Clinical Care Guideline: Substance Use Disorders

It was estimated that in in 2024, 48.4 million Americans aged 12 or older (or 16.8 percent of the population) had a substance use disorder (SUD) in the past year, including 27.9 million people who had an alcohol use disorder (AUD) and 28.2 million people who had a drug use disorder (1). Drug overdoses are one of the leading causes of injury death in adults with an estimated 79,384 drug overdose deaths in 2024. Overdose death rates including those involving synthetic opioids (such as fentanyl) and stimulants (such as cocaine and methamphetamine) have significantly increased over the past several decades with some leveling off and even decreasing in the last few years (2). However, the number of Americans aged 12 or older who had a past year drug use disorder increased from 24.5 million (or 8.7 percent of the population) to 28.2 million (or 9.8% of the population) in 2024 (1). Cannabis is the most commonly used drug and decrease in perceived risk has led to an increase in use. However, cannabis use has been linked to mental health and physical health issues, including impact on cognitive functions and association with psychosis (3). 

This care guideline is intended to equip psychiatric providers with a brief summary of the evidence-based, best-practice knowledge for the effective treatment of Substance Use Disorders (SUD). 

Diagnostic Considerations for Substance Use Disorder               

The criteria below apply to adults and children/adolescents:    

Note: The criteria below apply to various substances. 

• A pattern of use that causes a clinically significant impairment or distress manifested by two or more of the following within a 12 month period:
  • A desire to cut down use or unsuccessful efforts to control or cut down usage
  • Using larger amounts than intended or over a longer period of time 
  • Cravings for the substance
  • Tolerance
  • Withdrawal without substance
  • Recurrent use when it is physically hazardous 
  • Important occupational, social, and recreational activities are given up or reduced due to the use
  • Recurrent use despite having physical or psychological problems exacerbated by the substance 
  • Continued use despite having social or interpersonal problems related to the substance
  • Failure to fulfill obligations at work, home, and school
  • A great deal of time is spent on finding, using, or recovering from the substance
• The severity of symptoms:
  • Two to Three symptoms - MILD
  • Four to Five symptoms - MODERATE
  • Six or more symptoms - SEVERE
• Different types of SUD in the DSM-5
  • Alcohol Use Disorder
  • Opioid Use Disorder (kratom can fall under this)
  • Sedative, Hypnotics, or anxiolytic use Disorder 
  • Nicotine Use Disorder
  • Phencyclidine Use Disorder
  • Other-Hallucinogen Use disorder (MDMA, psilocybin, LSD, salvia)
  • Inhalant Use Disorder (paint, solvent, fuel, glue, etc)
  • Stimulant Use Disorder (doesn’t include medications given under medical supervision)
  • Cocaine Use Disorder 

It is important to note that substances can be used to help cope and deal with other mental health disorders such as depression, anxiety, trauma-related disorders, insomnia, bipolar, and personality disorders. As a result, a clinical best practice is to engage in a differential diagnostic assessment before determining co-occurring conditions. 

For complete diagnostic criteria of Adjustment Disorder, consult the Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.). American Psychiatric Association. (2022). https://doi.org/10.1176/appi.books.9780890425787

When documenting care, be sure to include the specific symptoms of SUD experienced by the patient. This ensures your note reflects alignment with the diagnosis and demonstrates the medical necessity for the service.

Symptom Screening and Monitoring

There are various screening and assessment tools that can be implemented. A great resource to help select what tool to use is the NIDA Screening and Assessment Tools Chart.

When assessing substance use disorders in adolescents, the psychiatric provider needs to remember that substance use cannot be disclosed to legal guardians without an ROI as this is protected under confidentiality.

Substance use disorders are often co-occurring with several other mental health issues including depression, anxiety, trauma-related disorders, conduct problems, bipolar disorder, impulsivity, etc. When assessing for other co-occurring conditions, it is important to get a thorough history to determine if any of these disorders were substance-induced.

• For example, a patient may be using methamphetamine and/or cocaine when they experience a manic/hypomanic episode. It is the psychiatric provider's responsibility to determine if the manic/hypomanic symptoms were due to substance use or led to substance use which is where a thorough history/assessment is essential. Evidence of symptoms preceding the onset of substance use, symptoms persisting for a substantial period of time (e.g., about 1 month) after the cessation of acute withdrawal or severe intoxication, or history of recurrent non substance-related episodes are all in support of an independent mental health disorder. However, we must treat current symptoms regardless of etiology. 

