AUTHOR
Ellen Feldman, MD, Altru Health System, Grand Forks, ND
PEER REVIEWER
Douglas Teller, MD, Clinical Associate Professor, Internal Medicine Clinical Assistant Professor, Psychiatry, Wright State University, Kettering Medical Center, Kettering, OH
EXECUTIVE SUMMARY
In the United States, 20.3 million people have an addiction or substance use disorder (SUD). Of these 20.3 million individuals, only 4.2 million reported receiving treatment in 2019. Of these 4.2 million, 948,000 received treatment at a “doctor’s office,” representing a small increase from 2018. However, as in past years, nearly half of the group reported that treatment consisted solely of self-help groups.
- An estimated 275 million adults worldwide reported using drugs during 2020. Of these, about 13%, or 36.3 million individuals, met criteria for a diagnosis of an SUD. According to recent statistics gathered by the United Nations Office on Drug and Crimes, 70% of the negative health effects from substance use worldwide is caused by opioid abuse.
- Stigma is a powerful social mechanism shaped by attitudes and/or behaviors, including labeling, stereotyping, and separating, which contribute to loss of status and discrimination.
- Individuals with mental illness, and particularly those with SUD, report that both overt stigma and perceived stigma are barriers to seeking treatment.
- Addictive drugs are, in essence, rewarding drugs. Reward pathways in the brain are modulated largely by dopamine levels.
- Complications from the use of addictive drugs include a depletion of dopamine and impaired executive functioning as the result of interruptions in both dopaminergic and glutaminergic signaling and pathways. This leads to poor executive functioning, resulting in a negative effect on the ability to problem solve, self-regulate, self-examine, and prioritize.
- Motivational interviewing, which recognizes that change is more likely when a person decides for themselves to change, may enhance the efficacy of brief interventions.
- The approach is collaborative rather than unilateral, goal-directed, and geared toward motivating by encouraging patients to voice their own arguments for change.
- Medication-assisted treatments are available for alcohol, opioid, and tobacco abuse.
- Local resources are available for individuals with SUD. Such support may include individual and group counseling, family counseling, and mutual-help organizations, including 12-step and non-12-step programs (such as Alcoholics Anonymous or SMART Recovery).
“Addiction is a treatable, chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual’s life experiences. People with addiction use substances or engage in behaviors that become compulsive and often continue despite harmful consequences. Prevention efforts and treatment approaches for addiction are generally as successful as those for other chronic diseases.”1
This definition of addiction, developed in 2019 by the American Society of Addiction Medicine (ASAM), is worth a careful read. In this review, the italics are placed to emphasize the concept of viewing addiction through the lens of chronicity, much as we view the treatment and management of other persistent diseases, such as diabetes or hypertension.
Results from the 2019 National Survey on Drug Use and Health (NSDUH), an annual survey of about 70,000 representative Americans 12 years of age and older, reveal 20.3 million people living in the United States have an addiction or substance use disorder (SUD). Of these 20.3 million individuals, only 4.2 million reported receiving treatment in 2019. Of these 4.2 million, 948,000 received treatment at a “doctor’s office,” representing a small increase from 2018. However, as in past years, nearly half of the group reported that treatment consisted solely of self-help groups.2 Many indications point to a worsening of substance misuse during the COVID-19 pandemic and a continued gap between patients in need of treatment and patients receiving treatment.3
Geographic and financial barriers, as well as bias and stigma, work together to present formidable roadblocks for patients with SUD looking for direction. The primary care provider (PCP) may be the only healthcare contact for many of these patients. Learning to recognize and modify stigmatizing language helps open a discussion about substance use. Mastering techniques to recognize and diagnose patients with SUD accurately allows the PCP more confidence in initiating or guiding toward appropriate treatment. With expertise in understanding management of other complex, chronic disorders and experience in implementing an integrated, individualized treatment plan, the PCP has the background to take the lead in managing patients with SUD.4
This review addresses the role of the PCP in the prevention, identification, and management of patients with SUD. To gain perspective, a historical conceptualization of SUD is presented. Moving to the present day, topics range from self-
awareness regarding unrecognized bias, applying current Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) diagnostic criteria and ASAM levels of care in the office, using appropriate screens, and an overview of pharmaceutical and brief therapeutic treatment recommendations for SUD. Patient examples help maintain focus on clinical aspects of care.
