment with opioid agonist therapy
- Must be provided through certified Opioid Treatment Programs (OTPs) for outpatient maintenance 2
Alcohol Use Disorder
- Pharmacotherapy options:
- Benzodiazepines as front-line medication for alcohol withdrawal management 3
- Oral thiamine supplementation during withdrawal management 3
Stimulant Use Disorders (cocaine, methamphetamine)
- No recommended pharmacologic treatment for stimulant dependence in primary care settings 3
- Behavioral therapies have demonstrated effectiveness 3, 1
- Brief interventions (5-30 minutes) incorporating individualized feedback 3, 1
Cannabis Use Disorder
- Brief intervention with motivational interviewing techniques 3, 1
- Short duration psychosocial support for treatment 3
Benzodiazepine Dependence
- Planned withdrawal using gradually tapering doses over 8-12 weeks 3, 1
- Convert to long-acting benzodiazepines rather than short-acting ones 3, 1
Behavioral Interventions
- Psychosocial support should be routinely offered to all patients with SUDs 3, 1
- Cognitive Behavioral Therapy (CBT) is effective for targeting cognitive, affective, and environmental risks 1
- Contingency management is particularly effective for stimulant use disorders 1
- Mutual help groups (e.g., Alcoholics Anonymous, Narcotics Anonymous) provide ongoing support 3
- Family involvement in treatment when appropriate 3, 1
Treatment Settings and Referral Criteria
Outpatient Treatment
- Appropriate for patients with relatively stable and safe living environments 3
- Services include group and individual counseling and pharmacotherapy 3
Residential Treatment
- Indicated for patients needing a stable and safe living environment 3, 1
- Therapeutic community model for more intensive support 3
Indications for Specialist Referral
- Failure to respond to brief interventions 3, 1
- Need for medically supervised withdrawal 3
- Comorbid chronic pain requiring opioid therapy 3
- Co-occurring alcohol or benzodiazepine abuse 3
- Uncontrolled or unstable psychiatric disorder 3, 1
Addressing Barriers and Special Considerations
- Undertreatment is a significant concern, with only a small percentage of individuals receiving professional treatment 1
- Integration of SUD treatment with primary care and mental health services improves outcomes 1
- Address social determinants such as housing and employment 1
- Implement harm reduction strategies including naloxone distribution and safe injection education 1
- Telehealth options can improve access to treatment 1
Treatment Outcomes and Follow-up
- Longer time in treatment and compliance with treatment plans are associated with lower risk of substance use 4
- Addiction should be viewed as a chronic disorder with remissions and relapses like any other chronic disease 5
- Treatment intensity should be adjusted according to the severity of the disorder 6
- Continuous monitoring and follow-up are essential components of care 1
By implementing these evidence-based approaches and considering the specific needs of each patient with substance use disorder, healthcare providers can significantly improve outcomes and quality of life for these individuals.