When treating substance use disorders it is the psychiatric provider's responsibility to monitor response to treatment. There are times when the patient may benefit from a higher level of care such as inpatient detox, residential treatment, partial hospital program and/or intensive outpatient treatment, or in-person psychiatry to help manage their substance use. When determining the level of care, it is important to review the usage (what, frequency, quantity, etc.) of the substance and level of impairment as well as any co-occurring mental health disorders and medical comorbidities. The American Society of Addiction Medicine Criteria (ASAM) provide a clinical framework to help determine the appropriate level of care. Rula’s Care Coordination team can support with referrals to SUD-specific Outpatient, Intensive Outpatient (IOP),  Partial-Hospitalization Programs, and planned admissions to inpatient/residential programs including medical detox. Patients should be directed to call 911 or go to the nearest emergency room in case of severe withdrawal symptoms or intoxication.

When asking patients about substance use, it is important to remain objective and empathetic. Addiction is not a random event, a choice, or laziness but a chronic illness similar to diabetes or hypertension. Many people will not openly discuss their substance use so it is important for the psychiatric provider to ask questions about substance use in detail.  Motivational interviewing is key to help guide the treatment. It is important to understand the stage of change that the patient is in. Refer to this useful guide about stages of change and motivational interviewing.

Evidence-Based Approaches to Treatment 

At Rula, the substance use disorders that we come across as psychiatric providers are most commonly alcohol, cannabis, and tobacco use disorders. We will focus on these substances primarily for evidence-based treatment approaches while briefly touching on other use disorders. 

Psychotherapy

• Cognitive behavioral therapy (CBT)
• Motivational interviewing (MI)
• 12-step facilitation 
• Community reinforcement approach
• Recovery-focused behavioral therapy
• Peer linkage and network support 

When treating substance use disorders with psychotherapy, it is important for the therapist to help the patient understand the root problem of the addiction. It is recognized that SUD co-occurs frequently with other psychiatric disorders including depression, anxiety, trauma-related disorders, and bipolar disorders. The therapist can then manage the SUD by also treating the co-occurring psychiatric disorder with specific evidence-approved psychosocial interventions including trauma-related psychotherapy. This informed consent about treatment approaches results in shared decision-making between patient and therapist.

Medications

Alcohol:

Alcohol use disorder as well as alcohol intoxication/withdrawal can pose a significant risk to the patient. It is important when assessing treatment for intoxication/withdrawal that the psychiatric provider takes into account the below to determine the level of care and withdrawal risk:

• History of alcohol withdrawal delirium 
• History of alcohol withdrawal seizure 
• Numerous prior withdrawal episodes in the patient’s lifetime (kindling effect) and severity of past withdrawal symptoms
• Comorbid medical or surgical illness including but not limited to cardiac conditions, neurological conditions (especially traumatic brain injury), and medications the patient may be taking
• Pregnancy
• Older age (>65) 
• Long duration of heavy and regular alcohol consumption
• Concomitant use of other addictive substances
• Physiological dependence on GABAergic agents such as benzodiazepines or barbiturates
• Seizure(s) during the current withdrawal episode 
• Hallucinations during the current withdrawal episode
• Marked autonomic hyperactivity on presentation 
• Unstable vital signs
• Over-sedation
• Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) scores
  • CIWA score of less than 10 indicates minimal withdrawal 
  • CIWA score greater than 10 can indicate a risk for severe withdrawal
  • CIWA score greater than 19 indicates severe withdrawal and should be managed inpatient care with medical monitoring 

Ultimately, the level of care should depend on the patient's current signs and symptoms and the risk of developing complicated/severe withdrawal.

It is important to order labs when managing alcohol use disorder. Include in lab panel CBCD, CMP, Hepatitis screening, and STI screening (if consents to this).

Managing alcohol intoxication/withdrawal in an outpatient setting

Uncomplicated alcohol withdrawal management can sometimes be managed in ambulatory settings. However, it is recommended that providers refer their patients in need of alcohol withdrawal management to addiction services as a general telehealth outpatient setting such as Rula does not allow for the appropriate level of monitoring. 

