It was estimated that in 2019, 20.4 million Americans had a substance use disorder. According to the CDC, 95,000 Americans die each year from alcohol use due to suicide, disease, and accidents. Opioids and psychostimulants such as cocaine are the next substances most commonly used by Americans. It was estimated that 49,860 Americans died in 2019 from opioid overdose while psychostimulant is the next most common drug overdose (1). Cannabis is another common substance used in America, especially among adolescents and college students. There has been research showing that cannabis usage in adolescents can increase the risk of psychosis/schizophrenia as well as chronic respiratory conditions in adults.
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
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The severity of symptoms:
- Two to Three symptoms - MILD
- Four to Five symptoms - MODERATE
- Six or more symptoms - SEVERE
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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 comorbid 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
The AUDIT-C is a validated, 3-question rapid screener for alcohol use/dependence. There are various screening tools that can be implemented including but not limited to DAST-10 (drug abuse screening test), and the Screening to Brief Intervention (S2BI). A great resource for screening/monitoring is Screening, Brief Intervention, and Referral to Treatment (SBIRT).
| 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 comorbid with several other mental health issues including depression, anxiety, trauma-related disorders, conduct problems, bipolar disorder, impulsivity, etc. When assessing other comorbid 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 substance caused the mania rather than mania causing substance use which is where a thorough history/assessment is beneficial. At times, the patient may need to remain sober for several months before determining a diagnosis. 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 inpatient detox, residential treatment, and/or intensive outpatient treatment 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 medical comorbidities or acute physical issues. Also, psychiatric providers can seek guidance from the American Society of Addiction Medicine (ASAM) to help determine the appropriate level of care.
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When asking patients about substance use, it is important to remain objective and empathetic. For some individuals, addiction is a maladaptive coping mechanism in which they may turn to substances as a way to numb or distract from emotional pain or distress. Addiction is not a random event, a choice, or laziness. 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. It is important to meet patients who use motivational interviewing to help guide the treatment. It is important to note the stage of change that the patient is in here is an example of stages of change when using 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. Please use the TIP 45 as a resource for other substance 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 is highly comorbid with other psychiatric disorders including depression, anxiety, trauma-related disorders, and bipolar disorders. The therapist can then manage the SUD by also treating the comorbid 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
- Previous withdrawal symptoms
- Hx of delirium tremens
- Hx of seizures
- Complicated medical hx including but not limited to cardiac conditions, neurological conditions, and other medications the patient may be taking
- Over-sedation
- Hx of hallucinations with detox
- > 65 years old
- Numerous withdrawals in the past from alcohol (kindling effect)
- Long-duration or heavy alcohol consumption
- Physical dependence on BZO or barbiturates
- Unstable vital signs
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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 w/d and should be managed inpatient care with medical monitoring
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Ultimately, the level of care should depend on the patient's current signs and symptoms, the risk of developing complicated/severe withdrawal as well as the psychiatric provider's comfort level in treating alcohol withdrawal. Patients with low levels of support or an unsafe environment may benefit from detoxing in a medical facility. Also, if a patient is having active SI, it would be appropriate for the patient to detox in inpatient care. |
Managing alcohol intoxication/withdrawal in an outpatient setting
If the psychiatric provider deems that it is safe for the patient to detox in an outpatient setting the following can be considered:
- Binge drinking
- MI to discuss cut-down measures
- Gabapentin as needed for anxiety
- Subthreshold for “high-risk drinking”
- CIWA scoring 10 or less treated with supportive care or pharmacology such as Gabapentin unless they are at risk for complicated w/d then use BZO taper or symptom-triggered therapy
- Men - less than 4 drinks/day and less than 14/week
- Women - less than 3 drinks/day and less than 6 week
- Use MI to discuss cut-down measures
- “High-risk” drinking without risk of complicated/severe withdrawal
- Usually a CIWA score of 10-18
- Increased follow-up visits - daily up to five days with a medical professional to determine CIWA scores as well as vital signs
- Can have patient and/or family members monitor vital signs and CIWA scores - report to the provider
- Monitor symptoms every 1-4 hours in the first 24 hours, as clinically indicated
- Once stabilized can monitor CIWA/vitals for 4-8 hours for 24 hours
- Monitor for 36 hours when severe w/d can occur
- Educate patient and family on more severe withdrawal symptoms including seizures and hallucinations - in which the patient should be taken to the emergency room
- Order a daily MVI along with Thiamine
- Order Benzodiazepine (Ativan, Valium, Librium) taper that consists of at least 5 days and should be discontinued after taper alternative can use a symptom-triggered therapy during the w/d stage- click here to look at specific mg/dosage recommendations (Librium)
- If the patient has liver disease, use Ativan
- Order smaller quantities to prevent the risk of diversion
- Monitor for excessive sedation or ongoing alcohol usage
- If the patient does not tolerate BZO in the past, they will need to go to HLOC
- Discuss the importance of abstinence from alcohol when taking BZO and the risks associated with this including respiratory depression and death
- Risks related to heavy machinery
- Can utilize Clonidine PRN for elevated BP
- Monitor closely to determine if the patient needs HLOC
| It is important to order labs when managing alcohol use disorder. Include in lab panel CBC, CMP, Hepatitis screening, and STI screening (if consents to this). |
Medications for AUD (MAUD)
- Naltrexone (not used in patients with cirrhosis)
- Make sure that the patient is not taking any opioids as this will cause withdrawal
- Discuss that if they need surgery they will need to let their provider know they are on this medication
- Acamprosate (Campral) - three times a day dosing
- Disulfiram (Antabuse)
- It can be used on a PRN basis
- Avoid all alcohol products as any ethanol will cause severe side effects
- Highly compliant patient
- Abstinence is the goal
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 detoxification for THC. 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
Medication-assisted treatment for Cannabis Use Disorder
As of now, 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. (7)
- Cannabinoid (CBD)
- Gabapentin
- N-acetylcysteine (NAC)
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 cessation of nicotine occurs, it is important to assess other medications the patient is taking as 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.