Historical Conceptualization of Substance Use
The early history of humanity is sprinkled with references to the use of substances with psychoactive properties. Properties of opium (extracted from the poppy flower) and alcohol (a fermented drink made from honey, rice, or grapes) were known as far back as 10,000 BCE. In ancient Greece, opium and its derivatives were used medicinally and for spiritual purposes, while there is evidence of recreational use of alcohol in the Middle East and China during this time.5,6
Cannabis, originally from Afghanistan, also is deeply rooted in early history. Although practical purposes, such as utility in rope making, fueled its spread through trade, medicinal use followed soon afterward in many areas, including ancient India and China.5,6
These substances spread across the world via trade and cultivation, with written records of specific properties and use in diverse civilizations attesting to a wide range of applications.5,6
The rise of the church after the fall of the Roman Empire seemed to influence beliefs and attitudes toward intoxication significantly, in particular those involving alcohol. In 1647, Agapios, a Greek monk, was the first to document an association between excessive alcohol use and disease. Meanwhile, the “anti-opium” movement began to build, citing medical and moral objections to continued use (and focusing on some of the political implications of ending opium trade).5,6
By the mid-1800s, the addictive potential of opium became known, adding more fuel to the movement to end recreational and medicinal use of this substance. By the early 1900s, the term “addict” became widespread in the United States, and racial stereotypes, especially around cannabis use, emerged. Criminalization of “substances” soared with the passing of the 18th Amendment to the U.S. Constitution, ushering in an era of prohibition.5,6
The repeal of Prohibition in 1933 was followed closely by the establishment of Alcoholics Anonymous in 1935, perhaps a step toward looking at treatment outside of correctional institutions for individuals with disordered substance use.5-7
Yet with the publication of the first Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1952, through subsequent editions until 1980, substance use was not classified as a standalone disorder but viewed as arising most commonly from a separate disorder of mental health (such as a personality disorder). The third edition of the DSM began slowly to move away from this conceptualization. The most recent (2013) edition dramatically demonstrated a new perspective on SUDs, basing diagnosis on an understanding of a biopsychosocial model, describing functional impairment and recognizing that SUD presents on a spectrum from mild to severe according to the number of symptoms and degree of impairment.5-7
It is useful to note that societal influences, including political, spiritual, and socioeconomic forces, have contributed to a shifting perception of substance abuse over time, and contributed to our view of SUD and treatment direction today. It is unlikely that the current DSM classification and description of SUD is the final or most definitive word; very well it may be that, as society moves forward, so will our understanding of this disorder, its underpinnings, and its treatment.
Epidemiology and a Word About COVID-19
An estimated 275 million adults worldwide report using drugs during 2020. Of these, about 13%, or 36.3 million individuals, met criteria for a diagnosis of an SUD.
According to recent statistics gathered by the United Nations Office on Drug and Crimes (UNODC), 70% of the negative health effect from substance use worldwide is caused by opioid abuse because of the potential for lethal overdose and association with human immunodeficiency virus (HIV) and hepatitis C, as well as other medical and mental health comorbidities. Nowhere is this more evident than in the United States; the UNODC notes that one-quarter of drug-related deaths worldwide occur in this country, driven mostly by opioids and overdoses.8
On a brighter note, UNODC notes a six-fold increase since 1999 in medicinal availability of two pharmaceutical agents used to treat opioid disorders: methadone and buprenorphine.8
Additional information from UNODC is that cannabis potency continues to increase, with the main psychoactive component of this substance rising from 4% to 16% between 1995 and 2019 in the United States. UNODC notes that during this same period, the percentage of adolescents who viewed cannabis as harmful fell about 40%, despite evidence of harm from long-term use.8
Among individuals who inject drugs, hepatitis C causes the greatest harm, followed closely by HIV. UNODC reports sobering statistics: More than 11 million individuals worldwide inject drugs and more than half of these people have hepatitis C, 1.6 million have HIV, and 1.3 million are living with both of these infections.8
The World Mental Health (WMH) Survey, conducted by the World Health Organization (WHO) in 2019, had a goal of determining the prevalence of alcohol use disorder among developed nations worldwide. Using sophisticated statistical calculations to address the heterogeneity of results, the final report found a mean lifetime prevalence of adult alcohol use of 80% and a mean lifetime prevalence of alcohol use disorder of 8.6% (10.7% among “non-abstainers”).9
The NSDUH surveys representative samples of the U.S. population annually in an effort to understand the prevalence and trends of drug and alcohol use, tobacco use, and mental health disorders. The most recent results available are from the 2019 survey. These results reveal that:
- 60.1% of individuals 12 years of age and older in the United States used a substance in the month prior to the survey; “substance” is defined as tobacco, alcohol, or illicit drug, or kratom (a tree from Southeast Asia with leaves that have psychoactive properties);
- 85.6% of respondents reported alcohol use during a lifetime; notably, this value is greater than the mean of 80% worldwide lifetime prevalence found in the WMH;
- 5.3%, or 14.5 million individuals, 12 years of age and older had a lifetime prevalence of alcohol use disorder; notably, this value is lower than the 8.6% worldwide lifetime prevalence found in the WMH;
- Alcohol use disorder prevalence varies by gender and age, with 1.3% of boys 12 to 17 years of age having alcohol use disorder, and a slightly higher rate in girls at 2.1%; however, this trend is reversed when looking at ages 12 years and older, with a 6.8% prevalence in men and 3.9% in women.
