Substance Use Disorders

Introduction

Substance use disorders (SUDs) are among the most common and costly medical problems in Veterans and active duty military personnel.[1] In 2011, over 70% of patients in specialty care programs were tobacco-dependent.[2] Combat exposure is a risk factor for SUDs, including tobacco use, just as it is for other mental health problems, including post-traumatic stress disorder (PTSD) and major depression.[3] SUDs and mental health conditions frequently co-occur as a “dual diagnosis.” Approximately one-third to a half of patients seeking treatment for SUDs also meet criteria for PTSD, with some studies reporting even higher prevalence of PTSD among those with SUDs.[4] Individuals often use substances to self-medicate symptoms of physical or mental health conditions, or stress.

Screening and Brief Intervention (SBI)

It is essential to identify not only people who have SUDs but also those who are at risk for developing SUDs. Routine screening of adults for tobacco use[5] and unhealthy alcohol use,[6] followed by brief behavioral counseling (often based on motivational interviewing principles) when needed, have been shown to reduce tobacco use and drinking, respectively, and related harms in primary care and mental health settings. For alcohol, evidence for efficacy is strongest for brief (10-15 minutes) multicontact interventions for nondependent drinkers.[7] Although evidence on the efficacy of drug SBI[8] is still limited and inconclusive, due to the scope of drug use–related problems (especially prescription-based drugs) and the successes of tobacco and alcohol SBI services, many professional organizations recommend implementation of routine drug SBI for adults in primary care.[9,10]

Barriers to Seeking Help

Barriers to seeking help may include stigma and negative beliefs about mental health and addiction-related care, general discomfort with “asking for help,” a “zero tolerance” approach to drug misuse in active duty members, and confidentiality concerns, including the sharing of protected medical records between the VA and the Department of Defense (DoD).[1]

Treatment Considerations

  • Address all areas of life that have been affected by substance use, providing the patient with appropriate tools supporting recovery in these areas.
  • Assess for and treat mental and physical health conditions co-occurring with SUDs; concurrent treatment of co-occurring mental health problems (e.g., anxiety) and SUDs (“dual diagnosis”) is critical for the success of recovery.[11]
  • Address potential barriers to healthy recovery, especially those that may increase relapse risk and affect treatment engagement.[1]
  • Determine the appropriate level of care to best support the patient’s recovery (refer to the section below).
  • Collaborate with the patient in the development of recovery goals,[1] and tailor the treatment plan to the patient’s individual needs and preferences.
  • Closely monitor treatment progress, especially in early recovery when relapse risk is highest.[1]

Levels of Care/Treatment Modalities

Residential treatment: Patients reside at the treatment facility for weeks to months and receive intensive behavioral treatment daily, in group and individual therapy settings

Intensive outpatient/day treatment: Patients attend group and/or individual therapy sessions several hours per day, several days per week in the outpatient settings

Outpatient treatment: Patients attend group and/or individual therapy sessions weekly or less frequently, based on individual treatment needs

Detoxification: Patients receive medical monitoring, treatment, and support during detoxification

Recovery from addiction and maintenance of recovery is an ongoing process that should be integrated into the patients’ daily life. Early-recovery programs (detoxification, residential, day, or outpatient treatments) are often intensive; they can help patients lay a foundation for successful recovery but are not “terminal” treatment programs by themselves. After early-recovery treatment is completed, it is best for the patient to get engaged in aftercare (continued care) outpatient programs for continued support while building on treatment gains and progressing in recovery.

Detoxification

Detoxification is often the first step in SUD treatment. This process can be psychological or both physical and psychological. Tobacco, alcohol, benzodiazepines, and opioids are common substances that cause physical dependence, with a resulting withdrawal. Alcohol and benzodiazepine withdrawal syndrome can be life threatening if untreated; it is critical to assess the patient’s current medical situation as well as past medical history for conditions that increase the dangers of symptomatic withdrawal. Patients with current symptoms or past history of 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. Benzodiazepines are the first-line treatment for alcohol withdrawal. Opioid withdrawal is not life-threatening from a medical perspective; however, it can produce severe symptoms that are difficult for the patients to manage and endure, often leading back to substance use. Clonidine, buprenorphine, or methadone can alleviate symptoms of and be used in the treatment of opioid withdrawal.

