What are the patient education and management strategies for Substance Use Disorder (SUD)?

From the Guidelines

Patient education and management for substance abuse disorders should focus on a comprehensive approach that includes both behavioral interventions and medication when appropriate, as supported by the most recent evidence from 1 and 1. Begin by establishing a therapeutic alliance with the patient through non-judgmental communication and motivational interviewing techniques to enhance their readiness for change. For alcohol use disorder, medications like naltrexone (50mg daily oral or 380mg monthly injectable), acamprosate (666mg three times daily), or disulfiram (250-500mg daily) can be effective, as noted in 1 and 1. For opioid use disorder, medication-assisted treatment with methadone (typically 80-120mg daily), buprenorphine (16-24mg daily), or naltrexone (380mg monthly injectable) significantly improves outcomes, as highlighted in 1 and 1. These medications should be combined with psychosocial interventions including cognitive-behavioral therapy, contingency management, and support groups. Patient education should cover the neurobiological basis of addiction as a chronic brain disease, realistic expectations about recovery including the likelihood of relapse, harm reduction strategies, and the importance of addressing co-occurring mental health conditions. Regular monitoring through urine drug screens, liver function tests when appropriate, and frequent follow-up appointments helps track progress and adjust treatment as needed. Family involvement can provide crucial support, while connecting patients with community resources like peer support groups and vocational services addresses social determinants of health that impact recovery. This integrated approach recognizes addiction as a chronic condition requiring ongoing management rather than a moral failing or acute illness, as emphasized in 1.

Some key points to consider in patient education and management include:

• Establishing a therapeutic alliance with the patient
• Using motivational interviewing techniques to enhance readiness for change
• Combining medication with psychosocial interventions
• Providing patient education on the neurobiological basis of addiction and realistic expectations about recovery
• Regular monitoring and follow-up appointments to track progress and adjust treatment as needed
• Involving family and connecting patients with community resources to address social determinants of health

Overall, a comprehensive approach that includes both behavioral interventions and medication when appropriate is essential for effective patient education and management of substance abuse disorders, as supported by the evidence from 1, 1, 1, 1, 1, 1, and 1.

From the FDA Drug Label

Patients should be reminded that the dose will “hold” for a longer period of time as tissue stores of methadone accumulate. Initial doses should be lower for patients whose tolerance is expected to be low at treatment entry Loss of tolerance should be considered in any patient who has not taken opioids for more than 5 days. Initial doses should not be determined by previous treatment episodes or dollars spent per day on illicit drug use For Maintenance Treatment Patients in maintenance treatment should be titrated to a dose at which opioid symptoms are prevented for 24 hours, drug hunger or craving is reduced, the euphoric effects of self-administered opioids are blocked or attenuated, and the patient is tolerant to the sedative effects of methadone. Most commonly, clinical stability is achieved at doses between 80 to 120 mg/day Abuse Buprenorphine hydrochloride contains buprenorphine, a substance with high potential for misuse and abuse, which can lead to the development of substance use disorder, including addiction All patients treated with opioids require careful and frequent reevaluation for signs of misuse, abuse, and addiction, because use of opioid analgesic products carries the risk of addiction even under appropriate medical use Patients at high risk of buprenorphine hydrochloride abuse include those with a history of prolonged use of any opioid, including products containing buprenorphine, those with drug or alcohol abuse, or those who use buprenorphine hydrochloride in combination with other abused drugs.

The management of substance abuse disorder patients involves careful dosing and monitoring.

• Initial doses of methadone should be lower for patients with low tolerance, and should not be determined by previous treatment episodes.
• Maintenance treatment should aim to prevent opioid symptoms for 24 hours, reduce drug hunger and craving, and block the euphoric effects of self-administered opioids.
• Buprenorphine has a high potential for misuse and abuse, and patients should be carefully evaluated for signs of misuse, abuse, and addiction.
• Patients with a history of prolonged opioid use, drug or alcohol abuse, or those using buprenorphine with other abused drugs are at high risk of abuse.
• Close monitoring is necessary to prevent overdose, respiratory depression, and other adverse effects.
• Dose adjustments should be made cautiously, and patients should be educated on the risks of substance use disorder and the importance of adherence to their treatment plan 2, 3.

From the Research

Substance Abuse Disorder Patient Education and Management

• Substance use disorders (SUD) are serious public health problems worldwide, with limited effective pharmacotherapies and high relapse rates even after treatment 4.
• The United States Food and Drug Administration (FDA) has approved several medications for opioid, nicotine, and alcohol use disorders, but none for cocaine or other psychostimulant use disorders 4, 5.
• Agonist replacement therapies, such as methadone and buprenorphine for opioid use disorders, have been shown to be effective in treatment 4, 5, 6.
• Buprenorphine-naloxone maintenance and methadone maintenance are substantially more effective than abstinence-based treatment for opioid use disorders 6.
• Methadone is preferred over buprenorphine-naloxone for patients at higher risk of treatment dropout, such as injection opioid users, while buprenorphine-naloxone is recommended for socially stable prescription oral opioid users 6.
• A practical decision-making algorithm can be used to address pertinent psychiatric and medical comorbidities when prescribing pharmacology for opioid use disorder 7.
• Comprehensive care processes for substance use disorders in adult mental health services are essential, but there is marked variation in routine practice across a range of substance use disorder assessment and diagnosis processes 8.

Treatment Options

• Methadone, buprenorphine, and naltrexone are FDA-approved medications for the treatment of opioid use disorder 5, 7.
• Buprenorphine-naloxone is recommended for patients at high risk of methadone toxicity, such as the elderly, those taking high doses of benzodiazepines or other sedating drugs, heavy drinkers, those with a lower level of opioid tolerance, and those at high risk of prolonged QT interval 6.
• Individual patient characteristics and preferences should be taken into consideration when choosing a first-line opioid agonist treatment 6.

Challenges and Future Directions

• Despite the availability of effective treatments, a majority of patients with opioid use disorder do not receive medical treatment 5.
• Future studies should identify agonist pharmacotherapies that can facilitate abstinence in patients who are motivated to quit their illicit drug use 4.
• Standardizing expectations and systematically monitoring the performance of substance use assessment and diagnosis can help improve care and reduce associated morbidity in adult mental health services 8.