Addiction Disorders

Addiction is a treatable chronic condition and involves complex connections among genetics, interconnected networks of the individual’s neurons, the environment, and people’s life experiences (American Society of Addiction Medicine, 2019). Individuals with addiction utilize substances or participate in actions that grow habitually and often persist, notwithstanding dangerous outcomes.

Substance use disorder (SUD) is a complex condition characterized by an uncontrolled use of substances despite harmful consequences. Individuals with SUD develop an intense focus on using substances such as alcohol, opioids, or other drugs to the degree that it impairs their daily functioning. They persist in using these substances even when aware of the problems they cause or will cause (American Psychiatric Association, 2022).

Many people consider addiction a disease, although some do not (Olsen, 2022). A disease is a condition of function or structure that creates signs or symptoms (Tikkinen et al., 2012). Addiction has defined causes and observable consequences. Addiction is different from other chronic diseases. It has high negative externalities, such as those who are addicted are often involved in criminal activity, participate in violent behavior, and engage in harmful behavior. Nonetheless, it is still classified as a disease.

Addiction is like many chronic diseases, such as diabetes mellitus and hypertension, for multiple reasons. Like other chronic diseases, addiction can be challenging to manage behaviorally, responds to ongoing treatment, requires lifelong management, and results from certain genetic and environmental factors.

Drugs strongly affect society. Most drug users can function in society while using illicit substances. SUDs significantly impact the United States’ workforce, affecting both employees and employers. Approximately 46 million Americans aged 18 or older experienced a SUD in 2022, with nearly two-thirds (about 30.1 million) of them being employed (National Institute for Occupational Safety and Health [NIOSH], 2024). Workplace deaths due to unintentional overdoses from nonmedical drug use increased by almost 500% from 2012 to 2020 (NIOSH, 2024).

Certain industries, particularly construction and extraction, experience some of the highest drug overdose death rates (NIOSH, 2024). Employers can play a critical role in addressing this issue by preventing SUDs and drug-related deaths, helping workers access treatment, and supporting employees in recovery. Implementing workplace-supported recovery programs can prevent substance use, encourage and facilitate treatment access, and support workers in recovery. Recognizing the impact of job-related factors on workers' well-being is essential.

Substance abuse is a significant problem among incarcerated adults. Eighty percent of state and federal prisoners report a history of substance use, and 50% report a SUD. Thirty-three percent report using at the time of their offense, including using while committing the crime, committing a crime to fund drug use, or a crime related to manufacturing and selling drugs (National Institute on Drug Abuse [NIDA], 2020).

Substance abuse imposes a significant financial burden on the United States. The annual cost of substance abuse exceeds $740 billion due to crime, lost work productivity, and healthcare expenses (NIDA, n.d.). The cost is likely much higher in today’s dollars. More recent data is available on the cost of SUD on the hospital systems.

Hospitals in the United States incurred approximately $13.2 billion in medical costs associated with SUDs in 2017. This figure includes expenses from emergency department visits and inpatient admissions where SUD was the primary diagnosis. The study highlights the significant financial burden SUDs place on the healthcare system and suggests that investing in effective prevention and treatment strategies could potentially reduce these substantial hospital-related costs (Peterson et al., 2021).

Substance abuse issues are a real concern in the management of pain. Inappropriate prescriptions of pain medications have the potential to increase patients' chances of medication abuse. Below are some statistics regarding the current state of substance abuse.

• In 2020, 40.3 million Americans had a SUD, and only 6.5% received treatment (NIDA, 2024).
• Black Americans, American Indians, and Native Alaskans had the largest number of fatal overdoses (NIDA, 2024).
• The number of annual opioid overdose deaths is more than six times higher than it was in 1999 (Federal Communications Commission, n.d.).
• In 2022, nearly 108,000 drug overdose deaths occurred in the United States, with approximately 82,000 (about 76%) involving opioids (Centers for Disease Control and Prevention [CDC], 2024).

The guidelines for prescribing opioids for chronic pain reiterate the need for adequate pain control and the challenges involved, particularly in chronic pain control. It recommends that providers utilize the "full range of therapeutic options" to treat chronic pain. The report states that it is hard to quantify the number of individuals who could benefit from long-term use of opioid medications (Dowell et al., 2022).