Unfortunately, according to the NSDUH, only about 7.2% of the individuals 12 years of age and older with alcohol use disorder received any treatment in the past year. Notably, the rate of alcohol-related emergency department visits has been increasing since 2006, and 95,000 deaths yearly are from causes related to alcohol use. Alcohol ranks as the third leading preventable cause of death in the United States, behind tobacco use and poor diet/sedentary lifestyle.2
It has been hypothesized that the psychosocial effect of the COVID-19 pandemic, including social isolation, increased anxiety, and reduced treatment services, will result in higher rates of SUD and lower rates of intervention. Schmidt et al compiled a comprehensive review of more than 50 studies published from the start of the pandemic until April 2021 and noted suggestive evidence of alcohol use increasing among subsections of the population and decreasing among others. Particularly at risk appear to be individuals with risky drinking behaviors pre-pandemic and people with a comorbid mental illness. This team did not find any published evidence regarding the effect of the pandemic on opioid abuse at the population level. However, public health messaging and other communications have warned about the convergence of increased use and interrupted services during the pandemic. Early numbers indicate a 30% rise in overdose deaths from 2019 to 2020; clearly, methodical, high-quality studies are needed to fully understand and address this issue.10
Stigma
Stigma is a powerful social mechanism shaped by attitudes and/or behaviors, including labeling, stereotyping, and separating, which contribute to loss of status and discrimination. Stigma in healthcare and in health facilities can be especially damaging, leading to poor outcomes for vulnerable individuals and affecting the healthcare workforce as well. Increasingly, it is becoming clear that recognition and correction of stigmatizing attitudes and behavior is essential to delivering quality healthcare.11,12
Individuals with mental illness, and particularly those with SUD, report that both overt stigma and perceived stigma are barriers to seeking treatment. In recognition of this and as one of several concrete steps to encourage clinicians to recognize and correct stigmatizing behaviors, several prominent medical societies (including the American Medical Association) have joined forces to promote the use of accurate scientific terminology when discussing substance use and SUD.12
“Words matter,” noted Botticelli and Koh in the Journal of the American Medical Association (JAMA) in 2016 and Slomski in JAMA in 2021.13,14 Both articles advocated for removing stigmatizing language from the everyday vocabulary of medical professionals, noting this can be an effective first step toward starting to change bias and perceptions of other healthcare workers, patients, and the general public. For example, describing the patient as “a person with SUD” rather than labeling the individual a “drug abuser” or “addict” reinforces the concept that SUD is a treatable medical condition rather than a personal characteristic or failing. Other recommendations include avoiding the term “drug habit,” which may convey a sense of choosing to use (rather than use because of chronic brain disease) and to discuss individuals being “in recovery or relapse” rather than “clean or dirty.”
Certainly, vocabulary changes alone must be matched with education and policy changes on many levels to defeat the stigma associated with SUD. However, the PCP can begin the process of defeating stigma and pull down some of the barriers surrounding access to treatment for patients with SUD by careful choice of medically accurate neutral terms that portray SUD as a treatable, chronic medical condition.12-14
The Biopsychosocial Model of Addiction
The etiology of SUD is far from simple. Current conceptualizations point to a complicated interplay of biological, psychological, and social factors contributing to addiction and the development of an SUD.15
Most addictive disorders have about a 50% heritability; that is, about one-half the risk of developing an addictive disorder stems from genetic factors. Most of our current knowledge regarding the role of genetics in SUD comes from family, twin, and adoption studies. However, newer techniques, such as genome-wide association studies (GWAS), show promise in the identification of subtle differences in deoxyribonucleic acid (DNA) sequencing; with continued research, this field is likely to show considerable progress.15,16
The remaining 50% of risk for addiction comes from a variety of risk factors, including adverse early childhood experiences (ACE) and a range of social factors. (In fact, the availability or unavailability of the substance constitutes a risk or a protective factor.) ACE includes trauma, abuse, neglect, and instability within a household. Each such experience is correlated strongly with at least a doubling of risk of early use of drugs as well as other negative health and mental health outcomes.15,16
The mechanism of this interaction between genetic and psychosocial factors in the development of addiction remains poorly understood. Epigenetics, or the process by which behaviors and environment affect gene expression, are suspected to play a role. Animal studies looking at this process point to a likelihood of novel targets for the intervention and treatment of SUD.15-17
One such novel treatment involves the development of “drug vaccines” that prevent substances from entering the brain. Although addictive drugs are not highly immunogenic, the strategy employed is to develop a vaccine by coupling the addictive drug with a denatured adenovirus. Animal studies and early human studies are showing promise for vaccines in the treatment of cocaine abuse.18
Addictive drugs are, in essence, rewarding drugs. Reward pathways in the brain are modulated largely by dopamine levels; although many pleasurable activities cause a release of dopamine, addictive substances tend to cause significantly larger surges of this neurochemical. Addictive drugs can be conceptualized to “hijack” the brain’s normal reward pathways, resulting in tolerance and cravings. The individual may transition from “enjoying” a substance to wanting or needing a substance to feel normal. This drive (“to feel normal”) may overpower the wish to avoid negative consequences.15-17
Complications from the use of addictive drugs include a depletion of dopamine and impaired executive functioning as the result of interruptions in both dopaminergic and glutaminergic signaling and pathways. This leads to poor executive functioning, resulting in a negative effect on the ability to problem solve, self-regulate, self-examine, and prioritize.15-17
Diagnostic Criteria
Introducing J.