To learn more about recommended evidence-based treatment for alcohol withdrawal management, refer to this practice guideline developed by the American Society of Addiction Medicine.

Medications for AUD (MAUD) 

Three medications are FDA-approved to treat AUD. You don’t need specialized training or licensing to prescribe those medications.

• Naltrexone 
  • Available in either daily oral or monthly injectable extended-release forms
  • Blocks opioid receptors involved in the rewarding effects of alcohol
  • Can be started when the patient is still drinking
  • Patient should be opioid free for at least 7-14 days otherwise it will trigger withdrawal 
  • Patient needs to inform their provider that they are taking naltrexone in case of surgery
  • LFTs should be checked at baseline before initiation and monitored on a regular basis (see Medication Monitoring Guidelines) and naltrexone is contraindicated in case of cirrhosis 
• Acamprosate (Campral)
  • Two pills three times per day 
  • Interacts with GABA and glutamate receptors and helps alleviates the emotional discomfort (e.g., anxiety, restlessness, dysphoria, and insomnia) associated with protracted withdrawal 
  • Should be initiated as soon as possible after withdrawal when the patient is no longer drinking
  • Contraindicated in case of renal impairment 
• Disulfiram (Antabuse) 
  • One pill once a day 
  • Interferers with alcohol metabolism causing flushing, nausea, and other symptoms when alcohol is consumed and all alcohol products should be avoided as it could lead to severe side effects
  • Should never be administered until patient has abstained from alcohol for at least 12 hours
  • Indicated for highly motivated patient for whom abstinence is the goal
  • LFTs and renal function should be assessed at baseline and LFTs monitored on a regular basis (see Medication Monitoring Guidelines)

To learn more about recommended evidence-based treatment for AUD, refer to this resource developed by the National Institute on Alcohol Abuse and Alcoholism.

Cannabis:

It was once believed that cannabis didn't cause withdrawal symptoms. However, recent evidence shows that heavy THC users do experience withdrawal, even though it's not yet listed in the DSM-5. Symptoms that typically begin about 24 hours after stopping cannabis use include:

• Anxiety
• Irritability
• Restlessness
• Low appetite
• Sleep disturbance
• Tremors
• Tachycardia
• Diaphoresis
• GI discomfort (nausea, vomiting, diarrhea)
• Depression

Generally, the patient does not need pharmacological interventions for THC withdrawal management . Cannabis withdrawal symptoms often appear 1 day after abstinence, peak during days 2-6 and remit around 2 weeks. The psychiatric provider should assess for the above in addition to depression and suicidal ideation as well as anxiety. Below are some medications that have been studied to help address ongoing withdrawal or unmasked mental health symptoms after cessation of THC:

• Buspirone (Buspar) - targets ongoing anxiety
• Trazodone - targets ongoing sleeping issues
• SSRIs/SNRIs - target ongoing depressive symptoms

Medications for Cannabis Use Disorder

There are currently no FDA-approved medications for Cannabis Use Disorder; however, the medications below have been researched and shown to have some benefits. If a psychiatric provider is going to recommend the below, it is important to educate the patient that these are not FDA-approved. 

• Gabapentin
• N-acetylcysteine (NAC)
• Topiramate

To learn more about Cannabis Use Disorder, refer to this resource.

Nicotine:

When assessing nicotine dependence, the psychiatric provider can use this rating tool Fagerstorm test.

Patients can experience nicotine withdrawal which includes the following:

• Dysphoric mood
• Irritability
• Anxiety
• Insomnia
• Restlessness
• Decreased heart rate
• Increased appetite 
• Difficulty concentrating

When a patient stops using nicotine, the provider should assess potential effects on patient medication levels because nicotine is metabolized through the CYP-450 system which most psychiatric medications are metabolized through as well. It is important to make appropriate medication adjustments. 

Medications for Nicotine Use Disorder

FDA approved medications for Nicotine Use Disorder include Nicotine Replacement Therapy (NRT), bupropion, and varenicline. Patients should establish a quit date within 1–2 weeks of initiating medication treatment. Medications can be combined for better response, especially for patients with more severe nicotine dependence. 