The report states that between 1999 and 2014, more than 165,000 people died from opioid overdoses (Dowell et al., 2022). Research has found practices that have contributed to the opioid overdose epidemic, the most important of which are prescribing high doses of opioids, overlapping opioid and benzodiazepine prescriptions, and the use of extended-release opioids for acute pain (Dowell et al., 2022).

Prescription drug misuse is the use of prescription medication in a manner or intent inconsistent with how it was prescribed. Misuse includes using medication to get high, selling or sharing it with others (diversion), overuse, having multiple prescribers, and concurrent use of alcohol or other illicit substances. Misuse is a necessary but not solely a sufficient criterion for a SUD (American Psychiatric Association, 2022).

Susceptible individuals are at risk of misusing medications that stimulate the brain's reward center, including opioid analgesics, stimulants, benzodiazepines, or tranquilizers. Drug abuse is when drugs are not used medically or socially appropriately. Controlled substances may lead to dependence, either physical or psychological, or both. Physical dependence transpires when there are withdrawal symptoms such as anxiety, elevated heart rate, hypertension, sweating, an unstable mood, or dysphoria after the substance is stopped (Szalavitz et al., 2021).

Psychological dependence is the perceived need for the substance. It makes the person feel as though they cannot function if they do not have the substance. Psychological dependence often kicks in after physical dependence wears off. It typically lasts much longer than physical dependence and often is a substantial contributing factor to relapse (State of Wyoming Legislature, n.d.; Szalavitz et al., 2021).

NIDA provides multiple definitions for substance use/abuse-related terms (State of Wyoming Legislature, n.d.). Addiction is psychological dependence and extreme behavior patterns associated with the drug. At this point, there is typically a loss of control regarding drug use. The drug is continued despite severe medical and social consequences. Tolerance, increasing doses of the medication needed to produce an equivalent effect, is typically seen by the time addiction is present. Physical dependence can occur without addiction. Individuals who take chronic pain medication may be dependent on the medication but not addicted.

Addiction is a major concern for those taking opioids. When prescribing opioids, it is important to determine who is likely to participate in aberrant drug-related behaviors. Inappropriate use may occur in those with major depression, psychotropic medication use, younger age, or those with a family or personal history of drug or alcohol misuse (Dowell et al., 2022; Webster, 2017).

Aberrant behaviors may include abuse, misuse, or addiction. Examples of aberrant drug-related behaviors include (Dowell et al., 2022; Maumus et al., 2020):

• Requests for early refills
• Not taking medications as prescribed
• Failure to keep appointments
• Visits in distress
• Frequent reports of lost medication
• Using multiple prescribers
• Positive urine drug test for illicit substances
• Altering prescriptions
• Resistance to referrals
• Resistance to providing prior medical records
• Resistance to change in therapy
• Increasing the dose without telling the prescriber
• Requests for specific drugs

In ancient civilizations, addiction was often associated with the use of psychoactive substances for religious, medicinal, or recreational purposes. The Sumerians (circa 4000 BCE) referred to opium as the "joy plant," and its use spread throughout the ancient world. In ancient Egypt and Greece, there was widespread knowledge of alcohol's intoxicating effects. Greek philosophers, including Aristotle, acknowledged excessive drinking as a vice, although addiction was not yet conceptualized as a disease (Crocq, 2007).

Religious texts, such as the Bible and the Quran, also reference substance use, often framing it in moral or spiritual terms. In these eras, addiction was viewed as a moral inadequacy or failing of character rather than a medical condition. The lack of scientific understanding contributed to this perspective, and treatments were often punitive or ritualistic.

The spread of substances such as coffee, tobacco, and distilled spirits in the Middle Ages and Renaissance further expanded the scope of addiction. For instance, the introduction of tobacco to Europe in the 16th century sparked debates about its health effects and the compulsive behaviors it induced (Leone & Evers-Casey, 2022). During this period, addiction remained largely a moral issue, with religious authorities often condemning substance use as sinful.

Opium, meanwhile, continued to play a significant role in medicine and recreation. By the 17th century, the opium trade had become a cornerstone of colonial economies, particularly through the British East India Company. Opium addiction, especially in China, escalated during the 19th century due to the opium trade and wars, leading to widespread social and economic disruption (Brownstein, 1993).

