Substance Use

A Whole Health Approach to substance use incorporates complementary and integrative health (CIH) practices like yoga, meditation, hypnotherapy, and biofeedback. Discover new ways to empower patients and their families through transcranial magnetic stimulation (TMS), or mindful awareness.

Whole Health emphasizes mindful awareness and Veteran self-care along with conventional and integrative approaches to health and well-being. The Circle of Health highlights eight areas of self-care: Moving the Body, Surroundings, Personal Development, Food and Drink, Recharge, Family Friends, and Co-Workers, Spirit and Soul, and Power of the Mind. The narrative below shows what a Whole Health clinical visit could look like and how to apply the latest research on complementary and integrative health to substance use.

Meet the Veteran

David is a 30-year-old who completed his six years of active duty in the Army as a Special Forces Weapons Sergeant a year and a half ago.  He recently met with his primary care clinician for the first time since he returned home from active duty. He shared that reintegration into civilian life has been difficult for him, and as a result his relationships with his wife and 8-year-old daughter have been strained. He disclosed he is not satisfied with his job and longs for the sense of purpose and feeling of camaraderie he had in the Army, in defending the greater good. He stated he has been having difficulty getting into a routine of regular physical activities and wishes he had buddies to work out with. He shared that he has only been able to get 6 hours of sleep on a good night, sometimes waking up a few times per night, and sometimes going for a hike at night in the woods to clear his mind. He feels stressed all the time. He is looking for help with sleep and stress coping, and for relief from the nightmares he has been having for the past year about casualties that had occurred during his last deployment.

As part of his exam, a brief substance use screening revealed unhealthy substance use, including, on average, 4-6 five drinks per day and recent occasional use of illicitly-obtained opioid pain medications.  He also smokes two packs of cigarettes per day. Upon further exploration, David reported he is using alcohol and opioids to help cope with the difficulties of his transition to civilian life, sleep problems, and nightmares that seem to be more frequent lately.

Personal Health Inventory

On his Personal Health Inventory (PHI), David rates himself a 2 out of 5 for his overall physical well-being and a 1 out of 5 for overall mental and emotional well-being, where 5 indicates the optimal well-being. When asked what matters most to him and why he wants to be healthy, David responds:

“I like having a sense of purpose, serving the common good, and satisfaction of a job well done. Family, the camaraderie and structure of Army life, and always having someone who’s got my back, matter to me.”

For the eight areas of self-care, David rates where he currently is and where he would like to be in the future. David decides to first focus on the areas of Working the Body and Personal Development by finding buddies to work out with and by looking for a new job.

For more information, refer to David’s PHI.

Introduction

Lifetime prevalence of a substance use disorder (SUD) has been estimated at 52.5% among Veterans, with alcohol/drug and tobacco use disorders affecting 38.7% and 35.2% of veterans, respectively.[1]  Past-year SUD prevalence in Veterans has been estimated to impact 5.7% of women and 7.4% of men overall; the 18-25 age group overall has the highest prevalence, with males highest of all (14.7% of women and 30.1% of men).[2]  Past-month heavy episodic drinking, daily cigarette use, illicit drug use, and prescription drug use in Veterans age 18-25, is also extremely high and of concern with 42.9%, 26.3%, 28.7%, 14.1% of women and  55.9%, 33.4%, 38.0%, 18.3%, of men, respectively (across all age groups: 19.0%, 21.0%, 10.5%, 5.0% of women, respectively; and 23.9%, 16.4%, 8.4%, 3.0% of men).[2]  According to the Centers for Disease Control, over 29.2% of Veterans report current tobacco use,[3][4] however, the rate of tobacco dependence is much higher among Veterans with alcohol or drug use disorders; in FY10, 79% of patients in drug and alcohol residential treatment programs were tobacco-dependent.[5]

Substance use is a complex health condition negatively impacting many areas of the individual’s life.  Harms associated with substance use can span the physical, mental, emotional, spiritual, and interpersonal domains of well-being and affect relationships, work performance, financial status, and housing status.

Combat exposure, PTSD, and sexual trauma are risk factors for addiction and mental health problems.[6][7][8]  In addition, mental health conditions and SUDs frequently co-occur, and their presence increases the risk of suicide.[9]  Regarding PTSD alone, approximately one-third to one-half of patients in the general population seeking treatment for SUDs also meet criteria for PTSD, with some studies reporting even higher prevalence of this co-occurrence.[10]

Since substances can be used to self-medicate symptoms of physical (e.g., chronic pain) or mental health (e.g., PTSD, depression, anxiety) conditions, or for stress coping, it is crucial to identify co-occurring physical or mental health conditions when assessing individuals for SUDs and other addictions.  Identification and concurrent treatment of co-occurring physical and mental health conditions using evidence-based psychological treatments and/or pharmacotherapy, are critical to ensure treatment of both conditions and increase the likelihood of a successful recovery.[11]

It is common for people to use substances to self-medicate symptoms of pain, stress, anxiety, depression, PTSD, or other mental health problems.  Veterans can also rely on substance use as a coping strategy to readjust to civilian life.  The hallmark feature of addiction is “loss of control” over the substance of use, leading to continued use despite the development of significant adverse consequences.  A person’s life revolves around using the substance or securing the next “fix,” in spite of these negative consequences related to substance use, which are often destructive to personal and professional life.  When treating substance use, it is crucial to address all areas of life that have been affected by it and to provide the patient with therapeutic tools and interventions supporting recovery from both the substance itself and the indirect effects of substance use (e.g., strained relationships), in addition to healing co-occurring problems, such as mental health or physical health conditions (e.g., chronic pain) that may have contributed to the development and maintenance of substance use.  Healthy recovery usually involves abstaining from the use of addictive substances, engaging in professional treatment, and building a substance-free, supportive social support network.

When addressing SUDs, it is important to

  1. Screen for them, so that you know they are there in the first place.
  2. Seek out root causes. What are the underlying reasons for the SUD?
  3. Be aware of comorbidities.  These can include mental health problems, stress, and pain, among many others.

Due to the complex nature of SUDs and their effect on many if not all areas of a patient’s life, it is essential for the clinician to perform a comprehensive bio-psycho-social assessment of patients with SUDs.[12]  Clinicians must fully understand not only the substance use itself, but also the interaction of substance use with the patient’s life.  This understanding is necessary in order to adequately tend to the patient’s needs and tailor any interventions or referrals to that specific patient.  Recovery is a lifelong process involving changes across multiple domains of a person’s daily life, including physical, behavioral, inter- and intra-personal, psychological, and social spheres; therefore, it is vital to assess all life domains from the first patient contact.  A comprehensive bio-psycho-social assessment is also critical for identifying and addressing potential barriers to healthy recovery and issues that can increase risk of relapse and affect progress and engagement during treatment.[12]  Such issues may include relationship difficulties in family, work, or social settings, lack of engagement with or access to a supportive environment, underemployment, and unresolved or pending legal or disciplinary issues.[12]

With the prevalence and scope of problems related to SUDs, it is essential to identify both those who have and those who are at risk for developing SUDs.  In an outpatient national sample of 63,397 Veterans, of those that screened positive for unhealthy alcohol use, 25% of women and 28% of men had a current alcohol or substance use disorder diagnosis.[13] Evidence provides a strong support for screening and brief intervention (SBI) as a tool to address unhealthy alcohol and tobacco use—both recommended services by the U.S. Preventive Services Task Force (USPSTF) for routine implementation in primary care settings.[14][15][16] Routine screening of adults for unhealthy alcohol and tobacco use, followed when needed by brief counseling (often based on motivational interviewing principles), have been shown to reduce tobacco and alcohol use, respectively, and related harms in primary care and mental health settings.[16][17]  The SBI approach may be particularly relevant to rural communities where access to specialty care can be problematic.

