Medical Treatment for Substance Use Disorder (SUD)
The most effective treatment for substance use disorder (SUD) involves an integrated approach combining pharmacotherapy with evidence-based behavioral therapies, tailored to the specific substance used and individual needs. 1
Comprehensive Treatment Approach
Assessment and Screening
- All individuals at risk for or with HIV should receive screening, diagnosis, and treatment for SUDs 1
- Early identification of substance use problems is critical, using standardized screening tools in healthcare settings 1
- Screening, Brief Intervention, and Referral to Treatment (SBIRT) should be implemented in various settings including primary care 1
Pharmacotherapy Options
- FDA-approved medications are available for specific SUDs: 1
- Opioid use disorder: methadone, buprenorphine, naltrexone, and buprenorphine/naloxone combinations 1, 2
- Alcohol use disorder: naltrexone and acamprosate 1
- Tobacco use disorder: nicotine replacement therapy, bupropion, and varenicline 1
- No FDA-approved medications currently exist for cocaine, stimulant, or cannabis use disorders 1, 3
Behavioral Therapies
- Evidence-based behavioral approaches should be provided for all SUDs, including: 1
- Cognitive-behavioral therapy (CBT)
- Contingency management
- Motivational enhancement therapy
- Relapse prevention strategies 1
- Combined pharmacotherapy with CBT shows greater efficacy than usual care with pharmacotherapy 1
- CBT performs similarly to other evidence-based therapies when combined with pharmacotherapy 1
Substance-Specific Approaches
Opioid Use Disorder
- Medication-assisted treatment (MAT) is the gold standard, combining medications with behavioral therapies 1
- Methadone must be provided through certified Opioid Treatment Programs (OTPs) 2
- Buprenorphine can be prescribed in office-based settings by qualified providers 1
- Naloxone should be provided for overdose prevention as part of harm reduction 1
Alcohol Use Disorder
- First-line pharmacotherapy includes naltrexone and acamprosate 1
- Medication treatment of alcohol use disorder improves antiretroviral therapy adherence and viral suppression in people with HIV 1
Stimulant Use Disorders
- Primarily treated with behavioral therapies as no FDA-approved medications exist 1
- Contingency management shows the strongest evidence for effectiveness 1
- Clinical guidelines recommend pharmacotherapies in certain situations despite lack of FDA approval 1
Special Considerations
Co-occurring Mental Health Disorders
- Integrated treatment for co-occurring mental health disorders and SUDs is essential 1, 4
- Clozapine shows efficacy for individuals with schizophrenia and SUD 4
- Naltrexone is effective for individuals with severe mental illness and comorbid alcohol use disorders 4
Harm Reduction
- Harm reduction services should be offered to all persons who report drug use, including: 1
- Naloxone distribution
- Safe injection education
- Fentanyl and xylazine drug test strips
- Referral to syringe service programs 1
Treatment Delivery Considerations
- SUD treatment should be integrated into HIV prevention and treatment services 1
- Peer support, telehealth, extended hours, mobile clinics, and walk-in options improve accessibility 1
- Treatment should follow a chronic care model with intensity adjusted to disorder severity 5
Emerging Approaches
- Neuromodulation techniques (transcranial magnetic stimulation) show promise as adjunctive treatments 1
- Novel pharmacological targets being investigated include serotonin 2A receptors, glucagon-like peptide 1 receptors, and the orexin/hypocretin system 3
- Digital interventions for prevention, early intervention, and treatment are expanding access options 1
Common Pitfalls to Avoid
- Withholding SUD medications due to concerns about drug interactions with HIV or HCV treatments (most have few clinically significant interactions) 1
- Focusing solely on abstinence rather than harm reduction approaches 1
- Failing to address stigma, which remains a significant barrier to treatment access 5
- Neglecting continuing care services, which are essential for long-term recovery 1