The 19th century marked a turning point in the understanding of addiction, influenced by advancements in medical science. The isolation of morphine and the invention of the hypodermic syringe revolutionized pain management but also exacerbated addiction.

The 20th century saw the emergence of addiction as a public health issue. The Prohibition era in the United States (1920–1933) sought to curb alcohol addiction but inadvertently fueled organized crime. Similarly, the mid-century "War on Drugs" criminalized many substances, often disproportionately targeting marginalized communities while neglecting addiction's medical dimensions.

In parallel, scientific research on addiction has advanced. The discovery of neurotransmitters like dopamine elucidated the brain's role in addiction, leading to the development of pharmacological treatments and behavioral therapies. Organizations such as Alcoholics Anonymous (founded in 1935) emphasized community support and accountability, fostering new approaches to recovery.

In the 21st century, addiction is recognized as a complex relationship of biological, psychological, and social components. The opioid crisis, the rise of behavioral addictions like internet gaming, and increasing awareness of mental health have further highlighted the need for comprehensive strategies to address addiction (Volkow & Blanco, 2021).

While humanity’s relationship with addictive substances and behaviors is as old as civilization itself, the growing understanding of addiction as a medical condition offers hope for more effective interventions and compassionate care.

Addiction treatment has swung to a chronic care model, working with patients over time instead of short-term interventions during an acute crisis with addiction. Patients are taught skills to encourage self-management of addiction. Treatment involves connecting patients to community resources.

According to Horseman and Meyer (2019), addiction is characterized by compulsive drug-seeking, impulsive consumption, and negative emotions when the drug is unavailable. The brain's reward pathway, particularly the mesolimbic system comprising the ventral tegmental area (VTA) and the nucleus accumbens (NAcc), is crucial for experiencing pleasure and reinforcement. Drugs of abuse raise dopamine levels in this system, reinforcing drug-taking behaviors (Uhl et al., 2019). For instance, stimulants like cocaine block dopamine reuptake, while opioids bind to specific receptors, both leading to increased dopamine activity.

Chronic drug use leads to neuroadaptations, including changes in synaptic plasticity and dendritic spine density in the NAcc and VTA. These structural changes can enhance the reinforcing effects of drugs, making it harder to quit. Additionally, the prefrontal cortex, accountable for decision-making and impulse control, becomes compromised, reducing an individual's ability to resist drug cravings (Horseman and Meyer, 2019; Uhl et al., 2019).

Stress and environmental cues are linked to addiction. Stress can trigger the release of corticotropin-releasing factor (CRF), which interacts with the brain's reward system, potentially leading to relapse. Environmental cues associated with drug use can activate the reward pathway, causing cravings and increasing the risk of relapse (Horseman and Meyer, 2019; Uhl et al., 2019).

Understanding the neurobiology of addiction is necessary for developing effective treatments. Targeting specific neurotransmitter systems and neural circuits involved in addiction could lead to more effective interventions, but it is important to consider individual differences in neurobiology when designing treatment plans (Horseman and Meyer, 2019; Uhl et al., 2019).

In recent times, opioid therapy has become more commonly used. In the past, it was only used for severe acute pain and cancer pain. A position paper from the American Academy of Neurology suggested evidence for adequate short-term pain relief with opioids (Franklin & American Academy of Neurology, 2014). However, no good evidence exists for the continuation of pain relief or enhanced function for long periods without experiencing serious risk of dependence, overdose, or addiction (Dowell et al., 2022).

Opioids function by activating opioid receptors that are located in the spinal cord and the brain. The majority of the pain relief related to opioids is due to their actions on the periaqueductal gray (PAG) cells and the descending pain pathways (Lueptow et al., 2018). Opioid receptors are molecules located on the surface of cells; opioid substances attach themselves to them and release their effects.

There are three different types of opioid receptors found in the brain: Mu, Kappa, and Delta receptors (Herman et al., 2024). Mu and Kappa receptors are also found in the spinal cord and mediate pain transmission from the brain's peripheral nervous system. The most important pain receptor in opioid abuse and treatment is the Mu receptor. When opioids activate Mu receptors, the most significant potential for pain relief and addiction is initiated (Herman et al., 2024). However, Kappa and Delta receptors also play a role in opioid addiction.