For alcohol, the evidence for efficacy is strongest for brief (10-15 minutes) multi-contact interventions for nondependent drinkers  VA/DoD Clinical Practice Guidelines require that all patients in primary care (medical and mental health care settings) be screened for unhealthy alcohol use during all new patient encounters and at least annually, and those with a “positive screen” receive brief intervention and a referral to specialty treatment, if needed[18] Although research on the efficacy of SBI for drug use and misuse has been less robust, the U.S. Preventive Services Task Force (USPSTF) added in 2019 the recommendation to routinely screen for drug misuse in adults, including pregnant women.[19]  In addition, although the 2013 USPSTF recommendations limited screening for hepatitis C virus (HCV) infection to people with an increased risk for it, such as individuals who use drugs, the updated 2019 USPSTF statement recommends universal screening for HCV infection in adults ages 18-79.[20] American Academy of Pediatrics recommends routine implementation of SBI focused on substance use in adolescents.[21]

The SBI approach often incorporates motivational interviewing techniques and follows the 5 As (Ask, Advise, Assess, Assist, Arrange) or the FRAMES (Feedback, Responsibility, Advice, Menu of Strategies, Empathy, Self-Efficacy[22]  The National Institute of Drug Abuse (NIDA) Resource Guide provides comprehensive guidelines outlining a step-by-step approach to the screening for substance misuse and brief intervention delivery in primary care settings.[23]  The evidence-based initial screen for SUDs can be as short as a set of three single questions about heavy drinking, tobacco use, or prescription or illicit drug misuse.  Negative answers to these questions constitute a “negative screen” and complete the SBI process.  Positive responses to one or more questions trigger a more in-depth assessment and lead to tailored brief advice or intervention, as appropriate.  Although the NIDA’s guide primarily focuses on drug SBI, it outlines the initial screening questions for all substances (alcohol, tobacco, and drugs), providing links to alcohol- or tobacco-specific SBI guidelines, which can be accessed online, at point-of-care.  Please refer to the “Resources” sections for links to these guidelines.

VHA supports access to evidence-based SUD treatments, as specified in the VA/DoD Clinical Practice Guidelines for the Management of Substance Use Disorder (2015).[18]  Unfortunately, certain barriers contribute to reduced help-seeking by some Veterans (stigma, discomfort with “asking for help,” negative beliefs about mental health care) and active duty members (“zero tolerance” policies on drug misuse, barriers to care due to deployment, the sharing of previously protected medical records between the VA and DoD).  Although many individuals (roughly one-third) can recover from SUDs on their own without formal treatment, evidence shows that treatment for SUDs is effective, with treatment duration possibly playing a substantial role in relapse prevention.[24][25]  Active participation in mutual self-help groups (e.g., Alcoholics Anonymous, Narcotics Anonymous) can also increase likelihood for a successful, long-term recovery.[25][26]

Treatment that integrates addiction-related care with primary and mental health care, and coordination of employment, housing, and other needed social services, is a priority.  High-quality holistic, integrated care should provide services for SUDs as well as problems in multiple domains of health and life that can be affected by SUDs: mental health; employment and housing; physical health; nutrition and exercise; rest and self-care; coping and communication skills; self-awareness, connection with others and self; growth and goal-setting; and general recovery and re-engagement in life without the use of substances.

While people are in treatment, it is important for clinicians to closely monitor their progress, especially early in recovery when the risk of relapse is highest.[12]  The clinician and the patient should collaborate together in developing treatment plans and goals for recovery.[12] Treatment plans should be tailored to the patient’s individual needs and preferences and take into consideration availability of different treatment modalities (e.g., residential versus outpatient).  Smooth and gradual transitions between levels of care as indicated can additionally facilitate recovery.

Self-Care

Surroundings: Physical and Emotional Environment

Physical (external) and emotional (internal) surroundings are influential factors that may aid or hinder recovery from SUDs.  Bringing awareness to one’s physical and emotional surroundings, identifying, and then reducing or eliminating external and internal individual risk factors for relapse (triggers) are critical for relapse prevention and recovery. Addictive substances act as powerful behavior reinforcers, especially when they become associated with a variety of internal and external stimuli (triggers),[27] which, in turn, can trigger a craving or urge to use the substance or re-engagement in problematic behaviors during recovery.

Safe, comfortable and healthy surroundings that facilitate the ability to relax and enjoy positive activities are important assets to one’s recovery.  A supportive environment provides the necessary foundation an individual needs while experiencing triggers and learning how to cope with them without reaching for a substance.  External or environmental triggers or cues can draw a person back to substance use or other unhealthy behaviors (e.g., gambling).  It is important for the patient to identify his or her individual triggers at home, work, socially, and in other environments, and strive to avoid or remove them so that the risk of relapse is decreased.  For example, certain places (e.g., bar, casino), objects (e.g., bottle of alcohol, pills in the medicine cabinet, drug paraphernalia), or people associated with prior substance use can be strong triggers to use, especially early in recovery.  Some environmental triggers may not be easy to remove, such as billboards advertising alcohol, the presence of a bar down the street, or a previous drug dealer continuing to call. In such cases, patients can minimize “exposure” by avoiding these areas, blocking unwanted phone numbers, learning effective coping skills, and reaching out to recovery-supportive others for support.  It is important for patients to consider how they have responded to external triggers that serve as cues for substance use: “Are there ‘negative’ or ‘unhealthy’ or ‘unhelpful’ things in my physical environment that I’m sensitive to (noise, clutter, lighting, smells, conflict, certain people)?”  “What can I change and what can’t I change?”  “How will I deal with the things I cannot change?”

Internal environments play an essential role in recovery.  Negative emotional states or thoughts (“internal triggers”) are known relapse risk factors. Many individuals use substances to “deal with” negative thoughts, stress, or emotions. In some instances, simply the presence of a negative thought or emotion may feel overwhelming and result in substance use; in others, difficulty coping with a negative thought or emotion may wear on the individual and eventually, over time, lead to the return to substance use. Internal triggers are unique and specific to the individual—what triggers one person may not trigger another. It is important to help patients identify their unique triggers and learn new, adaptive coping skills to apply when experiencing negative thoughts or emotional states. For some individuals, a positive emotional state can also be a trigger to use substances and should be addressed. Psychological therapies, such as Cognitive Behavioral Therapy (CBT), 12-step and mindfulness-based approaches, can help identify both physical and emotional states that may precipitate the process of relapse.  Common risk factors for relapse have become known under the acronym “HALT” (Hungry, Angry, Lonely, Tired); boredom can also be a risk factor.  It is important to ask oneself, especially if a craving or urge to use is happening, “Am I hungry? Angry? Lonely? Tired? Bored?” and address these underlying issues.  Being mindful and aware of one’s personal state of being is crucial for addiction recovery and supports important self-care choices for overall health and well-being.

Nutrition: Food & Drink

In SUDs, nutrition and related health often suffer.  For example, excessive consumption of alcohol affects carbohydrate, lipid, and protein metabolism, and absorption of vital nutrients.[28]  It is common medical practice to recommend a daily multivitamin and thiamine (vitamin B1) supplementation in alcohol dependent individuals.[29]  Part of a healthy lifestyle in recovery includes a well-balanced diet to provide the body with needed nourishment. A healthy diet supports good health in general, may ease the detoxification process, facilitate recovery, and reduce craving.  In a pilot study, nutritional therapy and nutritional counseling helped alcohol-dependent participants in a rehabilitation program reduce craving and abstain from alcohol.[28]

In addition to a well-balanced diet, which is a staple of healthy lifestyle, individuals with SUDs should strive to avoid using any addictive substances, including illicit drugs, alcohol, tobacco, or prescription-based medications with an addictive potential, as the use of these substances can lead back to a pattern of misuse and compromise recovery and personal growth.  In addition, substance use, especially alcohol or drugs, may exacerbate mental health conditions (e.g., anxiety, depression, bipolar disorder, etc.), and suicide risk, and interfere with positive effects of other treatments.