Pharmacotherapy

Pharmacotherapy can aid recovery from substance dependence and enhance outcomes in some SUDs (refer to the section below), especially opioid dependence and tobacco dependence.[12]

Commonly Prescribed “Maintenance” Pharmacotherapy

Alcohol

  • Naltrexone should not be used in patients requiring opioid therapy for pain. Extended-release injectable naltrexone can result in better outcomes compared to the daily oral preparations.
  • Acamprosate can additionally have antianxiety effects.
  • Disulfiram is often reserved for more refractory cases and recommended to be taken in a witnessed fashion.

Opioids

  • Methadone can be administered through licensed programs only.
  • Buprenorphine can be prescribed as an office-based therapy by physicians trained in buprenorphine prescribing.
  • Naltrexone should not be used in patients requiring opioid therapy for pain. Extended-release injectable naltrexone can result in better outcomes compared to the daily oral preparations.

Tobacco

  • Nicotine replacement therapy is often recommended as scheduled daily doses (transdermal patch) plus as-needed doses (e.g., gums, lozenges, or inhalers) for “break-through” nicotine craving.
  • Varenicline may alter mood and increase the risk of depression and suicidal ideation; when using this medication, screening and monitoring for depression is recommended.
  • Bupropion, as an atypical antidepressant, is also used as a therapy for depression.

OPIOID OVERDOSE WARNING

Those who abstained from opioids, even for a relatively short period of time, are at increased risk for accidental overdose. It is critical to educate patients about the danger of unintentional overdose after a period of “staying clean.” With abstinence (or even reduced use), the individual’s tolerance level for the drug decreases; resorting to using prior (e.g., prerelapse) doses of opioids can cause overdose and death. Injectable-naloxone kits may help prevent a fatal opioid overdose in active users.

Opioid Overdose Prevention Toolkit

Whole Health Approach to the Treatment of SUDs

High-quality holistic, integrated care should provide services for SUDs as well as the other areas of life that can be affected by SUDs: mental health; physical health; nutrition and exercise; rest and self-care; coping and communication skills; self-awareness; connection with others and self; growth and goal-setting; employment and housing; and general recovery and reengagement in life without the use of substances.

Surroundings (physical and emotional environment)

  • Risk factors for relapse (“triggers”) are often unique and specific to the individual.
  • Physical and emotional surroundings (“external triggers”) can trigger cravings or urges to use a substance during recovery, and precipitate relapse.
  • Negative emotional states (“internal triggers”) are known risk factors for relapse.
  • Some common risk factors for relapse have become known under the acronym of “HALT” (Hungry, Angry, Lonely, Tired).
  • Bringing awareness to one’s physical and emotional surroundings, identifying and then reducing or eliminating external and internal personal risk factors for relapse are critical aspects of relapse prevention and recovery.

Food and Drink (nutrition and fuel)

  • In SUDs, nutrition and related health often suffer.
  • Individuals with SUDs should strive to avoid any addictive substances, as their use can lead to a pattern of misuse and compromise recovery.
  • A healthy diet positively influences health in general, and may ease the detoxification process, facilitate recovery, and impact craving.[13]
  • Excessive consumption of alcohol affects carbohydrate, lipid, and protein metabolism, and absorption of vital nutrients;[13] it is a common medical practice to recommend a daily multivitamin and thiamine supplementation for alcohol-dependent individuals.