J., a 27-year-old engaged female and an established patient with a history of headaches, asks for an urgent appointment for “personal matters.” She comes in, stating, “I fell asleep at work in a meeting and my secretary realized I had been drinking. My boss wants me to bring a doctor’s letter saying I can return to work.” She explains, “Drinking problems are in my family — my dad died with a bad liver and my grandfather died drunk in jail.” She notes that, because of this, she always has been careful with alcohol. She adds, “During the pandemic I guess I did start to drink a little too often.” She says that, with her return to on-site work, she started to drink before the workday. “I know that was stupid, but it didn’t really feel like one or two drinks was affecting me anymore and my job is quite stressful,” she says. “I learned my lesson — I don’t plan to drink again on workdays! I don’t want to be like my dad.”
DSM-5 gives concrete guidelines for diagnosis of SUD.19 Substances specified in DSM-5 include alcohol, caffeine, cannabis, hallucinogens, inhalants, opioids, sedative/hypnotics, stimulants, and tobacco-related disorders.19 For most of these categories (apart from caffeine), the diagnostic criteria are as follows:
“A problematic pattern of use leading to clinically significant impairment or distress, as manifested by at least two of the following over a 12-month period.” Eleven criteria are listed, each falling into one of four domains.
1. Impaired control:
- Taking more than intended;
- Experiencing cravings;
- Spending a lot of time obtaining, using, or recovering from use;
- Unsuccessful efforts to stop or cut use.
2. Social impairment:
- Continued use despite failure to fulfill major obligations;
- Continued use despite deterioration in interpersonal or social relations caused by use;
- Giving up important social, occupational, or recreational activities because of use.
3. Risky use:
- Recurrent use in a hazardous situation;
- Continued use despite knowing use will worsen physical or psychological problems.
4. Physiologic adaptation:
- Tolerance to the effects of the substance;
- Withdrawal when reducing or stopping use.
Severity is determined by the number of criteria met: two to three criteria indicate a mild disorder, four to five criteria indicate a moderate disorder, and six or more criteria indicate a severe disorder.19 These DSM-5 guidelines provide a direction for further history-taking.
At this point, the PCP is faced with three main questions to answer regarding J.:
- Does J. have an SUD?
- If so, how severe is it?
- What are the options for treatment?
Given the little we know so far, it is reasonable to consider a working diagnosis of an alcohol use disorder, at least mild, with risky use, and probable tolerance (“… it didn’t really feel like one or two drinks was affecting me anymore.”) However, a more complete history is needed for accurate diagnosis and to advise J. on the best course going forward.
Obtaining the complete history may be tricky. J., in labeling her father and grandfather with “drinking problems” and in labeling her own actions as “stupid,” already has introduced stigma into the interview. It will be useful for the PCP to keep this in mind as the interview proceeds, and to be particularly aware that the use of medically appropriate terms may help J. reframe her own situation and formulate treatment goals.
SBIRT: Screening, Brief Intervention, Referral to Treatment
SBIRT is an acronym describing an integrated, structured approach to catch substance abuse in early stages and address it appropriately. Initially developed as a public health measure, this process has significant evidence for efficacy in reducing risky alcohol use and growing evidence of efficacy in addressing unhealthy drug use.20 Specifically:
S: Screen to measure severity of unhealthy use;
BI: Brief intervention focusing on increasing insight and understanding motivation for treatment;
RT: Referral to treatment at the appropriate level (specialty care for those in need of this level of care).
Early detection of SUDs, coupled with effective intervention, leads to the potential for improved quality of life and decreased medical and psychosocial comorbidities. Accordingly, many national medical organizations and the U.S. Preventive Services Task Force (USPSTF) recommend screening for unhealthy alcohol use and unhealthy drug use in adults presenting to primary care clinics. Screening tools help to pinpoint the level of substance use and lead to targeted intervention strategies. Scoring can be used to determine progress over time. However, it is important to note that screens alone never are diagnostic or an endpoint; all screens require interpretation, a clinical interview, and resources for follow-up.21
The PCP may be confronted with a bewildering choice of screening tools, ranging from ultra-short, with a focus on a single disorder, to slightly longer and focused on multiple disorders of mental health. A 2017 comprehensive review article specifically looked at properties of publicly available scales measuring mental health disorders suitable for use in the primary care setting. Mulvaney-Day et al identified 24 such validated tools: 13 short screens (five or fewer items) and 11 longer questionnaires.22 Table 1 lists and describes a subset of these screens, focused specifically on alcohol and substance use.