Rest & Sleep: Recharge

Sleep, rest, and relaxation are essential components of self-care, healing, and optimal functioning, and are crucial ingredients of recovery.  Inadequate sleep, fatigue, and tension (stress) increase the risk of relapse.[30]  Adults typically need 7-9 hours of good-quality sleep per night.[31]  Sleep, rest, and relaxation, along with taking time to do activities that nourish a person on mental, emotional, physical, and spiritual levels, promote the healing and maintenance of body and mind and help build a foundation for healthy balance in recovery.  It is not uncommon for patients to have used alcohol as a “sleeping aid,” thinking that it helps with sleep. Contrary to this relatively common belief, however, alcohol may “help” with falling asleep, but overall it tends to impair restorative sleep by impacting sleep maintenance and causing “lighter,” fragmented sleep with awakenings and difficulty with returning to sleep.  Poor sleep quality can lead to increased daytime sleepiness and impaired daily functioning,[32] and increases the risk of relapse.

Moving the Body

There are many physical and psychological benefits to physical activity and exercise that make it a useful adjunctive treatment for SUDs and health in general. Exercise can be helpful for reducing tension/stress, anxiety, depression, and sleep problems (all known relapse risk factors) and may have positive effects on the brain’s reward system, which is often affected by substance use.[33][34]

Research is limited, though, on the impact of exercise on SUD outcomes, with inconsistent findings for exercise as an adjunctive treatment in alcohol and other drug use disorders.  Results for nicotine addiction are more promising.  In addition to traditional exercise programs, yoga and tai chi may be useful for SUD recovery[35] and improving psychological health and stress coping that are important components of successful recovery.[36][37]

Due to the multidimensional benefits of exercise for physical and mental health, and the potential benefits of exercise for SUDs, exercise may be a good adjunctive treatment option for those expressing interest who do not have medical contraindications to exercising.  The recommended exercise program should be tailored to the patient’s needs, abilities, and interests.  Starting with a mild-to-moderate intensity exercise program, with a gradual, “as tolerated” increase in intensity and/or duration, can lessen the risk of injury and potential adverse effects that may stem from overly strenuous exercising.  The American College of Sports Medicine provides guidelines on pre-participation screening when assessing the patient’s risk and providing clearance for engaging in an exercise program.[38]

Personal Development

Taking a look at personal and work life and how time is spent in each domain is extremely important for the development of healthy balance in life.  Personal and work-related activities can influence one’s sense of well-being.  While some activities are nourishing or restorative, others can be stressful and draining, diminishing one’s energy and ability to stay internally balanced and grounded.  It is important, especially in SUD recovery, to ensure that one has an adequate “supply” of positive, nourishing, restorative activities to minimize the impact of negative or depleting activities in daily life.

Personal growth and development are important areas to consider as they are often affected by substance use.  There are many approaches to help support personal development, which can include goal setting, connecting with others, connecting with self, taking responsibility for one’s actions, maintaining life balance, and addressing the underlying issues that have been related to substance use, such as unresolved grief, trauma, negative interpersonal relationships or living environment.  In addition, helping patients clarify values is crucial for the development of positive life goals and personal growth.  Exploration of patient values can aid in the healing process, help patients connect with what brings fulfillment in life, and uncover potential strengths that may aid in recovery.  More information, is available in the “Values” Whole Health tool.  Setting goals is a critical element of addiction treatment and a recovery-oriented approach, and tying treatment goals to overall life goals can be helpful.  Unaddressed, co-occurring mental health problems can impede the recovery process and impact one’s ability to engage in life in a positive way and should be addressed.

Family, Friends, & Co-Workers

There is a significant body of literature documenting the importance of healthy social support for the success of SUD recovery.  Peer pressure to use substances or spending time with those who use substances are known risk factors for substance use.  Patients should be encouraged to consider opportunities to find and/or create a personal support network. Generally, most individuals with SUDs have developed strong social systems that support continued use.  As they begin to recover from substance use, these friendships and associations are threatened, sometimes leading to an increase in peer pressure to use substances or lack of support for the patient’s recovery efforts.  Loss of friendship and relationships can lead to grief and other strong emotions that can leave the person vulnerable to relapse or other adverse outcomes.  Recovery-oriented support systems are critical to maintain progress. It is important to connect the patient to recovery-oriented resources early in the recovery process so that they can develop a support network.

Support can come from recovery coaches, peer support specialists, mutual self-help groups (e.g., Alcoholics Anonymous, Narcotics Anonymous, SMART Recovery), religious and other communities, friends, and family.  It is also important to connect the patient with a mental health professional to assist in the development and promotion of healthy interpersonal skills, which are necessary for building and maintaining healthy relationships. Educating family and other key support individuals about SUDs and recovery, and integrating them (with the patient’s permission) into treatment planning can help support recovery.  Some of the evidence-based psychological interventions for SUDs are focused on engaging the patient’s key individuals in the treatment to help support the patient (refer to the “Interventions” section for details).

Spirit & Soul

Engagement in, and reward from, meaningful activities and interactions with others can improve well-being and quality of life. Perceived connection to others may decrease the sense of isolation and loneliness, which can contribute to relapse. Spirituality can aid SUD recovery. Spirituality is defined broadly and does not necessarily refer to any particular religion (though spirituality is oftentimes a part of religion).  Limited research suggests that spiritual or religious involvement can be a protective factor against SUDs and relapse.[39][40]  Involvement in religious communities or 12-step programs can be a great source of spiritual support during recovery.  It is important to note that although spirituality is often the foundation of many 12-step mutual self-help groups (i.e., Alcoholics Anonymous, or AA; Narcotics Anonymous, or NA), it is not a requirement for participation or recovery. (Please refer to the section on “Recovery-Oriented Mutual Self-Help Programs,” below, for more information on 12-step groups). Patients with mental health problems may tend to have a lower general perception of connection with others or the universe; in addition to treating their underlying problems, they may need additional support from peers or providers to grow spiritually and improve their sense of connectedness.[41]

Spiritual Self-Schema (3-S) is an intervention focused on spirituality and designed for the treatment of SUDs and HIV risk behaviors.  Preliminary research indicated that, after receiving the 3-S therapy, participants increased their spiritual experiences, values, and practices, and shifted perceptions of “self” from “addict-self” to “spiritual-self” as well as decreased impulsivity, drug use, and other HIV risk behaviors.[42][43]

Power of the Mind

Mind-body practices have been shown to improve general health and well-being, the ability to cope with daily experiences and stressors, and can be helpful with SUD recovery.

Mindfulness Meditation

Mindfulness meditation is a practice that trains the mind in nonjudgmental attention to present moment experiences, and can benefit the “whole person.”  Mindfulness-based interventions focus on helping train the mind in mindful awareness, defined as the intentional, accepting, and nonjudgmental focus of attention on one’s thoughts, emotions, and sensations occurring in the present moment, and simply observing as they come and go.  Mindfulness Meditation is generally considered safe, with research supporting its efficacy for various mental health and physical health conditions, including addiction.[44][45][46][47][48]  By practicing mindfulness meditation, one can improve stress-coping, enhance well-being, and decrease the impact of distressing thoughts, emotions, and sensations on one’s inner experience.  Mindfulness can support healing of the body and mind and the pursuit of personal growth.  It can exert positive effects on quality of life and health in general.  Cultivating skills in mindful, nonreactive awareness of relapse triggers (thoughts, feelings, sensations, environmental factors) and other experiences as they are occurring are important components of the development and maintenance of addiction recovery.  Additional information is offered in the “Complementary and Integrative Health Therapies” section.