Opioid agonists, partial agonists, and antagonists are drugs that interact with opioid receptors in the brain. Agonists, like heroin or morphine, fully activate these receptors, producing pain relief and euphoria. Partial agonists, such as buprenorphine, also bind to these receptors but activate them to a lesser extent, providing pain relief without the same level of euphoria or risk of overdose. Antagonists, like naloxone, block opioid receptors, reversing the effects of opioids and potentially causing withdrawal symptoms. Understanding these distinctions is crucial for managing pain, treating opioid addiction, and preventing overdose.

The Controlled Substances Act divided drugs and other substances into five schedules, updated annually here(United States Drug Enforcement Agency, 2018). Schedule I controlled substances have no recognized medical use in the United States; they include heroin and lysergic acid diethylamide (LSD).

Schedule II substances may potentially be abused and may lead to severe physical or psychological dependence. Schedule II narcotics include oxycodone, hydrocodone, fentanyl, methadone, hydromorphone, morphine, opium, cocaine, methamphetamine, and codeine.

Schedule III or IV substances have less abuse potential than those substances that are Schedule I or II. They are at high risk for psychological dependence and low to moderate risk of physical dependence. Examples of medications in this class include buprenorphine (Suboxone) and products with less than 90 milligrams (mg) of codeine per dosage unit, such as Tylenol with codeine. Schedule III includes anabolic steroids such as Depo-Testosterone and ketamine.

Schedule IV controlled substances have a lower potential for abuse when compared to Schedule III controlled substances. Examples of this class include benzodiazepines, midazolam, tramadol, and carisoprodol.

Schedule V controlled substances have a low abuse potential compared to Schedule IV and include cough preparations that contain less than 200 mg of codeine, such as Robitussin AC®.

Most controlled substances alter mood, feeling, or thought due to their effect on the central nervous system. Medications likely to produce euphoria are more likely to be abused, but medications may be abused to aid in sleep, reduce pain, anxiety, or depression, and improve energy.

The prescribing of opioids for pain management has been a cornerstone of modern medicine, offering relief for millions suffering from acute and chronic pain. However, the widespread misuse of opioids has led to a public health crisis, with significant rates of addiction, overdose, and death, which underscores the importance of appropriate prescribing practices that balance effective pain relief with the minimization of risks.

The opioid epidemic in the United States can be traced to the 1990s when aggressive marketing by pharmaceutical companies and the underestimation of addiction risks led to a surge in prescriptions. The result was a significant rise in opioid misuse and dependency. This history highlights the critical need for vigilance in prescribing practices to ensure opioids are used responsibly and only when clinically necessary. Nonetheless, the balance between adequate pain relief and preventing misuse remains difficult.

The treatment plan should be established before commencing treatment. In this plan, the patient and the provider should discuss the benefits, risks, and alternatives before starting treatment. In addition, the clinician needs to discuss how the patient will be monitored, including how the patient will be evaluated for potential misuse of the prescribed medication. The use of written documents is often included in the plan. It is essential to document that decision-making was implemented, including informed consent, a discussion on goal setting, and a defined monitoring plan.

When high doses of opioid prescriptions are given, there is an increased risk of overdose death. For chronic pain in adults, limited research is available on dosages over 90 morphine mg equivalents (MME) per day or higher (Dowell et al., 2022). Clinicians should carefully justify doses above this threshold, balancing the potential benefits against the significantly increased risks of harm.

When escalating opioid dosages, providers are advised to evaluate the patient’s response to treatment, including pain reduction and functional improvement, while assessing for adverse effects or signs of misuse. When opioid doses between 50 and 90 MME/day are given, there may only be a slight increase in pain and no difference in functional improvement when compared to doses of less than 50 MME/day (Dowell et al., 2022).

The World Health Organization (WHO) analgesic ladder was established to manage cancer pain and published in the 1980s (Anekar et al., 2023). It is a framework for managing pain, originally designed for cancer pain but widely applied to other types of pain management. It provides a stepwise approach to choosing analgesic medications based on pain severity.

Step 1 - Mild Pain

• Medications: Non-opioid analgesics, including acetaminophen or nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, are employed for mild pain.
• Adjuvants: Medications such as antidepressants and anticonvulsants may enhance pain relief.