Table 1. Examples of Screens to Measure Alcohol or Drug Use for Patients Presenting to Primary Care | ||
Screening Target |
Notes | |
Alcohol Use Disorders Identification Test (AUDIT-10) (10 items)26 |
Harmful/unhealthy drinking |
|
Alcohol Use Disorders Identification Test – Concise (AUDIT-C) (Three items)27 |
Hazardous drinking |
|
Kreek-McHugh-Schluger-Kellogg (KMSK) Substance Use Disorder Scale28 |
28 items for combined substances (eight-item opioid, seven-item cocaine, six-item alcohol) |
|
Screening Instrument for Substance Abuse Potential (SISAP)29 |
Measures overall risk of dependence or abuse of any substance |
|
Drug Abuse Screening Test (DAST-10)30 |
Assessing drug use disorder (not alcohol or tobacco) |
|
Notably, cannabis now is legal for medicinal use in more than half of U.S. states and for recreational purposes in 18 states.23 With this status, the screening questions for “illicit” drug use may be seen as confusing or ambiguous. Recognizing this, some healthcare systems have moved to a separate screen for cannabis use. For example, Kaiser Permanente in Washington state screens all primary care patients annually with a seven-item behavioral health screen that includes the question, “How often in the past year did you use marijuana?”24 This approach echoes the single-question screen for drug use in primary care validated in 2010, which asks, “How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?” A positive answer (one time or more) moves the patient into a full screen.25
The PCP routinely asks patients to complete the 10-question, five-minute, self-administered Alcohol Use Disorders Identification Test (AUDIT-10) when a patient responds with a non-zero answer on a prescreen question recommended by the National Institute of Alcohol and Alcoholism (NIAA): “How many times in the past year have you had more than four drinks in one day (men) or more than three drinks in one day (women or patients older than 65 years of age)?”26,31 J. scores a 12 on the AUDIT-10, signifying the need for brief intervention. (Note: A score of 14 or above on AUDIT-10 indicates moderate to severe alcohol use disorder and the probable need for intensive intervention.) J.’s score helps reinforce the original diagnosis of alcohol use disorder, mild. The PCP notes one-quarter (3) of the points on the AUDIT-10 stem from J. endorsing feelings of guilt after drinking and decides this may be an opening for the clinical interview and brief intervention.
When thinking about unhealthy alcohol use and discussing this with patients, it is useful for the PCP to keep in mind guidelines regarding such use. The NIAA defines at-risk drinking as more than 14 drinks/week or more than four drinks in any one day for men up to 65 years of age. For women and individuals 65 years of age and older, these limits are reduced to seven drinks weekly or more than three drinks on any one day. Additionally, NIAA sends a clear message: “Drinking less is better for health than drinking more.”32
A standard drink is any beverage containing 0.6 fluid ounces of alcohol, including:
- 12 fluid ounces of beer;
- 8 fluid ounces to 9 fluid ounces of malt liquor;
- 5 fluid ounces of table wine;
- 1.5-fluid ounce shot of distilled spirits.33
Brief Intervention
The brief intervention, the second step of SBIRT, is structured to promote self-awareness and self-efficacy (a sense of competence and confidence in ability to achieve a goal) to enhance motivation for behavioral change. The specifics of the brief intervention vary according to patient risk level; however, there are basic components of this technique that may be applied at any level.20,34
- Ask the patient for permission to discuss substance use. This usually is best introduced after a basic establishment of rapport. If a screen was completed, asking to discuss the results of the screen can be a logical segue to begin a more in-depth conversation about substance use. For example, a PCP could remark, “Thank you for completing the screen. Would you like to see how it is scored and interpreted in terms of your health?”
- Give feedback. Let the patient know the level of risk (at risk to high risk) associated with information provided on the screen or interview. Remember to listen and encourage the patient to verbalize thoughts about this risk level. Provide accurate information about any related health risks tied to the substance use.
- Enhance motivation. Ask the patient, on a scale of 0 to 10, how ready they are to change their use of substances; after the patient responds, ask why the patient did not choose a lower number. This is one technique that encourages the patient to examine his or her own motivation for change. Borrowing other techniques and approaches from motivational interviewing may be useful here.
- Summarize and develop a plan. The PCP can provide recommendations, ranging from abstinence for patients at high risk to reduced use for at-risk patients and options for treatment, but eliciting the patient perspective is key. The central question in this step is to ask the patient, “Where does this conversation leave you in terms of making a change to substance use?” After the patient verbalizes ideas or a plan, encourage setting specific goals and provide follow-up.
Motivational interviewing (MI) may enhance the efficacy of brief interventions. MI was developed by psychologists William Miller and Stephan Rollnick in the 1980s as an approach to talking with individuals about substance use that differed significantly from techniques in use at that time, such as shame and confrontation. MI recognizes that change is more likely when a person decides for themselves to change.
The principles of this technique demonstrate respect and a desire to understand the patient’s ideas about behavioral change. The approach is collaborative rather than unilateral, goal-directed, and geared toward motivating by encouraging patients to voice their own arguments for change. During a clinical interview conducted via MI, the patient is encouraged to examine values, principles, fears, and hopes.35,36
Although a mastery of MI is a complex undertaking, understanding some of the guiding principles may be helpful in conducting brief interventions. The OARS model, outlined in the following paragraph, may be particularly helpful.35
- O: Open-ended questions (not able to be answered with a single yes/no response); try to avoid “why” questions, since these can promote defensiveness.
- A: Affirmations; find the true internal strengths of the patient and acknowledge them. This differs fundamentally from praise and relies on the interviewer to note positive characteristics elicited by the interview. (For example: “Coming here today must have been difficult after you had such a bad experience at your appointment two years ago.”)