Transcendental Meditation

Transcendental Meditation (TM) trains the brain in focusing attention by concentrating on and repeating a short phrase (“mantra”) in one’s mind.  Evidence on the efficacy of transcendental meditation in SUDs is less extensive than for mindfulness meditation.  The “Complementary and Integrative Health Therapies” section below has more information.

Biofeedback

Biofeedback involves training individuals to intentionally regulate bodily functions (e.g., breathing, heart rate, blood pressure) for overall health improvement.[49]  There is very little research on the effects of biofeedback in SUDs. Please see the “Complementary and [50]Integrative Health Therapies” section below for more information.

Key Points:  Healthy Foundations for Treating Substance Use Disorders

  • Take relapse triggers into account. These can be in the external environment such as billboards, driving by the place where one bought substances, etc., or internal, including one’s emotional states.
  • Promote a healthy diet that includes appropriate nutrients (e.g., thiamine).
  • Good sleep is key. Alcohol impairs restorative sleep. Relapse rates increase with poor sleep, fatigue, and stress.
  • More research is needed, but exercise has the potential to support recovery.
  • Explore with individuals their strengths and positive qualities, and ensure that they have plenty of positive, nourishing, and restorative activities and experiences from which to draw.
  • Healthy social support is key—starting in early recovery. Relationships shift as people move away from social connections that promote substance use; finding new, healthy connections and support is important for SUD recovery.
  • Spirituality, which can be the foundation of many 12-step programs, is central to recovery for many people.
  • Mindfulness meditation is beneficial for many health issues, with research showing its promise for addiction recovery.

Conventional Approaches

Substance Abuse Treatment

As with any therapeutic intervention, it is important to conduct both medical and psychological assessments to determine the patient’s level of treatment need, preferences, and goals; treatment should be tailored appropriately to provide optimal support for the individual’s recovery.  Each patient’s life circumstances, needs, abilities, and challenges are unique.  Some individuals may do well with only a brief counseling session with a trusted provider.  Others may benefit most from engaging in longer outpatient therapy; some may need a referral for specialty medical or mental health services, help with securing affordable housing, career counseling, or connecting to other organizations and resources. And still others may need a higher level of care, such as medically monitored detoxification, followed by a few weeks of residential treatment before transitioning to outpatient care.  There may also be health insurance barriers that the patient may need help navigating. It is important to identify the least restrictive level of care that will benefit the patient, and work from there.  For example, an individual who is engaging in risky alcohol use three days per week may not need a referral to a residential treatment program, and an office-based brief intervention or referral to outpatient treatment may be most appropriate, whereas an individual with alcohol dependence may require a higher level of care, well beyond the brief intervention.

Importantly, treatment programs (e.g., residential, day treatment, intensive outpatient) are not “terminal” by themselves. After early recovery treatment is completed, the patient should continue with aftercare (continued care) treatment to maintain recovery. Aftercare outpatient programs are typically less intensive and focus on continued support while building on the prior treatment gains.

For patients with co-occurring SUDs and mental health problems, it is crucial to provide treatment that can address both these issues concurrently—for example, referring them to a therapist who is trained in both SUDs and mental health.  SUD treatment should never be withheld from an individual, even if the patient is not ready to address the mental health condition; likewise, mental health treatment should never be withheld from a patient who is not ready to address their SUD.  It is important to meet patients where they are at and engage them in a shared decision-making process, which is a key aspect of the SBI approach and motivational interviewing.  Helping patients connect with the appropriate scaffolding of services is critical to promote healing and success in their recovery efforts.

When working with patients to help them get connected to and engaged in SUD treatment, it is essential to assess and then facilitate the patient’s readiness for change.  Motivational interviewing (MI) has been shown effective for promoting motivation to change and treatment engagement.[22]  The premise of MI, often emphasized in the context of SBI, which commonly utilizes the MI strategies, is to first evaluate and collaboratively explore with patients their level of readiness for change, and then help increase motivation to change.  Patients are more likely to make and sustain changes if they choose to engage in treatment on their own terms and participate in goal setting through a nonconfrontational, collaborative process of working with their clinician toward the development of treatment goals.

Forming a strong therapeutic, working alliance with the patient is essential for achieving treatment success.[51]  When patients are open to connecting with their clinician, they are allowing that professional into their lives and trusting them for direction and support.  It is best to employ evidence-based strategies, such as MI and collaborate with the patient to negotiate and develop a mutually approved treatment plan.[22]

Confrontational approaches have been related to patient dropout and poorer treatment outcomes, can harm the therapeutic relationship, and create a barrier to change. It is the clinician’s responsibility and an important aspect of a clinician’s duties to nurture the clinician-patient healing relationship, as it can facilitate optimal conditions for the patient’s engagement in treatment and pursuit of health goals.

Attributes of effective clinicians include empathy, goal direction, expressing understanding and support, and the use of external resources.[51]  Learning about a patient’s cultural and racial identities, worldview, spirituality, values, and strengths will help advance the working alliance. Understanding cultural context can especially help with tailoring a treatment plan that not only addresses the substance use and mental health, but also addresses any cultural trauma that can play a role in substance abuse and/or mental health conditions (e.g., Native American cultural trauma related to the loss of land, spiritual traditions, and culture). Some cultures may have different approaches to recovery as well. For example, in Native American communities, there are culturally grounded recovery-oriented mutual self-help groups, such as the Wellbriety Movement that may be a better fit than the ‘mainstream’ 12-step programs.[52][53] For a comprehensive treatment plan, incorporating traditional cultural perspectives with community support (e.g., AA, NA, SMART Recovery, Wellbriety), and other therapeutic methods, and delivered in a culturally sensitive way, may help overcome culturally driven barriers to treatment and improve outcomes in SUDs among Native Americans.[52]

Opioid Overdose Prevention

Those who use opioids—prescribed or illicitly-obtained—are at increased risk of respiratory depression and overdose. This risk is particularly high in those who are opioid-naïve or abstained from opioids, even for a relatively short period of time. It is especially critical to educate patients about the danger of unintentional overdose after a period of staying off or reducing the use of opioids. With abstinence (or even reduced use), the individual’s tolerance level decreases; resuming opioid use with the prior (pre-cessation, prereduction), dose carries a high risk of overdose and death due to a diminished tolerance. Naloxone, an opioid antagonist delivered by injection or intranasally, used to reverse the effects of an opioid overdose, is recommended to be prescribed or dispensed to all at-risk individuals for the prevention of fatal overdose.[54]

It is also important to educate patients that illicitly obtained drugs, including opioids and non-opioid drugs (including marijuana), can be adulterated with all sorts of substances, including cocaine, and fentanyl and its analogs. The increase in illicit fentanyl and its analogs, often added without the knowledge of the user (or seller/dealer), has recently led to surges in overdose deaths. Potent opioids (e.g., fentanyl) are particularly dangerous, especially in those who do not have tolerance to opioids, such as opioid-naïve individuals or those who stopped opioid use.