Step 2 - Moderate Pain

• Medications: Weak opioids, such as codeine or tramadol, are often combined with non-opioid analgesics.
• Adjuvants: Continue or adjust as needed.

Step 3 - Severe Pain

• Medications: Strong opioids, such as morphine, fentanyl, or oxycodone, are used.
• Adjuvants: Continue to address specific types of pain or side effects.

Principles

1. By the clock: Medications should be given at regular intervals rather than on demand to maintain consistent pain control.
2. By the mouth: Use oral formulations for ease and patient comfort.
3. By the individual: Tailor the medication and dose to each patient's needs.
4. Attention to detail: Address side effects (e.g., nausea, constipation) and adjust treatment as necessary.

The systematic approach outlined by the WHO ensures effective pain management, minimizing suffering while reducing the risk of overmedication or undertreatment. When starting therapy, the dose should be started at a low dose and titrated to obtain pain control and minimize side effects. Tolerance often develops as a patient gets used to the medication (Anekar et al., 2023).

Treatment is typically started with a short-acting medication, and the medication is then titrated upwards to control pain while side effects are monitored. After establishing the dose of the medication necessary to supply sufficient pain relief with minimal side effects, the medication can be switched to a sustained-release form and given once or twice a day. When a long-acting medication is used, breakthrough medication can be given.

A periodic review of the patient's pain and clinical status is essential to ensure that opioids need to be continued or discontinued. Any change in the patient's health, degree, or nature of pain, mental health, and overall function should be noted. The clinician and patient should review the proper dosage and medication schedule. Decisions on the benefits of pain management should focus on previously decided upon goals. A positive response to treatment can include reducing pain, improving quality of life, or improving function.

An essential role of the practitioner is prescribing controlled substances. Controlled substances have inherent risks, so the prescriber must realize that the primary goal of prescribing opioids should be to maintain patient safety. A prescriber should follow multiple steps to ensure safe and effective patient care.

To prevent prescription drug abuse, the clinician needs to ensure (Dowell et al., 2022; Manchikanti et al., 2023):

• Patients are assessed and reassessed.
• Treatment agreements are used.
• Prescription monitoring occurs.
• Safe prescription methods are practiced.

Patients' risks should be assessed, and contraindications should be immediately identified. Contraindications to opioid treatment include those who have an inconsistent follow-up, suffer from current untreated addiction, or have poorly controlled mental illness.

When taking a patient history, document the opioid currently prescribed, its dose, frequency, and duration. It is essential to query the State Prescription Drug Monitoring Program (PDMP) to confirm the patient's medication use. Also, it is essential to contact past providers to obtain medical records.

Before controlled substances are prescribed, history of illegal substance use, alcohol use, tobacco use, prescription drug use, family history of substance abuse and psychiatric disorders, history of sexual abuse, legal history, behavioral problems, employment history, marital history, social network, and cultural background should be assessed. A history of substance abuse does not prohibit treatment with opioids but may necessitate more intensive monitoring or referral to an addiction specialist.

Multiple tools are available to evaluate opioid risk. The Opioid Risk Tool is a tool used in primary care to screen adults for the risk of aberrant behaviors when prescribed opioids for chronic pain (Brott et al., 2022). It is a copyrighted tool, encompasses five questions, and takes about one minute to use. It classifies a patient as low, moderate, or high risk of abusing opioids. Those who are high risk have a high likelihood of aberrant drug-related behavior. It is not validated in individuals without pain. The five questions include asking about family and personal history of substance abuse (alcohol, prescription drugs, or illegal drugs), age (risk is 16-45 years old), psychological disease, and preadolescent sexual abuse history. The questions are scored with different points assigned for each question, which vary between men and women, and the total score is tallied. The patient is placed into low, moderate, or high risk.

Regular follow-up is essential and should occur at least every three months. When assessing the patient with pain, the five A's should be assessed: analgesia, addiction, activities of daily living, adherence, and adverse effects (Maumus et al., 2020). Part of the follow-up should be urine drug testing, which can detect medication adherence and illicit and non-prescription drug use. It is critical that the clinician adequately document any interactions with patients, assessments, and results of testing and treatment plans.

