How to treat a patient with substance abuse disorder and hyperphagia?

Treatment Approach for Substance Use Disorder with Hyperphagia

Treat the substance use disorder as the primary condition using motivational interviewing, pharmacotherapy when indicated, and referral to specialty treatment, while addressing the hyperphagia as a potentially related symptom that may improve with addiction recovery. 1

Initial Assessment and Engagement

Use motivational interviewing techniques rather than confrontation to engage this patient, as confrontational approaches decrease motivation for change and increase resistance. 1 Key principles include:

• Resist the "righting reflex" - avoid telling the patient what to do; instead help them generate their own arguments for change 1
• Elicit the patient's own motivations for change rather than imposing external reasons 1
• Use the "elicit-provide-elicit" technique when giving advice to assess readiness and reduce defensiveness 1
• Provide affirmations to counter the guilt and shame most substance-dependent patients experience 1

Determine Severity: Abuse vs. Dependence

Assess whether this is substance abuse or substance dependence, as this determines treatment intensity. 1

Substance abuse is characterized by consequences from use but the patient can still cut back if motivated. 1 For these patients:

• Advise abstinence as the goal 1
• If not ready for abstinence, harm reduction is appropriate (e.g., not driving while intoxicated) 1
• If the patient agrees to cut back but cannot, this indicates progression to dependence 1

Substance dependence is a chronic relapsing illness requiring longitudinal care including pharmacotherapy, specialty referral, mutual help meetings, and ongoing counseling. 1

Treatment Algorithm for Substance Dependence

Step 1: Pharmacotherapy Based on Substance Type

For opioid dependence:

• Buprenorphine/naloxone (Suboxone) is preferred for office-based treatment 1
• Longer-term maintenance treatment is indicated rather than brief tapers, which have high relapse rates 1
• Alternative: Naltrexone 50 mg daily (oral) or 380 mg monthly injection, though this works best in highly motivated populations like healthcare professionals 1, 2
• Ensure 7-10 days opioid-free before starting naltrexone to avoid precipitated withdrawal; patients switching from buprenorphine or methadone may need up to 2 weeks 2

For stimulant dependence (cocaine, methamphetamine):

• No pharmacotherapy is currently recommended for primary care settings 1
• Behavioral therapies are the mainstay of treatment 1

For alcohol dependence:

• Naltrexone 50 mg daily or acamprosate 1

Step 2: Mandatory Referrals

Refer to specialty addiction treatment for: 1

• Comorbid chronic pain requiring opioids
• Co-occurring alcohol or benzodiazepine abuse
• Uncontrolled psychiatric disorder
• Failed office-based treatment

Connect patient to mutual help meetings (Alcoholics Anonymous, Narcotics Anonymous) as these demonstrate considerable effectiveness in achieving abstinence and improving psychosocial functioning. 1, 3, 4

Step 3: Facilitate 12-Step Program Engagement

Actively facilitate meeting attendance rather than just recommending it, as this increases involvement and reduces substance use. 4

• Call the local AA/NA hotline to arrange a temporary contact who will take the patient to a meeting that same day 3
• Work through resistance patiently by reminding patients of their painful experiences with substance use 3
• Provide the pamphlet "The AA Member: Medications and Other Drugs" to counter misinformation about psychiatric medications in recovery groups 3

Step 4: Address Specific Problems Within Treatment

Match professional services to the patient's specific employment, family, or psychiatric problems within your treatment program, as this increases treatment completion by 20-30%. 5

Managing the Hyperphagia Component

The hyperphagia may represent:

• A substitution behavior during early recovery
• A symptom of an underlying psychiatric disorder
• Part of the substance use pattern itself

Monitor whether eating behavior improves as substance use decreases. 6 If hyperphagia persists or worsens:

• Screen for co-occurring eating disorder, as dual diagnosis of eating disorders and substance use disorders requires parallel, simultaneous treatment 6
• Assess for inadequately treated psychiatric symptoms (anxiety, depression) that may drive both substance use and eating behaviors 1

Critical Pitfalls to Avoid

Do not prescribe benzodiazepines for any anxiety symptoms in this patient with substance abuse history, as they have high abuse potential. 7 Instead:

• Use SSRIs (escitalopram, sertraline, paroxetine) as first-line for anxiety without abuse risk 7
• Consider SNRIs (venlafaxine) as alternative first-line option 7
• Beta-blockers (propranolol) can address physical anxiety symptoms 7

Do not restrict pharmacotherapy only to patients committed to abstinence - even reductions in substance use have important health benefits. 1

Do not use confrontational approaches - these generate resistance and decrease treatment engagement. 1

Ongoing Management

Provide longitudinal chronic care with ongoing counseling and care coordination, recognizing substance dependence as a chronic relapsing condition. 1 Treatment success requires:

• Regular follow-up appointments
• Coordination with addiction specialists and mutual help programs
• Family involvement when possible 1
• Compliance-enhancing techniques for all treatment components 1