Opioid Overdose Prevention Toolkit:

https://store.samhsa.gov/system/files/sma18-4742.pdf

Detoxification

Detoxification is often the first step in SUD treatment.  Detoxification refers to the period of time when the body eliminates toxic substances and readjusts to the absence of the substance.  Tobacco, alcohol, opioids, benzodiazepines, and other sedatives are common substances that cause physical dependence, with a resulting withdrawal, once the use stops.  In the case of alcohol, benzodiazepines, or other sedatives, physical withdrawal can be life threatening if untreated, with symptoms ranging from increased blood pressure, heart rate, tremor, irritability, to hallucinations, seizures, and, finally, delirium tremens. It is critical to assess the patient’s current medical situation as well as past medical history for conditions that increase the risk and dangers of advanced withdrawal or may contribute to more intense severity of symptoms during the detoxification process (e.g., co-occurring mental health problems, past history of advanced withdrawal). Patients with current symptoms or a past history of sedative withdrawal, especially advanced withdrawal (hallucinations, seizures, or delirium tremens), should be medically monitored and treated with appropriate pharmacological means to decrease the symptomatology and danger of complications.

Tobacco and opioid withdrawal are not life-threatening conditions; however, they can produce severe cravings and other symptoms that are often difficult for patients to manage and endure, often leading back to substance use to alleviate the withdrawal symptoms, which, in the case of opioid use, increases the risk of overdose death.

Pharmacotherapy

Although psychosocial treatments can be applied as stand-alone modalities for many SUDs, addition of pharmacotherapy can enhance outcomes in some SUDs, and can be a crucial part of withdrawal management.  In alcohol dependence, benzodiazepines are the first-line pharmacological treatment for withdrawal.  Naltrexone and acamprosate are commonly used for alcohol relapse prevention; naltrexone should not be used in patients requiring opioid therapy for pain. Disulfiram is currently often reserved for more refractory cases as long-term use has been associated with adverse events such as hepatic injury and neuropathy; it is recommended to be taken in a witnessed fashion for best outcomes.

For opioid withdrawal, clonidine, methadone, or buprenorphine treatment protocols can be used.  In opioid use disorder, maintenance therapy can be conducted using methadone (administered through licensed programs only), buprenorphine, or naltrexone; extended release injectable naltrexone can result in better outcomes compared to the take-daily oral preparations in the treatment of opioid use disorder.[18][29][55]

The chances for successful nicotine use cessation can be substantially increased by pharmacotherapy: nicotine replacement therapy (patches for scheduled use; nicotine gums, lozenges, or inhalers for as-needed use to manage cravings); bupropion (can reduce nicotine cravings); or varenicline.[29] Before prescribing varenicline, it is important to screen and monitor for depression symptoms, as this medication may alter mood and increase the risk of worsened depression and suicidal ideation. Barriers to pharmacological treatments need to be considered.  These can include pharmacy procedures or formulary restrictions, lack of provider skills or knowledge, and lack of confidence in treatment effectiveness.[56]  If pharmacotherapy is indicated, being aware of and addressing the barriers can improve the patient’s access and willingness to engage in pharmacotherapy.

Evidence-based Psychological Treatments

Evidence-Based Psychological Treatment (EBPT) is a recommended, first-line approach to the treatment of SUD.  EBPT can be delivered in a variety of formats (e.g., individual, group, couples, or family therapy) and settings (residential, day treatment, outpatient), and vary in duration, frequency, and intensity. Brief EBPTs, often based on motivational interviewing or motivational enhancement, can be delivered in the primary care clinician’s office, often as a part of a Screening and Brief Intervention (SBI) process; these SBIs have been shown effective for harm reduction in SUD, especially for nicotine and unhealthy alcohol use. SBI is feasible for routine implementation in primary care. Some individuals may do well with only one brief intervention session; for those living in rural areas with limited access to resources, a brief intervention session in the doctor’s office may be their only accessible intervention.

It is essential to identify individuals who may need a higher level of care, beyond the brief intervention in primary care settings, and refer them to SUD treatment. Most levels of SUD care provide both individual and group therapy options. The different levels of SUD care or treatment include the following:

  • Outpatient treatment, where the patient attends group and/or individual therapy sessions weekly or less frequently, based on individual treatment needs.
  • Intensive outpatient/day treatment programs, where the patient attends group and/or individual therapy sessions several days per week, several hours per day (often for several weeks)
  • Residential treatment, where the patient resides at a treatment facility for several weeks to months, depending on individual needs, receiving intensive treatment daily, in group and/or individual therapy settings. Therapeutic communities (TCs) offer the longest support in monitored residential drug-free settings, and use a hierarchical model with graded stages of treatment that reflect increased levels of responsibility (both personal and social) so patients can learn social norms and effective social and coping skills, and assimilate to “regular” life through peer influence and group processes.[57]

Substance use disorder is a chronic relapsing brain disease, and recovery requires long-term care, effort, commitment, and support that need to become an ongoing part of the patient’s life.  Detoxification and early recovery programs (e.g., residential, day treatment) can help patients stop using substances and start building a foundation for a successful recovery.  They are not “terminal” treatments though: recovery is a lifelong, ongoing process. To maintain treatment gains after early treatment and continue building and reinforcing new, recovery-based patterns, it is best to connect patients with an aftercare program for continued support as they progress in recovery.

Within the context of SUD treatment, effective EBPTs have been shown to focus on use or addiction and enhance patient motivation to stop or reduce substance use and/or problematic behaviors; improve self-efficacy and interpersonal functioning; promote a therapeutic alliance; strengthen coping skills to manage affect in an adaptive, substance-free way; reinforce contingencies crucial for recover; and strengthen social support for recovery.[27]  There is no evidence that one type of EBPT intervention is superior to others.[58] However, motivational interviewing (MI) and Cognitive Behavior Therapy-based interventions may be especially well suited for patients with SUD and co-occurring mental health conditions, such as PTSD, depression or anxiety.[59] EBPTs that have shown benefit for SUD and addiction include CBT, behavioral activation, behavioral couples therapy (which involves the partner in treatment planning), cognitive behavioral coping skills training, community reinforcement approach (CRA) and family training (CRAFT), contingency management/motivational incentives, motivational enhancement therapy (MET), MI, mindfulness meditation, supportive-expressive therapy, 12-step facilitation, and cognitive behavioral relapse prevention/coping skills therapy.[27][45][59][60][61][62]

MI and CBT interventions may be particularly well-suited for patients with alcohol use disorders and co-occurring depression or anxiety, with longer treatment duration corresponding to better outcomes.  Since a supportive, healthy social network can reduce the risk for relapse, some interventions for SUD provide the opportunity for involvement of a patient’s partner, friends and/or family members in the treatment. Community Reinforcement and Family Training (CRAFT) aims to increase patient treatment engagement and teaches concerned loved ones how to change behavior in order to improve personal well-being and facilitate the patient’s progress in treatment.[63] Marital and family therapy (MFT) can help families cope with the challenges of living with an SUD-affected person, and motivate the individual to enter treatment.[64] Behavioral Couples Therapy (BCT) has also been shown effective in treating SUDs and is increasingly available in VHA system; it includes the spouse or partner/family member in treatment and addresses the interpersonal relationship as well as the SUD. Evidence is unavailable for the efficacy of BCT for dually affected couples (where both partners suffer from SUDs).[65]

Peer Support Providers

Trained peer support providers (e.g., peer support specialists, recovery coaches) are support workers in recovery from addiction who have formal training in how to engage an individual in a wide range of activities and resources, which are mutually agreed upon as potentially helpful with promoting the individual’s recovery. Peer support providers are trained to share personal recovery-related experience in a therapeutic way to build trust but not to become like a “sponsor” as in the 12-step programs. They are seen as mentors to help develop recovery skill building, and goal setting for the individual. Considered as para-professionals, they can plan and develop self-help groups, supervise other peer workers, provide training, administer programs, and educate the public to raise awareness[66]. Within this context, national groups have formed leveraging peers’ experience and voice to advocate on a wide range of policy reform and on new models of peer support services for people in recovery from SUD. Faces and Voices of Recovery, formed in 2000, has become the national organization for people in recovery, family members and others to find resources in their area or get involved in advocacy efforts to reduce stigma and create more progressive policies around treatment, housing, and recovery issues.[67]

Recovery-oriented Mutual Self-help Groups

Recovery-oriented mutual self-help groups can also provide benefits for SUD recovery and personal growth through self-exploration and support of others pursuing recovery.  Examples include 12-step recovery programs (such as AA, NA, CMA, and other related programs), and Self-Management and Recovery Training (SMART Recovery®). Many people find these programs helpful to their recovery, regardless of whether or not they are also involved in professional treatment, as they can provide a rich source of support for recovery.