Nicotine Replacement treatment (NRT)
- Patients need to set a quit date
- Usually 1-2 weeks after initiation of NRT
- Wellbutrin SR
- Nicotine Gum
- Nicotine Patch
- Can combine the above treatments, if necessary
- After the acute withdrawal period is over, patients can be weaned off of NRT
- Usually around 12 weeks
Stimulants/Methamphetamine:
- May need to utilize antipsychotics during the intoxication/withdrawal phase
- Studies have shown that Wellbutrin and Naltrexone together have shown promising results in stimulant use disorder.
Sedatives/Hypnotics:
It can take several months to taper off of benzodiazepines. It is important to monitor CIWA sores and vital signs to determine if HLOC is appropriate as BZO withdrawal has the same risks as alcohol withdrawal including seizures, autonomic instability, and delirium tremens.
- Utilize a longer-acting BZO to help patients taper
Opioids:
When detoxing a patient from opioids, the following can be utilized - Clinical Opiate Withdrawal Scale (COWS) is the screening tool for symptoms.
- Clonidine
- Lucmyra
- Hydroxyzine/Gabapentin for anxiety
- Suboxone (not utilized at Rula)
- Methadone (not utilized at Rula)
Medications for Opioid Use Disorder
- Naltrexone
- Must be opioid-free for at least 7 days to prevent withdrawal
- Must be educated that this will lower tolerance of opioids
- Suboxone
- Not currently utilized at Rula
- Methadone
- Not currently utilized at Rula
** Must always order Narcan for OUD patients **
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.
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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 that can be found in the AMD note template. 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 by asking the psych support team for their emails.
- 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 Resources for People who Think About Suicide (and their supporters) | NAMI Massachusetts
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Rula’s team of care coordinators is available to help your client access these additional clinical services outside of Rula. Click here to learn more about how to easily refer your client for a Higher Level of Care (HLOC). However, if your patient is an acute risk to self or others i.e. active SI with plan, intent, or means then please follow this protocol here. Please reach out to the RNs and Lead NPs to help you in this situation for additional support. |
Cultural Considerations
The vulnerability of exposure to substance use disorders is often influenced by cultural 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.”(9)
Tools/Resources:
- Opioid Use disorder
- Patient Care | Smoking and Tobacco Use | CDC
- Providers Clinical Support System - Medications for Alcohol Use Disorders (PCSS-MAUD) | SAMHSA
- SBIRT Toolkit.pdf
- DSM-5 Substance Use Diagnosis Examples ICD-10 Code
- Patient Education - SBIRT for Substance Abuse
- ASAM alcohol withdrawal management
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 used 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, these pharmacological treatments are not FDA-approved 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
- ADOLESCENT SBIRT
- Substance Use Resource for Teens
References
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VA/DoD Clinical Care Guidelines for the Management of Substance Use Disorders
https://www.healthquality.va.gov/guidelines/MH/sud/VADoDSUDCPG.pdf
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American Society of Addiction Medicine
https://www.asam.org/education
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SAMHSA
https://store.samhsa.gov/sites/default/files/sma15-4131.pdf
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American Psychiatric Association (APA)
https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/substanceuse-1410197810077.pdf
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NIH methamphetamine
https://www.nih.gov/news-events/news-releases/combination-treatment-methamphetamine-use-disorder-shows-promise-nih-study
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AACAP
https://www.jaacap.org/article/S0890-8567(09)61641-5/pdf
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NIH cannabis
https://www.ncbi.nlm.nih.gov/books/NBK538131/
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Culture and Substance Abuse: Impact of Culture Affects Approach to Treatment
https://www.psychiatrictimes.com/view/culture-and-substance-abuse-impact-culture-affects-approach-treatment
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National Alliance on Mental Illness (NAMI). (n.d.). Identity and Cultural Dimensions.https://www.nami.org/your-journey/identity-and-cultural-dimensions/
Updated