- R: Reflective listening: Listen carefully and voice back to the patient the concept, idea, or theme the patient is attempting to convey.
- S: Summarizing.
J. states that she is shocked to learn her AUDIT-10 score suggests alcohol use disorder. The PCP confirms she has not experienced withdrawal or cravings or any medical symptoms related to excessive alcohol use. “I promised my mother and father that I would never start drinking. I never did until nine months ago. I started with a glass of wine before bed, then several glasses, and now I’m drinking in the morning — and even worse, hiding most of this from my fiancé,” she says. “Hearing my score now, I want to cry. I’m thinking I may just have to stop altogether.” She identifies her fiancé as a person who will support her goal to stop drinking, saying, “He has worried and suspected I was drinking more than he knew — and we want to have children soon.”
The PCP agrees with her that abstinence is a good choice and offers referral information for online and area resources to help J. reach this goal. J. takes the information, saying she “will try on my own for now” and accepts a follow-up appointment in two weeks to check her progress. The PCP agrees to write a letter for J.’s work stating that, “J. came to my office today. Her medical condition has been identified and recommendations for treatment have been conveyed.”
Perhaps the most significant part of this encounter was creating an environment where J. felt comfortable enough to reveal details about her use, express some difficult emotions, and formulate a goal. It may or may not be realistic for J. to reach her goal of abstinence without turning to other resources. However, given her decision, the PCP is appropriate in offering information about such resources (in case these are needed) and providing a quick follow-up. It also could be helpful to ask J. to track her cravings and/or notify the office of a relapse, much in the same way a patient may monitor home blood pressure or glucose readings.
Treatment of SUD
Introducing K.
K. is a 32-year-old graduate student, the son of a colleague with a medical history significant for a fractured clavicle while playing rugby four months ago. He had been given a seven-day prescription of opioids following the injury, and you see documentation on the electronic medical record of two urgent care visits since with refills; no other prescriptions are noted on the state database. He comes in today stating that he has been “buying pain pills from friends, and even from strangers,” and notes, “I missed two weeks of school so far this semester … I keep thinking I will stop the pills — but maybe if I get a longer prescription, I can just wean myself off. I don’t want to be addicted.” A physical examination reveals a slight elevation in pulse, enlarged pupils, no track marks, and a urine drug screening positive for opioids.
Treatment of SUD can fall into two general categories: pharmacologic and non-pharmacologic. In the best of worlds, these two modalities are intertwined into an individualized treatment program. However, many patients receive neither of these interventions.2
As of 2019, there were 3,000 addiction specialists in the United States. Many communities simply do not have this resource available, and it may fall to the PCP to initiate and/or continue medication treatment for patients with SUD, especially individuals with alcohol use disorder or opioid use disorder.37
Before initiating treatment, it is useful for the PCP to develop a working understanding of the ASAM “dimensions,” which lend a structured approach to determining the level of care for an individual patient. These dimensions consider the complex, multifactorial nature of substance abuse.38
Dimension One: Withdrawal potential and any indication of acute intoxication. A careful history can help determine if this patient can be treated safely as an outpatient.
Dimension Two: Medical comorbidities. Consider unstable comorbidities that require inpatient services, such as chronic liver disease and cognitive disease.
Dimension Three: Emotional and behavioral comorbidities, such as mood disorder, psychosis, and/or suicidal threats that require psychiatric care.
Dimension Four: Readiness to change. Although a PCP may feel comfortable initiating treatment, it is most important to understand the patient’s perspective and attitude toward this step. ASAM provides a description of six stages of readiness from pre-contemplation to contemplation to preparation, action, maintenance, and relapse. These stages are described in Table 2.
Table 2. Readiness to Change40 | |
Stages |
Definition |
Pre-contemplative |
Has not considered or does not want to change |
Contemplative |
Thinking about making a change in the future |
Preparation |
Starting to plan for a change |
Action |
Implementing the plan for change |
Maintenance |
Continuing the plan/desired behaviors |
Dimension Five: Relapse history and potential for relapse.
Dimension Six: Recovery environment and support system.
The PCP can consider each factor in deciding if a patient with SUD can be treated safely in an outpatient setting. If outpatient treatment is appropriate, the PCP next decides if the treatment is best initiated in the PCP office or a different setting; in reality, this usually will depend on the availability of specialty care. A PCP also may opt to recommend medication combined with specific therapies or therapists. It is useful to have a working knowledge of resources in the community and/or online offerings to expedite this process.38,39
Other options for more intensive care include intensive outpatient treatment (generally conducted by a licensed addiction counselor [LAC] several times weekly); a rehabilitation center; a psychiatric inpatient facility; or a medical center.39
When treating K., the PCP is faced again with three questions:
- Does K. have an SUD?
- If so, how severe is it?
- What are the options for treatment?
Looking at the DSM-5, K. meets the criteria for opioid use disorder, at least moderate (taking more pills than intended, unable to stop, risky behavior, and missing school are among the criteria noted). A clinical interview (with motivational interviewing, if possible) should focus on understanding his readiness to change, the history of any medical or psychiatric comorbidities, the history of substance use, any traumatic events, and his current support systems.