Recovery-oriented mutual self-help groups create a forum (“fellowship”) for individuals in recovery to connect with others who have similar experiences and goals and to start building relationships within a substance-free support network. Development of a healthy support network is critically important for those whose only previous social support consisted of others who were using substances. These programs are free, anonymous, and easily accessible (especially AA 12-step groups), and can be available over the course of a patient’s lifetime. Many of these programs, especially those based on the 12-step model, have a spiritual foundation, however spirituality is defined broadly, not associated with any religion, and not a requirement for participation; many atheists can find support in these programs. SMART Recovery, a science-informed approach, can provide an alternative to 12-step self-help groups.  Some people find benefit in attending both types of programs.

Evidence provides support for the efficacy of recovery-oriented mutual self-help programs in improving outcomes for recovery from SUDs.[68][69]  It is recommended that clinicians learn about these programs as it can help improve their ability to successfully refer patients to these programs.[40] More frequent AA attendance and more intense AA involvement, especially in the earlier parts of recovery, have been linked to better outcomes, especially abstinence, and compared to receiving support from non-AA members, support from AA members has been shown beneficial for maintaining abstinence.[26][70]  One study found that the AA meeting attendance and having a sponsor were the strongest predictors of abstinence over time; other activities such as use of a home group, befriending members, service work, or reading the literature also showed promise.[71]  Some of the possible “active ingredients” underlying efficacy of self-help groups are that they provide support, goal direction, structure, abstinence-oriented role models, increasing self-efficacy, healthier coping skills, and engagement in rewarding activities such as substance-free social activities and helping others overcome their substance use problems.[72] Not all individuals with SUDs are interested in or benefit from participation in self-help groups.[72] A meta-analysis of 21 studies found that those who self-selected to AA participation, but not those who were coerced into it, gained benefits.[73]

In addition to self-help 12-step groups for individuals with SUDs, similar programs are available for the families and friends of individuals with SUDs; for example, Al-Anon (or Nar-Anon), Adult Children of Alcoholics/Dysfunctional Families, or Alateen, can become a source of support and a valuable resource for adult and younger family members, respectively.[64]

Sometimes in rural areas with smaller, “tighter” communities, where “everyone knows everyone else,” anonymity can be a concern for the patient with the SUD or other mental health problems, or for the family of the patient.  In these situations, the patient may not feel comfortable attending a public “anonymous” group, such as AA or NA. In addition, there may not even be a meeting in a particular rural community. It is important to support these patients and help them connect with other community-based programs that could be supportive, such as various clubs and other organizations that can provide extensive sober social support.  Additionally, many 12-step or other recovery groups may have phone or online meetings the patient could attend. These alternative options can be as valuable as “traditional” community-based resources and can also be a helpful adjunct to professional treatment for many individuals.  For more information refer to the Whole Health tool “Recovery-Oriented Mutual Self-Help Groups.”

Key Points: Interventions for Creating Health Plans

  • Strong therapeutic relationships are of fundamental importance.
  • Individualize care. Practical considerations, including resource availability, are important.
  • Ensure co-occurring mental health conditions are being addressed.
  • Detoxification symptoms must be given priority; some may be life-threatening.
  • Keep pharmacotherapy in mind, as it has been found to be beneficial in many circumstances.
  • Evidence-based psychotherapies like CBT, behavioral activation, behavior couples therapy, Motivational Enhancement Therapy, MI, mindfulness meditation, relapse prevention, and many other approaches have shown benefit.
  • Peer support providers can provide additional support to patients during all stages of the recovery process, from treatment through aftercare.
  • Community-based programs (mutual self-help groups) are often beneficial. Clinicians are encouraged to be familiar with programs offered in their area.

Complementary and Integrative Health Therapies

Complementary and integrative health (CIH) practices (sometimes described as mind-body practices) are a heterogeneous group of therapeutic modalities that may provide benefit, especially when added to the traditional treatments for SUDs.  They can also be effective for improving self-care, which is vital to SUD recovery.  CIH therapies include meditation, deep breathing, Guided Imagery, massage, movement therapies, relaxation techniques, acupuncture, yoga, tai chi, qi gong, hypnotherapy, music therapy, supplements, and herbals.  Overall, research on complementary and integrative interventions as treatments for SUDs is limited by a relatively modest number of clinical trials, especially randomized clinical trials (RCTs), addressing a given intervention, with small sample sizes, and heterogeneity and limitations of the utilized methodology.  The RCT design is considered “gold standard” for evaluating efficacy of therapeutic modalities.  Rigorous design (e.g., RCT), adequate power (appropriate sample size for testing of a given hypothesis), and high-quality study conduct are crucial for reducing the risk of bias and error and ability to draw accurate conclusions.  Therefore, more adequately powered, rigorous RCTs are needed to establish conclusive evidence on the efficacy of the majority of complementary approaches.  For additional information, refer to “Introduction to Complementary Approaches” and “Substance Use Disorder Treatment: Complementary and Integrative Health Approaches”  Whole Health tool.

Overall, although many CIH practices are safe for most people, it is best for patients to consult with their clinical teams prior to engaging in a particular CIH modality. For example, caution may need to be taken with any type of meditation practice in those with underlying substantial mental health issues (e.g., untreated PTSD); these patients should consult with their mental health clinician before beginning a meditation program.

Mindful-Awareness Meditation

Mindfulness meditation is a practice that trains the mind in applying nonjudgmental attention and acceptance to present moment experiences (Please see “Power of the Mind” section above for more details). In recent years, mindfulness-based interventions have become the most commonly evaluated and applied meditation interventions in clinical and nonclinical settings, with research supporting their efficacy for various mental health and physical health conditions, including SUD.[44][45][46][47][48]  In addition to its potential positive impact on recovery outcomes, mindfulness meditation-based interventions have shown benefits for depression, anxiety, pain, and stress coping, and may be effective for PTSD symptoms,[44][74][75] all common problems among Veterans and documented relapse risk factors in SUDs and addiction. [76]

Mindfulness-based approaches, especially when adjunctive to standard-of-care treatments, can help improve outcomes in SUDs,[44] however, it is unclear which persons with SUDs might benefit most from mindfulness training. Specific mindfulness-based interventions evaluated in research settings for SUD recovery include Mindfulness-Based Stress Reduction (MBSR), the most common mindfulness-based program used in medical settings, and Mindfulness-Based Relapse Prevention (MBRP), which was developed specifically for those with addiction.[77] Both programs have shown some efficacy for relapse prevention in SUD recovery. Other mindfulness-based or mindfulness-including programs evaluated in research settings include Vipassana meditation; Mindfulness-Based Cognitive Therapy (MBCT); Acceptance and Commitment Therapy (ACT); and Dialectical Behavior Therapy (DBT). Such practices are considered safe overall; no serious adverse effects have been reported in relation to mindfulness practice.

Transcendental Meditation

Transcendental Meditation (TM) practice involves concentrating on and repeating a short phrase (“mantra”) in one’s mind for a given length of time. Evidence on the efficacy of TM for SUD recovery is less extensive than for mindfulness meditation.[44][78][79][80] Limited evidence suggests potential benefits of TM practice for decreasing drug, alcohol, and tobacco use.

