Addiction Medicine: Treatment for Substance Use Disorders

Addiction is a complex and multifaceted condition that affects individuals from all walks of life, regardless of age, gender, or socioeconomic status. Understanding the causes and symptoms of substance use disorders are crucial steps in addressing and treating this pervasive issue. Pharmacists play a vital role in helping manage medication assisted treatment for substance use disorders. 

Recommended course: Addiction Medicine: Part 1: Opioids and Other Scheduled Drug Classes 

What causes addiction? 

The root causes of addiction are diverse and intricate, often arising from a combination of genetic predispositions, environmental influences, traumatic experiences, underlying mental health disorders, and brain changes induced by prolonged substance abuse. 

  • Genetics: Research suggests that individuals with a family history of addiction, particularly first-degree relatives like parents or siblings, may have an increased susceptibility to developing addictive behaviors. 
  • Environmental factors: Children raised in unstable or abusive environments may be more prone to substance abuse as a coping mechanism. However, supportive family structures, positive relationships, and community engagement can mitigate the risk of addiction. 
  • Trauma: Trauma often leads to emotional difficulties, including substance abuse, as individuals seek relief from distressing symptoms. 
  • Underlying mental health disorders: Conditions like anxiety, depression, and bipolar disorder can exacerbate feelings of stress and anxiety. These can drive individuals to self-medicate with drugs or alcohol as a means of coping. 
  • Brain changes: Prolonged substance abuse alters the brain’s chemistry, particularly its reward circuitry, leading to diminished dopamine production and impaired pleasure response. Consequently, individuals may rely on drugs or alcohol to experience pleasure, perpetuating the cycle of addiction. 

Diagnosis of substance use disorders 

Diagnosing addiction is a complex process that relies on recognizing behavioral patterns, acknowledging the problem, and seeking professional intervention. The Diagnostic and Statistical Manual of Mental Disorders (DSM) categorizes substance use disorders, including alcohol-related disorders, opioid-related disorders, and stimulant-related disorders, among others. 

The diagnosis of substance use disorders typically begins with self-recognition or observations from family members or friends. Individuals exhibiting signs of addiction may consult a primary care physician or addiction specialist for evaluation and referral to treatment. 

During the diagnostic process, healthcare providers assess the frequency and impact of substance use on daily functioning. They may inquire about withdrawal symptoms and conduct physical examinations to evaluate overall health. 

Criteria for substance use disorder 

The DSM-5 outlines diagnostic criteria for substance use disorders, including patterns of substance use, failed attempts to moderate consumption, cravings, social and occupational impairments, withdrawal symptoms, and tolerance levels. 

Identifying and assessing risk in opioid use disorder 

Opioid use disorder (OUD) and misuse are prevalent in North America, posing challenges for healthcare professionals, especially nurses managing pain. Risk factors for OUD include unsuccessful control attempts, excessive time spent on opioids, persistent use despite problems, tolerance, and withdrawal symptoms. 

Assessing risk of opioid use disorder 

Tools such as SOAPP, DIRE Score, ORT-OUD, and OCC help assess OUD risk. SOAPP predicts aberrant behaviors in pain treatment. DIRE Score predicts efficacy and compliance. ORT-OUD predicts OUD development, and OCC monitors compliance during long-term opioid therapy. 

Treatment for substance use disorders: The pharmacist’s role 

The opioid epidemic poses significant challenges to healthcare professionals. Pharmacists are vital in OUD management, offering expertise in supervised withdrawal, medication therapy, patient education, and harm reduction. 

Pharmacists oversee safe detoxification using: 

  • Alpha-2 agonists: Clonidine and lofexidine manage withdrawal symptoms. 
  • Opioid antagonists: Naltrexone initiates withdrawal in abstinent patients. 
  • Innovative devices: NSS-2 Bridge and neurostimulators alleviate symptoms, with pharmacists educating patients and providers. 

Medication Assisted Treatment for substance use disorders (MAT) 

Pharmacists aid in: 

  • Methadone: Managing dosing to mitigate withdrawal and cravings. 
  • Buprenorphine: Facilitating access and counseling for safer treatment. 
  • Naltrexone: Collaborating for initiation and maintenance to reduce relapse risk. 

The use of naloxone in overdose management  

Naloxone, an opioid antagonist approved by the FDA, acts rapidly to reverse opioid overdose by binding to opioid receptors, effectively blocking and reversing the effects of opioids. Available in various formulations, including intranasal spray, intramuscular, subcutaneous, or intravenous injection, naloxone offers a reprieve, necessitating prompt medical intervention post-administration. 

The timely administration of naloxone is critical in mitigating the life-threatening consequences of opioid overdose. Recognizing signs such as respiratory depression, pinpoint pupils, and altered consciousness empowers individuals to intervene effectively. In emergencies, naloxone is a frontline defense, providing valuable time for medical responders to provide comprehensive care. 

Patient/caregiver counseling tips for responding to opioid overdose 

An opioid overdose demands swift and effective responses from both patients and caregivers. As part of a comprehensive approach to addiction treatment, the following tips for responding to an opioid overdose play a pivotal role in saving lives and fostering recovery. 

  • Recognize the signs: Identify shallow breathing and unresponsiveness and pinpoint pupils as signs of overdose. 
  • Take immediate action: Equip with naloxone for rapid reversal. Administer promptly for breathing and consciousness restoration. 
  • Ensure safety: Create hazard-free, calm environments for emergency care. 
  • Show compassion: Respond with empathy, free of judgment or stigma. 
  • Support recovery: Explore treatment options like therapy and support groups. 
  • Educate patients: Educate patients about opioid risks and the importance of naloxone. 
  • Follow-up: Encourage regular check-ins with healthcare providers and relapse prevention programs. 

Stimulants and benzodiazepine: Assessment, withdrawal, and treatment of substance use disorders 

Stimulants like cocaine, methamphetamine, prescription stimulants (e.g., amphetamine, methylphenidate), and caffeine affect the central nervous system. These cause euphoria, alertness, and increased energy. Symptoms of intoxication and overdose include confusion, paranoia, elevated heart rate, and blood pressure.  

Withdrawal symptoms of a stimulant use disorder include depressed mood, low energy, irritability, insomnia, and intense cravings. These tend to last 3-5 days, with protracted symptoms stretching 1-2 months. 

Treatment of stimulant use disorder  

Treating stimulant use disorder involves de-escalation techniques and, in severe cases, may consist of antipsychotic medications. Cognitive-behavioral therapy (CBT), contingency management (CM), and the Matrix Model are effective treatments aiming to reduce relapse risk and address underlying factors. Mirtazapine and bupropion also show promise in lowering stimulant use. 

Benzodiazepine use disorder  

Benzodiazepines (benzos) treat anxiety, insomnia, panic attacks, seizures, and muscle tension. Prolonged use can lead to dependence and addiction. Withdrawal symptoms include nausea, panic attacks, tremors, and anxiety. Severity and duration vary based on usage duration, dosage, type, method, and individual physiology. 

Assessment of a potential benzodiazepine use disorder includes evaluating benzodiazepine use, withdrawal symptoms, medical history, and co-occurring disorders. Treatment involves medical supervision, tapering off the drug, using longer-acting benzodiazepines, and additional medications like flumazenil to counteract the effects.