Medication-Assisted Treatment for Alcohol Use Disorder
There are several Food and Drug Administration (FDA)-approved medications for alcohol use disorder. These include:
- Naltrexone: This opioid blocker reduces the craving for alcohol and decreases pleasure from drinking. The daily dose typically is 50 mg to 100 mg orally per day and also may be delivered in long-acting injectable form (380 mg intramuscular injection every four weeks). Be cautious in patients with liver damage, since this agent can cause liver damage. Do not use in patients needing opioids for pain control.41
- Acamprosate: This agent acts as a modulator on glutaminergic receptors and may be used in maintaining abstinence. The daily dose of acamprosate is 666 mg three times daily. It may be used in patients with liver impairment, since it is excreted via the renal system. Use with caution in patients with renal disease.42
- Disulfiram: Although FDA-approved, evidence from head-to-head trials does not support its efficacy in alcohol use disorder. Recommendations are to use this agent only if there are no other options and the patient fully understands the risks involved. The mechanism of action involves interrupting the metabolism of alcohol, leading to a buildup of acetaldehyde, which causes a series of unpleasant symptoms (such as nausea, vomiting, and dyspnea.) The dose is 250 mg to 500 mg daily. This agent is contraindicated in patients with psychosis, liver failure, and severe coronary disease.43
Non-FDA approved medications used in the treatment of alcohol use disorder that have moderate levels of evidence for efficacy include topiramate and gabapentin.44,45
Notably, most of the trials of these medications included a psychosocial intervention as well as the specified agent; future studies regarding the benefits of using these alone are needed.
There is insufficient evidence for the use of antidepressant, anti-anxiety, and antipsychotic agents in the treatment of alcohol use disorder.46
Medication-Based Opioid Use Disorder Treatment
The United States is experiencing an opioid overdose epidemic. Compared to the previous 12 months, the Centers for Disease Control and Prevention (CDC) estimates a 26.8% (88,000) increase in overdose deaths in the United States for the fiscal year ending in August 2020, with people 25 to 54 years of age affected disproportionately.47
The CDC outlines three waves of this epidemic. The initial period began in the late 1990s, shortly after the introduction of oxycodone (approved by the FDA in 1995 and the most prescribed pain pill in the United States by 2001); most of the overdose deaths were from prescription opioids marketed initially as “non-addicting.” As the habituating properties of these newer narcotic agents became clear, prescriptions declined, and many patients turned to the street for opioids. The second stage of this epidemic began in 2010 as overdoses with heroin rose. The third wave, beginning in 2013 and continuing to the present day, involves synthetic opioids, especially involving fentanyl (a very potent synthetic opioid marketed as Duragesic or Sublimaze, but also produced illegally).47
In recognition of the severity of this epidemic and with a goal of expanding treatment resources, on April 28, 2021, the Department of Health and Human Services (HHS) amended the requirements for provider training prior to prescribing buprenorphine for opioid use disorder. Notably, this step echoes efforts in 2000 to expand access to opioid use disorder treatment with the Drug Addiction Treatment Act (DATA.) DATA amended the Controlled Substances Act and allowed providers with specific training to obtain waivers to prescribe Schedule III-V medications for the purpose of treating opioid use disorder.48
The April 2021 amendment appears in part as a response to feedback that the additional training presented a barrier to provider willingness to obtain a waiver. Now practitioners who want to prescribe buprenorphine or related substances (not morphine, which is Schedule II) for opioid use disorder need to file a notice of intent (NOI) with the Substance Abuse and Mental Health Services Administration (SAMHSA). However, “if the provider selects a limit of 30 patients on the NOI” and the provider is state and Drug Enforcement Agency licensed, the provider “will not need to certify as to the training, counselling, or other ancillary services.”48
This may open the door to more PCP involvement in prescribing for opioid use disorder. It is important to note that, although HHS has amended the training requirements, providers are strongly encouraged to obtain additional training in prescribing for opioid use disorder and to refer or provide psychosocial supports and counseling to patients with opioid use disorder.48 The following medications are FDA-approved for the treatment of opioid use disorder:
- Buprenorphine. This partial opioid agonist is highly effective for opioid use disorder with long-term use. It is available in combination form with naloxone (example: Suboxone) in an oral sublingual form for daily use. The idea of the combination is to prevent diversion, since injecting this combination precipitates acute withdrawal in opioid-dependent individuals. It also may be used as a single agent and comes in sublingual, subdermal implantable, and monthly injectable forms. Extreme caution is indicated when combining with any sedative-hypnotics, since this combination may lead to respiratory suppression.49
- Methadone. This opioid agonist is highly effective for the treatment of opioid use disorder. In the United States, methadone is permitted to be prescribed only within an opioid treatment program (such as a methadone clinic). If a PCP is treating a patient on methadone maintenance, be mindful of drug interactions and the risk of overdose and methadone toxicity, especially if methadone is combined with sedative-hypnotics.50 There also are medical risks if patients involved in a methadone program combine this substance with illicit drugs. For example, use of cocaine combined with methadone may lead to clinically significant prolongation of the QT interval.51