Yoga

Yoga is generally considered safe and healthy when practiced appropriately.  It is important for the clinician to discuss the risks and benefits of yoga with patients, as some poses should be avoided in patients with certain health conditions.[81].  Yoga can be helpful for relieving inner and outer tension and increasing a sense of well-being and connection with oneself. Although preliminary evidence suggests yoga may be a beneficial adjunct treatment, more research is needed to draw firm conclusions about the efficacy of yoga as an SUD treatment modality.[81]

Qi gong

Qi gong is a technique that combines mental focus, deep breathing, and gentle physical movement. Preliminary evidence suggests potential benefits of qigong in reducing withdrawal symptoms, craving, and anxiety in SUDs, but more research is needed. [82]

Massage

Massage can be helpful for relaxation, rejuvenation, and alleviation of muscle tension, and many people find it an enjoyable component of self-care.  Preliminary research has shown potential benefit of massage for reducing symptoms of alcohol withdrawal[83] and reducing anxiety in alcohol, cocaine, and opioid withdrawal; more research is needed to offer conclusive evidence.[84][85]

Acupuncture

Acupuncture is generally considered safe when performed by an experienced practitioner using sterile needles.[86]  Although acupuncture is usually well-tolerated when properly administered, it is important to discuss the potential risks of acupuncture in patients with certain medical conditions or who use medications increasing the risk of bleeding.[86]  Limited research evaluating the efficacy of acupuncture has produced mixed results, providing minimal evidence for its potential benefits as an adjunctive treatment for SUDs.  [87][88][89] One review and meta-analysis however, noted promise of acupuncture for reducing alcohol craving and withdrawal symptoms in those with alcohol use disorder.[90]

Energy therapies

Energy therapies (e.g., Reiki, therapeutic touch) rely on the channeling of bioenergy fields through the practitioner’s hands into the body of the patient, with the goal of restoring healthy energy flow and balance, and improving health.[49] There is no conclusive evidence to date supporting the efficacy of energy-based therapies for substance use disorder potential of transcranial magnetic stimulation (TMS) for reducing craving and substance use in alcohol, stimulant, and especially nicotine use disorders.[91][92][93]

Biofeedback

Biofeedback therapy is a process that involves training individuals to deliberately regulate bodily functions (e.g., breathing, heart rate, blood pressure) for overall health improvement.[49] There is very limited research on the impact of biofeedback on addiction outcomes, however preliminary evidence suggests potential benefits of electroencephalogram-based biofeedback for decreasing craving and mental health problem severity, and increasing abstinence rates in those with SUDs.[50][94]

Clinical Hypnosis

Clinical hypnosis is another possible tool that may help manage one’s internal landscape and response to triggers.  There is only limited research regarding its efficacy in the treatment of SUDs.  One preliminary study of Veterans with SUDs and co-occurring mental health problems treated in a specialized day treatment program has suggested positive effects of clinical hypnosis on abstinence, self-esteem, anger, and impulsivity.[95]  However, conclusive evidence is lacking for its use in addiction, calling for further research in this area. Although hypnosis is considered overall safe, research on its safety is limited. Clinicians should first assess the patient for the appropriateness of this treatment before recommending or applying hypnosis as a therapeutic modality.[96]

Music Therapy

Music therapy is another complementary approach that many people find relaxing and enjoyable; however, with only limited research evidence available, there is no consensus regarding its efficacy as an adjunctive treatment for SUDs.[97]

Biologically-based Therapies

Note: Please refer to the Passport to Whole Health, Chapter 15 on Dietary Supplements for more information about how to determine whether or not a specific supplement is appropriate for a given individual.  Supplements are not regulated with the same degree of oversight as medications, and it is important that clinicians keep this in mind.  Products vary greatly in terms of accuracy of labeling, presence of adulterants, and the legitimacy of claims made by the manufacturer.

Biologically-based therapies include the use of herbs, special macronutrient diets, megadoses of vitamins or minerals, and other nutritional supplements.  Overall, there is only very limited research, often of poor methodological quality, evaluating effects of biological therapies.  Many patients may show interest in biological therapies as “swallowing a pill” is often easier (especially when believed it is effective) than engaging in, for example, a behavioral treatment.  Although many biological therapies appear safe and may be helpful (e.g., St John’s wort, milk thistle), others may exert serious, even life-threatening, adverse effects (e.g., ibogaine, some Chinese herbal remedies, and kratom) or can lead to addiction (kratom, marijuana).[98]  Clinicians should exercise caution and appraise the evidence and safety profile of a given biologically-based therapy before approving it for their patients.

Therapies Supported by Evidence

  • Vitamin B1 (thiamine) deficiency is associated with alcohol dependence; administration of thiamine during alcohol withdrawal and prescribing it long-term in alcohol dependent patients is safe and constitutes “standard of care” in alcohol dependence[29][99].

Therapies with insufficient or inconclusive evidence on efficacy, but considered relatively safe when used appropriately

  • Early studies have suggested that 5-Hydroxytryptophan (5-HTP) may lessen alcohol withdrawal symptoms; however, more evidence is needed to confirm these findings, and this supplement should be avoided in patients with certain conditions.[100]
  • Limited research suggests that milk thistle may be helpful for the patients with alcoholic liver disease.[101][102]
  • In a small randomized trial with high attrition rate, kudzu root extract did not affect alcohol craving or drinking among Veterans in an SUD treatment program[103]; however, other preliminary research suggests decreased alcohol cravings.[104]

Therapies with inconclusive evidence on efficacy, and which may cause adverse effects

  • Evidence on kratom, ibogaine, Chinese herbal remedies (panax ginseng; panax quinquefolium; corydalis yanhusuo) and Heantos for the treatment of opioid addiction is insufficient, and some of these compounds may produce severe adverse events and have a potential for abuse.[98][105]
  • One review, focused on Chinese medicine (CM) treatments (Shenfu Tuodu, Fukang Pian, and Shifu Sheng), concluded that there is not enough methodologically sound evidence to draw any conclusions on the efficacy of CM in treating heroin addiction.[106] In addition, “there have been reports of Chinese herbal products being contaminated with drugs, toxins, or heavy metals, or not containing the listed ingredients.”[86] Some of the herbs used in CM can interact with other medications, causing serious side effects, or they can be unsafe for people with certain medical conditions.[86]

Overall, there is limited research related to the use of complementary and integrative therapies for addiction, with the exception of mindfulness meditation, which has been shown to be efficacious for the treatment of addiction.  Hypnotherapy, massage, acupuncture, various supplements, and other approaches have shown some promise, but there is a need for more research.

Follow-Up With David

Through the completion of his Personal Health Inventory and with the clinician’s guidance, David began to have a better understanding of how much the difficulty in transitioning from military to civilian status has been impacting his life.  He realized how much his comrades had meant to him and how lonely and disorganized his life has felt to him without the camaraderie and structure the Army provided.  He became aware that his drinking and drug use were the means to cope not only with nightmares but also with the transition to civilian life in general.  He reflected on his attempts to stop drinking and using opioid medications, and noted that it has truly been difficult for him to stop by himself and that he needs help.  He decided to start treatment to assist with quitting his substance use, especially after considering the negative impact alcohol and drug use has had on his relationships and health. He also identified physical activity as something he would like to resume on a regular basis.

David began making changes in his daily life by going for a short walk every morning before work.  He started taking thiamine daily, as prescribed by his doctor due to his alcohol use disorder.  He scheduled an appointment with a dually-credentialed addiction and mental health counselor who conducted a detailed biopsychosocial assessment of David’s mental health and substance use related issues.  With David’s input, and due to the concerns about active PTSD and the potential for alcohol and opioid withdrawal after ceasing substance use, the counselor connected David with a VA-based residential treatment program to help address his alcohol and drug use disorders, and mental health problems (PTSD, sleep trouble).  They agreed that, unless otherwise advised by his other clinicians, after residential treatment, David would resume weekly outpatient therapy sessions with the counselor to continue his care on a long-term basis, and get connected with a recovery coach.  The counselor also encouraged David to regularly attend 12-step meetings for peer support; engage his wife, if she is agreeable, in the outpatient treatment; and consider family therapy.