Written treatment agreements, which should be used between prescribers and patients when controlled substances are used, help guide the conversation. It discusses expectations, the risks, and the monitoring of controlled substances (Table 1).

As of 2025, prescription monitoring programs are available in all states. They provide an online database that lists all prescriptions of controlled substances dispensed for every patient by pharmacies. Ideally, the prescriber should check the database before prescribing controlled substances. If a patient has an undisclosed prescription for controlled substances, it is prescription drug misuse.

When abuse/misuse is detected, how should the clinician respond? If it is a single, minor deviation, then counseling and more intensive monitoring may be needed. Tapering controlled substances to reduce the risk of withdrawal is appropriate in more severe or persistent misuse cases. When diversion is the cause of misuse, immediate prescription removal is likely the most appropriate course. If a substance abuse disorder is suspected, a referral to an addiction specialist is recommended.

SUD is a medical condition characterized by the uncontrolled consumption of substances such as alcohol, drugs, or medications despite adverse consequences. It encompasses a spectrum of behaviors, from misuse to dependence, significantly impacting an individual's health, relationships, and responsibilities.

It has been reported that approximately 19.7 million people (7.2% of the population) had a SUD in the past year (Bose et al., 2018). Among adolescents (12-17 years), about 992,000 (4.0% of this age group) experienced a SUD. Among young adults (18-25 years), approximately 5.1 million (14.8%) had a SUD, the highest percentage among all age groups. Among adults (26 years and older), around 13.6 million (6.4%) were affected by a SUD.

Alcohol use disorder (AUD) affected an estimated 14.5 million individuals (5.3% of the population) in the past year. Illicit drug use disorder affected approximately 7.5 million people (2.8%). Among those with an SUD, 2.3 million individuals (11.9%) had both alcohol and illicit drug use disorders (Bose et al., 2018).

Despite the prevalence of SUDs, many individuals do not receive treatment. For instance, among adolescents aged 12 to 17 who needed substance use treatment but did not receive it at a specialty facility, only 1.9% perceived a need for treatment. Similarly, among adults aged 26 or older with an unmet treatment need, only 6.7% recognized the need for treatment (Bose et al., 2018). These findings emphasize the significant impact of SUDs across various age groups and highlight the ongoing challenges in addressing treatment needs.

Addressing SUD requires a comprehensive approach, including prevention, early intervention, and access to effective treatment and support services. Understanding the scope and impact of SUD is crucial for developing strategies to moderate its effects on individuals and society.

Assessment for SUD includes taking an inventory of the patient's drug use, including the type of drugs, the amount, and frequency. In addition, any consequences of drug use should be explored. A complete assessment includes interviewing the patient, family members, and previous medical reports. In addition, the clinician should evaluate the patient's desire to change and their stage of change. A complete medical evaluation may include medical, surgical, and psychiatric diseases, laboratory evaluations, and family and social issues.

A drug history assessment should be done non-judgmentally to improve the patient's honesty when taking the assessment. Start with asking about socially acceptable substances and move to illicit drugs. Ask about caffeine, nicotine, tobacco, alcohol, sedatives/hypnotics, stimulants, opioids, marijuana, cocaine, heroin, hallucinogens, and inhalants. The clinician should question any "other" substances, as many novel substances (such as bath salts or synthetic cannabinoids) have been used.

In addition to the type of substance used, ascertain the pattern of use, last use, frequency of use, and quantity used. The route of drug use should also be identified (e.g., oral, inhalation, injection, intranasal). Invasive routes of delivery suggest a more severe disorder, potentially complicated by more severe complications (e.g., injection use is with hepatitis/human immunodeficiency virus (HIV), and intranasal use is associated not only with infectious disease but also sinus perforation).

The spectrum of substance use provides a framework to understand how to classify the individual's risk (McNeely et al., 2024). The spectrum includes abstinence, low-risk use, risky use/at-risk use/hazardous use, and harmful use; as the patient moves up the spectrum, the consequences increase. Abstinent individuals are at no risk from substances and will not have any consequences. Individuals classified as low risk have more risk than those who are abstinent, but the consequences are still relatively low.

Unhealthy use is noted at the next step on the substance use spectrum, where the individual places themself at risk and may start to notice some consequences of substance use. When an individual gets to the harmful use spectrum, SUD is recognized. SUD can be classified as mild, moderate, or severe.