• Nicotine Replacement Therapy (NRT)
  • Available in patch, gum, lozenge, nasal spray, inhaler – OTC or by prescription
  • Different NRT formulations can be combined for better coverage of both baseline withdrawal control (patch) and breakthrough cravings (gum, lozenge, nasal spray, inhaler)
  • NRT can be combined with bupropion or varenicline for better efficacy
  • NRT is usually tapered over 8-12 weeks depending on patient response
• Bupropion SR (Zyban)
  • By prescription only
  • BID dosing for 3-6 months
  • Black box warning (suicidality)
  • Can be combined with NRT or varenicline for better efficacy
• Varenicline (Chantix):
  • By prescription only
  • BID dosing for 3-6 months
  • Black box warning for neuropsychiatric side effects was removed in 2016
  • Can be combined with bupropion or NRT for better efficacy

Stimulants/Methamphetamine:

• May need to utilize antipsychotics during the intoxication/withdrawal phase
• There are no FDA approved medications to treat Stimulant Use Disorder
• There are supporting data for the use of the following:
  • Bupropion and naltrexone in combination (4)
  • Topiramate
  • Mirtazapine
• There is some evidence supporting the use of psychostimulant medications but this is not something that should be done in a general telehealth outpatient setting such as Rula

To learn more about Stimulant Use Disorder treatment, refer to this practice guideline developed by the American Society of Addiction Medicine (ASAM).

Sedatives/Hypnotics:

Benzodiazepines and controlled hypnotics must be prescribed cautiously and in alignment with best practices and Rula’s controlled medication prescribing policy and if the provider’s state regulations allow per Rula Psychiatric Network Quality Standards. It is considered best practice to limit the use of those medications to reduce the risk of adverse events including misuse and addiction. Provider should review Rula Control Substance Prescribing Guide to learn more about best practices.

It can take several months to taper off of benzodiazepines. Utilizing a longer-acting benzodiazepine can help with tapering. It is important to monitor CIWA-B sores and vital signs to determine if HLOC is indicated as benzodiazepine withdrawal carries the same risks as alcohol withdrawal including seizures, autonomic instability, and delirium tremens. 

To learn more about benzodiazepine tapering, refer to this practice guideline developed by the American Society of Addiction Medicine (ASAM).

Opioids:

When managing opioid withdrawal, providers can use the Clinical Opiate Withdrawal Scale (COWS) to assess the severity of symptoms. 

The following medications can be used to mitigate the symptoms of opioid withdrawal:

• Clonidine
• Lucemyra 
• Hydroxyzine/Gabapentin for anxiety
• Suboxone (not utilized at Rula)
• Methadone (not utilized at Rula)

Medications for Opioid Use Disorder 

Three medications are FDA-approved to treat OUD. Only one, naltrexone, is offered at Rula.

• Naltrexone 
  • Available in either daily oral or monthly injectable extended-release forms
  • Patient should be opioid free for at least 7-14 days otherwise it will trigger withdrawal
  • Patient must be educated that taking naltrexone will lower their tolerance to opioids which could increase their risk of overdose in case they were to resume the use of opioids
  • Discuss that if they need surgery they will need to inform their provider that they are taking naltrexone
  • LFTs should be checked at baseline before initiation and monitored on a regular basis (see Medication Monitoring Guidelines) 
• Suboxone
  • Not currently offered at Rula
• Methadone
  • Only available in a certified Opioid Treatment Program (aka, methadone clinic) 

Critical: Providers must always order Narcan for patients with OUD.

To learn more about Opioid Use Disorder treatment, refer to this practice guideline developed by the American Society of Addiction Medicine (ASAM).

When discussing treatment approaches with patients and significant others, it is important to discuss the impacts of substance use on the body and mind. Here are some helpful tips to use when engaging a patient about SUD treatment.

• Consider past treatment for substance use
• Use motivational interviewing 
• Using Alcohol Anonymous (AA), Narcotics Anonymous (NA), SMART, DHARMA
• Provide treatment in a setting that promotes safe and effective care
• Do not automatically discharge a patient or judge a patient that drops out of treatment or returns to use
• If a patient drops out of care, re-engage the patient and their support system
• If a patient does not want to engage in treatment, the psychiatric provider can continue to utilize MI to help engage the patient while providing safe care for other comorbid conditions.  