- Naltrexone. This opioid blocker in injectable monthly form is highly effective for reducing cravings and relapse. Use of the oral form of naltrexone is limited because of poor patient adherence. A patient must be opioid-free (for several days) prior to starting this medication. It may be a particularly good agent for a patient with both opioid use disorder and alcohol use disorder.52
- Naloxone. This opioid antagonist rapidly reverses an opioid overdose. This does not treat opioid use disorder but can be lifesaving should an overdose occur. Prescriptions for this agent include a “naloxone kit,” and formulations include injectable, intranasal, and auto-injector. More information can be found at https://store.samhsa.gov/sites/default/files/d7/priv/sma18-4742.pdf.53
Tobacco Use Disorder
Globally, tobacco-related deaths, more than 5 million annually, exceed deaths from alcohol and illicit drugs combined. Although public policy and pharmacologic interventions appear effective in decreasing smoking, there is increased awareness that individuals with mental illness use tobacco at high rates. In the United States, 44% of all cigarettes are consumed by persons with mental health diagnoses; in inpatient and addiction treatment facilities, 50% to 95% of patients are smokers.54 The DSM-5 criteria for SUD apply for tobacco use disorder and replace the older diagnosis of tobacco addiction or nicotine dependence.19
There are seven FDA-approved medications for tobacco use disorder. Five of these are nicotine-replacement therapies.54
- Varenicline (Chantix). This partial agonist at the nicotinic acetylcholine receptor has good evidence for efficacy in relieving cravings for cigarettes and reducing symptoms of withdrawal. Use caution if the patient has mood disorders, since this agent can exacerbate mood symptoms.54
- Bupropion (Zyban). This antidepressant reduces cravings in tobacco users. Although FDA-approved, its efficacy is slightly lower than that of varenicline. It is contraindicated in persons with seizure disorders; use caution in individuals with eating disorders, electrolyte abnormalities, or those taking other antidepressants.54
- Nicotinereplacement therapies. These are available over the counter in patch, gum, and lozenge forms and by prescription as a nasal spray and an inhaler. Its efficacy is increased when used in combination with a longer-acting agent (such as a patch), combined with short-acting agents.54
Non-Pharmacologic Treatments for SUD
It is useful for the PCP to understand local resources available for individuals with SUD. Such supports may include individual and group counseling, family counseling, and mutual-help organizations, including 12-step and non-12-step programs (such as Alcoholics Anonymous or SMART Recovery).55
Individual and group therapies with suggestive evidence of effectiveness in treating specific SUDs include cognitive behavioral therapy, dialectical behavioral therapy, and motivational enhancement therapy. Contingency management (offering tangible incentives) has shown some evidence of effectiveness in moving toward abstinence, and exposure therapy may be used when SUD is combined with post-traumatic stress disorder (PTSD). The Matrix Model and Assertive Community Treatment are community-based interventions to provide assistance, referrals, and ongoing follow-up for individuals with SUD who meet eligibility requirements.55-57
There is strong evidence that combining psychosocial and pharmacologic therapies is effective in the treatment of tobacco use disorder. Quit-lines, text messaging interventions, brief counseling, and motivational interviewing all have shown varying degrees of success in helping patients stop the use of tobacco products.54 Although psychosocial treatments are helpful for patients with opioid use disorder, evidence does not support that mandates for this type of treatment are effective. Medication should be offered even if the patient is unable or unwilling to engage in support services. Reiterating this point is the following 2019 statement from the National Academies of Science, Engineering, and Medicine: “Withholding or failing to have available all classes of FDA-approved medication for the treatment of opioid use disorder in any care or criminal justice setting is denying appropriate medical treatment.”58
K. notes that he does not think he is ready to stop using opioids. He states that he wants to try to “wean off on my own,” but understands he will not get a prescription for more opioids. He gratefully accepts a prescription for a naloxone kit, which he says he will give to his partner and agrees to return for follow-up within a month. On the way out, he asks if he will need blood work if he decides to pursue buprenorphine and agrees to go for the blood tests (complete blood count, comprehensive metabolic panel, hepatitis screen, and urine drug screening) prior to his next appointment, “just in case I change my mind.”
Summary: Take-Home Points
- Consider screening all patients for SUD.
- If a patient screens for SUD or presents with symptoms of SUD, evaluate for severity according to DSM-5 criteria.
- Correct stigmatizing language.
- Use ASAM dimensions to recommend appropriate treatment.
- Connect with local specialists and psychosocial services.
- Use models of management of chronic disease.
- If the patient refuses psychosocial interventions, medication still should be offered and used as a monotherapy in the treatment of opioid use disorder of at least moderate severity.
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Results from the 2019 National Survey on Drug Use and Health reveal 20.3 million people living in the United States have an addiction or substance use disorder (SUD). Geographic and financial barriers, as well as bias and stigma, work together to present formidable roadblocks for patients with SUD looking for direction. The primary care provider (PCP) may be the only healthcare contact for many of these patients. With expertise in understanding management of other complex, chronic disorders and experience in implementing an integrated, individualized treatment plan, the PCP has the background to take the lead in managing patients with SUD.
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