During residential treatment, David completed medically-managed alcohol withdrawal, which required a low-dose, symptom-triggered benzodiazepine therapy for two days.  He had some difficulties with increased nightmares after his detoxification and was started on prazosin at bedtime, which decreased the frequency and severity of nightmares and improved his sleep. David stayed in residential treatment for eight weeks, receiving intensive psychotherapy for SUDs and PTSD, and learning healthy coping skills.

Since the detoxification and residential treatment, David has transitioned to outpatient counseling to continue addressing his substance use and mental health disorders, has attended 12-step support groups several times per week, and has remained alcohol and drug free.  He also has also committed to a daily exercise routine and has been working with a recovery coach who is a Veteran who can assist him with “staying on track” with recovery milestones. David is still smoking but cut down the number of cigarettes he smokes per day and plans to quit in the coming weeks when he feels ready.  David and his wife have started talking about the challenges they face and how they can overcome them; they will have their first appointment for family therapy in two weeks.  He has made a conscious effort to spend some time every day with his daughter, and he has started to search online for employment opportunities that may suit his needs better.  He recently connected with a social networking website and came across an old friend, Andy, from a previous deployment who had successfully transitioned back to civilian life.  They have started regular communication by phone and online, and plan to get together in the coming months as Andy lives in a neighboring state.  David has also started meditating for a few minutes each day, especially when he feels stressed or has an urge to drink or use; he has found meditation helpful.

Personal Health Plan

Name: David

Date: xx/xx/xxxx

Mission, Aspiration, Purpose (MAP):

My mission is to reconnect with my family and what brings me a sense of purpose, to receive help for my alcohol and drug use and nightmares, to stop smoking, and to learn how to deal with daily stress.

My Goals:

  • Abstain from alcohol, drug, and tobacco use.
  • Decrease nightmares, and improve sleep.
  • Get in better physical health.
  • Reconnect with family, and connect with other Veterans.
  • Learn strategies to cope in a healthy way with stress and transition to civilian life.
  • Regain a sense of purpose.

Strengths (what’s going right already)/Challenges:

Strengths

  • I’m motivated by having a sense of purpose and responsibility.
  • Hiking in the woods is something I do to help clear my mind when I have a lot on my mind.

Challenges

  • I lost the sense of purpose and camaraderie I had while in the Army.
  • Nightmares keep me up at night and cause me stress.
  • I’m overwhelmed by stress, family life, and used substances to cope.

My Plan for Skill Building and Support

Mindful Awareness:

  • Begin practicing mindfulness meditation at home. Let thoughts of the past or future fall away, and focus attention on the present moment. Allow awareness to rest on breathing–not controlling breathing, but just noticing each breath in and each breath out. When the mind drifts away from noticing the breath, just gently guide it back to simply noticing breathing. Notice the sensation of air coming in and going out of the nostrils during each inhale and exhale; or notice the chest or belly rising and falling. Allow your awareness to rest on the breath. Try to practice for at least 2 minutes each day.
  • When there is an urge to drink, smoke, or use drugs, take a couple minutes to pause and gently notice the thoughts, emotions, sensations, or actions that are happening right now. This process can help bring mindful awareness to possible triggers to use substances. Actively working toward developing mindful awareness of what is happening within me and around me in the present moment will help me progress toward my goals.

Areas of Self-Care:

  • Moving the Body
    • Exercise can reduce stress and improve mental health, sleep, and overall physical health. Start by walking daily, and consider calling local gyms to identify one to join. Start a minimal- to moderate-intensity exercise program at home or at a gym to help with stress reduction and addiction recovery.
  • Surroundings
    • Take time to consider surroundings both at home and at work. Become aware of my surroundings to help identify sources of security or stress and ask if it is something I would like to change. Work with a counselor to address stressors and how to manage them.
  • Personal Development
    • Take time to assess the amount of uplifting, nourishing, and rejuvenating activities in my life, compared to the depleting activities, which drain my energy. Identify whether there is an adequate balance of self-care in my daily Begin by exploring online job search engines to identify jobs that may bring fulfillment.
  • Food and Drink
    • People who excessively drink alcohol often develop a vitamin B1 (thiamine) deficiency. Start daily thiamine supplements, as prescribed by my clinician. Well-balanced diet will promote health in general and may also aid recovery.
  • Recharge
    • Sleep, typically 7-9 hours per night, is essential to improving stress coping, energy level, and restoration. Take some time before sleep to meditate. Work with a counselor to address nightmares and other symptoms that prevent restorative, healthy sleep.
  • Family, Friends, and Co-Workers
    • Connect with a counselor to address marital and family relationship difficulties, and seek out support groups. Connect with a recovery coach to help support ongoing recovery goals. Reach out to friends who have returned from active duty and other people I have positively connected with in the past.
  • Spirit and Soul
    • Add hiking in the woods to my weekly routine to nurture my connection to nature, and provide inner nourishment.
  • Power of the Mind
    • Start by practicing some mindfulness of breath exercises. Talk to a counselor to learn additional strategies for relaxation, coping, and stress management.

Professional Care: Conventional and Complementary

  • Prevention/Screening
    • Up-to-date
  • Treatment (e.g., evidence-based psychological treatments, medications, complementary and integrative approaches, supplements)
    • Substance use disorder and mental health counseling
    • Patient education about addiction, PTSD, and sleep hygiene
    • Cognitive Behavioral Therapy for sleep problems
    • Marital/family therapy
    • Recovery coach to support ongoing recovery goals
    • Daily physical activity
    • Daily mindfulness meditation
    • Medications: nicotine replacement therapy for nicotine use disorder; thiamine 100 mg daily due to alcohol use disorder; prazosin at bedtime for PTSD-related nightmares and sleep problems
  • Skill building and education
    • Mindfulness meditation
    • Nutrition
    • Sleep hygiene
    • Healthy exercise routine

Referrals/Consults

  • Substance use disorder and mental health specialty provider to help address substance use, PTSD, and sleep problems. Oftentimes addiction and substance use in general, and PTSD or other mental health symptoms are closely linked.
  • Start attending 12-step groups such as Alcoholics Anonymous and Narcotics Anonymous, which have a spiritual orientation, and/or SMART Recovery, which is not spiritually focused. These mutual self-help groups are free, anonymous, and provide support to those who are in SUD and addiction recovery.

Community Resources

My Support Team

Next Steps

  • Start walking daily
  • Schedule an appointment with a substance use disorder and mental health specialty clinician
  • Schedule an appointment with a recovery coach
  • Consider the above suggestions to see what resonates most
  • Follow up within the next 2 months to check on your progress.

Please Note: This plan is for personal use and does not comprise a complete medical or pharmacological record, and does not replace your medical record.

Resources

Resources For Patients

Resources For Clinicians (education, programs, guidelines, toolkits)

Alcohol and Drug Use and Misuse Related Resources

Nicotine Use Disorder Related Resources

Author(s)

“Substance Use Disorder” was written by Aleksandra Zgierska, MD, PhD and Cindy A. Burzinski, MS, CSAC, LPCT (2014, updated 2019).

This Whole Health overview was made possible through a collaborative effort between the University of Wisconsin Integrative Health Program, VA Office of Patient Centered Care and Cultural Transformation, and Pacific Institute for Research and Evaluation.

References

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