Recharge (rest and sleep)

  • Poor sleep, tension (stress), and negative affective states increase the risk of relapse in SUDs.[14]
  • Adequate sleep, rest, and relaxation are essential components of self-care, optimal functioning, healing, and recommitting to a healthy lifestyle in recovery.
  • Although adults typically need between 7 and 9 hours of good-quality sleep per night, optimal sleep patterns and requirements are person-specific.[15]

Working Your Body (energy and flexibility)

  • Physical exercise can benefit physical fitness and cardiovascular health, improve psychological health and energy, and help reduce symptoms of tension or stress, anxiety, depression, and sleep problems—all known relapse risk factors.[16]
  • Exercise can exert positive effects on the brain’s reward systems, which are often affected by substance use.[16]
  • 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.[17]

Personal Development (personal life and work life)

  • Personal and work-related activities can affect one’s sense of well-being.
  • It is important, especially in recovery, to ensure that one has an adequate “supply” of positive, nourishing activities, and minimizes the impact of draining or negative activities in daily life.
  • Goal setting, exploring personal values, connecting with others and self, taking responsibility for one’s actions, achieving life balance, and addressing the underlying issues that have been related to substance use are all areas that can promote personal development.

Family, Friends, and Coworkers (listening and being heard)

  • Spending time with those who are using substances is a known risk factor for personal substance use and should be limited or avoided, especially early in recovery.
  • Patients should be encouraged to consider opportunities to find and/or create a personal substance-free support network, as healthy social support is important for the success of recovery from SUDs.
  • Support can come from mutual self-help group involvement, religious communities, community groups, and friends and family.
  • Educating family and other key individuals about SUDs and recovery can further aid recovery.

Spirit and Soul (growing and connecting)

  • Perceived connection to others can help decrease the sense of isolation that can contribute to relapse.
  • Spirituality can be defined broadly and may not necessarily include any religion.
  • Spiritual or religious involvement can be a protective factor against SUDs and relapse.[18,19]
  • Spiritual self-schema (3-S), a spiritually anchored intervention, may help decrease impulsivity, drug use, and other HIV risk behaviors.[20,21]

Power of the Mind (relaxing and healing)

Mindfulness meditation

  • Mindfulness-based interventions have shown some efficacy for physical and mental health conditions,[22] including depression, anxiety, pain, and stress coping. [23]
  • Cultivating skills in mindful, nonreactive awareness to relapse triggers (thoughts, feelings, sensations, environmental factors) is an important part of relapse preventions and self-management in recovery.
  • Mindfulness-based approaches, especially when used as an adjunct to standard-of-care treatments, can help improve outcomes in SUDs.[23-25]
  • Mindfulness-based stress reduction (MBSR) is the most common mindfulness program used in medical settings. Mindfulness-based relapse prevention (MBRP), although patterned after the MBSR, was developed specifically for relapse prevention in SUDs. Both programs have shown some efficacy for relapse prevention in SUDs. Other programs evaluated in research settings include Vipassana meditation, spiritual self-schema (3-S), acceptance and commitment therapy (ACT), and dialectical behavior therapy (DBT).

Transcendental meditation

  • Transcendental meditation has shown potential benefits in SUDs that may include decreased drug, alcohol, and tobacco use;[26] however, research evidence is limited and inconsistent.[27]

Substance Use Treatment Interventions

Evidence-based psychological treatments (EBPT) are a recommended, first-line approach to the treatment of SUDs. They can be delivered in a variety of formats (individual, group, or couples therapy) and settings (residential, day treatment, outpatient), and they can vary in duration, frequency, and intensity. Effective EBPTs have been shown to enhance patient motivation to stop or reduce substance use, improve self-efficacy, promote a therapeutic alliance, strengthen coping skills, reinforce contingencies crucial for recovery, and strengthen social support for recovery.[28] There is no evidence that one type of intervention is superior to others[29,30] However, motivational interviewing and cognitive behavioral therapy–based interventions may be particularly well suited for patients with SUDs and co-occurring mental health conditions (“dual diagnosis”), such as depression or anxiety.[31] Adding contingency management to a treatment plan may help reduce treatment dropout rate.[32] Marital and family therapy can help families cope with the challenges of living with a SUD-affected person, and motivate the patient to enter treatment.[33] In addition, screening and brief interventions are evidence-based brief services, shown to be effective for harm reduction in SUDs, particularly tobacco and unhealthy alcohol use, and feasible for implementation in primary care (refer to the Screening and Brief Intervention section at the beginning of this handout for more information).