A screening test for other drugs should include a single question in primary care, which is validated as a brief screening test. The question to ask is, "How many times in the past year have you used an illegal drug or used a prescription drug for non-medical reasons?" This question is just as sensitive and specific as a drug abuse screening test, where an affirmative response is 100% sensitive and 74% specific for a drug use disorder (Smith et al., 2010).

While opioids are used for pain relief, they have the potential to be abused. Not only do they have analgesic properties, but they can also cause euphoria and depress the central nervous system. OUD is a chronic, recurrent problem that many individuals struggle with for years. It is associated with significant morbidity and mortality and can lead to many adverse health outcomes, including death from overdose, hepatitis, and HIV. OUD can take many forms and may include the use of heroin, misusing prescription opioids, or the use of diverted opioids (Taylor & Samet, 2022).

Treatment of OUD can include non-pharmacologic options, MAT, or a combination of the two. MAT includes the use of opioid agonists (methadone), partial agonists (buprenorphine), and opioid antagonists (naltrexone).

Heroin, a highly addictive opioid, continues to pose significant public health challenges in the United States. In 2021, approximately 1.1 million individuals aged 12 or older (0.4% of this age group) reported using heroin in the past year. Similarly, about 1.0 million people (0.4%) were estimated to have a heroin use disorder during the same period (NIDA, 2023). Heroin use has increased significantly over the last couple of decades, with rates doubling between 2002 and 2018 (Han et al., 2020). Overdose deaths from heroin were approximately 15,000 people in 2018, which equates to five deaths for every 100,000 Americans, but the percentage of death rates has decreased by 4.1% between 2017 and 2018 (CDC, 2020).

In 2017, in the United States, there were 70,237 drug overdose deaths, and 47,600 were caused by an opioid. In 2018, 67,367 drug overdose deaths occurred, and 46,802 involved an opioid. While there was a decrease in drug overdose deaths, the deaths from synthetic opioids increased by 10%, probably due to illicitly manufactured fentanyl (Wilson et al., 2020).

Heroin is a semisynthetic opioid developed from morphine, a natural alkaloid of the opium poppy. Heroin quickly crosses the blood-brain barrier, where it is metabolized into morphine and other active metabolites. These compounds bind to mu-opioid receptors in the central nervous system, producing analgesia, euphoria, and sedation effects. Heroin’s high lipid solubility accounts for its rapid onset of action, which contributes to its addictive potential. Chronic use leads to tolerance, dependence, and significant changes in brain structure and function, particularly in areas related to decision-making and stress regulation (Oelhaf & Azadfard, 2023).

Fentanyl is a fully synthetic opioid approximately 50-100 times more potent than morphine and about 50 times stronger than heroin (Ramos-Matos et al., 2023). Its pharmacodynamics involve selective binding to mu-opioid receptors, with rapid absorption and a short duration of action. Medical applications of fentanyl include pain management for severe conditions and anesthesia. However, its high potency increases the risk of respiratory depression, a leading cause of overdose deaths. Fentanyl is also lipophilic, allowing for rapid penetration into the central nervous system. Illicitly manufactured fentanyl, often mixed with other substances like heroin or cocaine, exacerbates overdose risks because even very small quantities can be lethal.

According to the 2023 National Survey on Drug Use and Health (NSDUH), approximately 28.9 million individuals aged 12 and older in the United States (10.2% of this age group) experienced AUD in the past year. This prevalence varies across different demographics. Among youth aged 12 to 17, 757,000 individuals (2.9%) had AUD, with a higher occurrence in females (3.8%) compared to males (2.0%). In adults aged 18 and older, 28.1 million (10.9%) were affected, with males exhibiting a higher prevalence (12.1%) than females (8.3%). Racial and ethnic disparities are also evident; for instance, 11.0% of White individuals and 9.6% of Black or African American individuals aged 12 and older had AUD, while the prevalence among Asian individuals was 5.7%. These statistics underscore the widespread impact of AUD across various age groups and demographic sectors in the United States (National Institute on Alcohol Abuse and Alcoholism, 2024).