Assessing Risk and Higher Level of Care Needs

Research suggests people with a substance use disorder have a higher risk of suicidal thoughts. Conducting routine screening of symptom severity, engaging in regular assessment of risk, completion of a safety plan, and referral for additional services (such as IOP, PHP, and group therapy) if clinically indicated are all critical components of supporting safety for patients who have been using substances. 

What if my patient has passive SI and/or chronic SI?

There are times when patients will endorse passive SI and/or chronic SI. It is important to complete the C-SSRS to determine the risk level of the patient, if the patient is not a high risk with active SI, then we can engage the patient in the following ways

• The first step for a patient who is expressing passive and/or chronic SI is to identify protective factors and future orientation. 
• Next, we should complete a safety plan in collaboration with the patient. We use the Stanley-Brown Safety Plan. It is important to do this with the patient to engage them in their treatment. 
• It is important to document that a safety plan was completed and patient agrees to safety
• Sometimes patients may struggle to answer questions on the safety plan including internal coping skills, people they can ask for help when/if a crisis occurs, and/or places that provide distraction. 
  • We can offer coping skills that may be of use i.e. deep breathing, coloring, music, grounding techniques, etc. See what the patient likes to do to help ease their emotions. 
  • Sometimes patients may not have people but have pets that they can go to when in a crisis
• It is important to assess SI at every follow-up visit as well as going over the safety plan to make adjustments, when needed. 
• The patient may benefit from increased therapy sessions. We can collaborate with the therapists through the portal messaging system. 
• We may want to see the patients more frequently than every month i.e. every 2 weeks until SI is stable.
• It is important to ask if the patient is using substances, if they are, it is important to talk about decreasing substance usage as this can increase impulsivity. 
• It is important to ask about access to firearms and discuss harm reduction. The best way to help protect a person in distress is to temporarily remove all lethal means, including firearms, from the home until the person is no longer in a state of crisis. 
• If the patient does not have resources or support, it is helpful to connect them to 988 Lifeline and Rula 24/7 Crisis Line (+1 (877) 371-5488).

Cultural Considerations

The vulnerability of exposure to substance use disorders is often influenced by cultural and environmental contexts, including those in poverty or who face stigma and discrimination, homelessness, abuse of all forms, political repression, communal/societal violence, etc. It's important to recognize that substances like psilocybin, alcohol, and opium have cultural significance in some communities and may not be viewed as harmful. When addressing substance use disorders, it's also essential to understand that certain cultures place a high value on family involvement in the treatment process.

“When a mental health professional understands the role that culture plays in the diagnosis of a condition and incorporates cultural needs and differences into a person’s care, it significantly improves outcomes.” (5) (6)

Additional Tools and Resources:

• DSM-5 Substance Use Diagnosis Examples ICD-10 Code
• SBIRT Toolkit.pdf
• Patient Education - SBIRT for Substance Use
• Providers Clinical Support System | SAMHSA (AUD and OUD)
• Patient Care | Smoking and Tobacco Use | CDC 
• Opioid Use disorder | APA
• Education | American Society of Addiction Medicine

Disclaimer: SUD in Children and Adolescents

This care guideline focuses on best practice guidelines for treating Adults with SUD, however, Substance Use Disorders can also present in children and adolescents. There are risk factors for developing substance use disorders in children and adolescents including genetic and environmental influences. There are screening tools utilized for adolescents including CRAFFT Interview (version 2.0) (screening tool for adolescents). The treatment in this population is similar to adults; however, some of these pharmacological treatments are not FDA-approved for children and adolescents so will need to have consent to use off-label prescribing in children and adolescents. 

** Substance use is confidential in children and adolescents **

For information on providing effective care for children and adolescents with SUD, check out the below resources:

• AACAP: Practice Parameter for the Assessment and Treatment of Children and Adolescents With Substance Use Disorders
• MCPAP: ADOLESCENT SBIRT
• AACAP: Substance Use Resource for Teens

References

1. SAMHSA: NSDUH 2024 
2. CDC: Drug Overdose Deaths in the US 2023-2024
3. NIDA: Cannabis
4. NIH: Combination Treatment for Methamphetamine Use Disorder
5. Psychiatric Times: Culture and Substance Abuse: Impact of Culture Affects Approach to Treatment
6. National Alliance on Mental Illness (NAMI): Community & Culture

Updated June 04, 2026 21:19