Evidence-based psychological treatments showing benefit for SUDs[28],[31-33]

  • Behavioral activation
  • Behavioral couples therapy (BCT)
  • Cognitive behavioral coping skills training
  • Cognitive behavioral therapy (CBT)
  • Community reinforcement and family training (CRAFT)
  • Contingency management/motivational incentives
  • Motivational enhancement therapy (MET)
  • Motivational interviewing (MI)
  • Relapse prevention
  • Twelve-step facilitation

Community-Based Recovery Programs

Community-based programs (or mutual self-help groups) include 12-step programs (such as Alcoholics Anonymous [AA], Narcotics Anonymous [NA], and other related programs). These programs are free, anonymous, and easily accessible. Many of these programs, especially those based on the 12-step model, have a general spiritual foundation (not necessarily religious), and do not require any specific spiritual or religious background for participation. SMART Recovery (Self-Management And Recovery Training), a science-informed approach, can provide an alternative to 12-step self-help groups. Research evidence provides support for the efficacy of mutual self-help 12-step programs for relapse prevention (refer to the section below).

In addition to 12-step programs for individuals with SUDs, similar, parallel programs are available for their families and friends; for example, Al-Anon or Alateen can become a source of support and valuable resource for adult and younger individuals with SUDs, respectively.[33]

Research Supporting 12-Step Groups

  • Community-based recovery programs (mutual self-help groups) have been shown to lead to improvements in SUD outcomes for individuals who are engaged in the programs;[34-36] active participation in these groups increases the likelihood of a successful, long-term recovery.[37,38]
  • Both meeting attendance and involvement in prescribed 12-step activities, especially in the earlier stages of recovery, have been related to improved outcomes and abstinence in SUDs.[39]
  • Compared to receiving support from non-AA members, support from AA members has been shown to be beneficial for maintaining abstinence.[38,40]
  • AA meeting attendance and having a sponsor (an AA member functioning as a mentor for AA-based recovery) were identified as the strongest predictors of abstinence over time.[41]

Complementary and Alternative Medicine Therapies

Among the complementary and alternative medicine (CAM) interventions, meditation interventions have received the most scientific attention, with evidence supporting the efficacy of mindfulness meditation-based interventions for relapse prevention in SUDs, as outlined above (“Power of the Mind”). Several other CAM modalities may provide potential benefits as adjunct treatments for SUDs. Limited or very limited research evidence exists for the efficacy of acupuncture, massage, yoga, energy therapies (e.g., qi gong, Reiki, therapeutic touch), hypnotherapy, and music therapy in SUDs.[42-49]

Of note, these CAM therapies are considered generally safe, and in addition to their potential positive effects on SUDs, they may help improve self-care, which is a vital component of successful SUD recovery. Very limited research has evaluated the effects of transcranial magnetic stimulation (TMS) and of electroencephalogram (EEG) biofeedback; these specialized modalities may also be beneficial in SUDs.[50,51]

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. Administration of vitamin B1 (thiamine) in alcohol withdrawal and prescribing it long-term in alcohol-dependent patients is safe and a part of “standard of care” for alcohol dependence.[12,43]

Overall, there is only very limited research, often of poor methodological quality, evaluating the effects of other biological therapies. Of note, while many of these therapies appear safe and may be helpful (e.g., St. John’s wort, milk thistle, or kudzu root), some may exert serious, even life-threatening, adverse effects or have a potential for abuse (Kratom, Ibogaine, Heantos, some of the Chinese herbal remedies);[52] clinicians should exercise caution before endorsing any non-well-studied biologically based therapies to their patients.

Resources for More Information

Patient Resources


Provider Resources


Alcohol and drug use—related resources

Smoking cessation—related resources

General resources

Author(s)

“Substance Use Disorders” was written by Aleksandra Zgierska, MD, PhD and Cindy A. Burzinski, MS, LPCT, SACIT (2014).

References

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