Alcohol has a risk threshold. The amount of alcohol that is thought to increase health risks is estimated at 14 standard drinks per week or more than four drinks in a day for a man under the age of 65, and seven standard drinks per week or more than three drinks on any day for women and adults over 65. A standard drink is 1.5 ounces of hard liquor, five ounces of wine, or 12 ounces of beer (National Institute on Alcohol Abuse and Alcoholism, 2024).

Specific factors that increase risk should be documented. Factors include any amount of alcohol in those with known liver disease and those who use substances that interact with alcohol, such as benzodiazepines or drug/alcohol use in pregnancy.

All primary care patients should be screened for unhealthy alcohol use annually. Multiple tools are available to detect unhealthy use. A commonly used tool is the Alcohol Use Disorders Identification Test – Consumption (AUDIT-C), which is a good screening tool in primary care (National Institute on Alcohol Abuse and Alcoholism, 2024). If a patient is determined to have moderate to severe AUD, they should be screened for adverse consequences of use, including medical issues such as cirrhosis.

The AUDIT-C test asks three questions (National Institute on Alcohol Abuse and Alcoholism, 2024):

• How often do you have a drink containing alcohol?
• How many drinks containing alcohol do you have on a typical day when you are drinking?
• How often do you have six or more drinks on one occasion?

Each of the three questions is given a score of zero to four, and the scores are added. Research has shown that it performs well with an optimal cut-off of five or more drinks for men and four or more for women (van Gils et al., 2021).

The CAGE questionnaire is a four-question screening tool often used in primary care. If used as a screening test, one positive response is considered a positive test (Johns Hopkins Medicine, n.d.). Below are the four questions of the CAGE questionnaire.

• Have you ever felt you should Cut down on your drinking?
• Have people Annoyed you by criticizing your drinking?
• Have you ever felt bad or Guilty about your drinking?
• Have you ever taken a drink first thing in the morning (Eye-opener) to steady your nerves or get rid of a hangover?

Cannabis is globally the third most commonly used psychoactive substance behind alcohol and tobacco. Cannabis is the most frequently used federally illegal drug in the United States. In 2021, approximately 52.5 million individuals, or about 19% of Americans, reported using cannabis at least once (CDC, 2025a). Research indicates that nearly three in ten cannabis users develop cannabis use disorder (CUD), characterized by an inability to stop using despite health and social problems. The likelihood of developing CUD is higher among those who begin using cannabis before age 18 (CDC, 2025a).

Cannabis use affects brain regions responsible for memory, learning, attention, decision-making, coordination, emotion, and reaction time (Dhein, 2020). Infants, children, and teens, whose brains are still developing, are particularly susceptible to these adverse effects. Long-term or frequent use has been associated with an increased risk of psychosis or schizophrenia in some individuals (Di Forti et al., 2019). During pregnancy, cannabis use may elevate the risk of complications.

Acute intoxication presents with conjunctival injection, increased heart rate, slurred speech, dry mouth, changes in blood pressure, and ataxia. The patient reports euphoria, sedation, relaxation, increased appetite, anxiety, memory impairment, concentration difficulty, perceptual disturbances, paranoia, or psychosis. Other adverse effects include chest pain, palpitation, nausea, and vomiting.

Mental health evaluation is a crucial aspect of the management of addiction. A complete mental status exam may be performed, and significant abnormalities may suggest possible acute intoxication or severe mental health disease. Therefore, determining mental health/psychiatric diagnosis is a primary step in managing these conditions and improving addiction management. Mental health conditions commonly seen along with SUDs include depression, anxiety, bipolar disorder, schizophrenia, attention deficit hyperactivity disorder, posttraumatic stress disorder, eating disorders, and personality disorders (Swimmer & Sandelich, 2024).

Even though drug/alcohol use can affect any body system, no physical exam finding is specific to a SUD. While some, if not most, individuals with a SUD will have no findings on physical exam suggestive of their disease, performing a good history and physical exam may help find complications of drug use.

• Poor physical hygiene 
• Signs of acute intoxication – unsteady gait, slurred speech, pupil changes, sedation, agitation, conjunctival injection, runny nose, sweating, watery eyes
• Scars at injection sites (track marks) – suggest intravenous drug use
• Weight loss – recent heavy drug use
• Nasal mucosa atrophy or perforation – intranasal drug use
• Stigmata of liver disease such as spider angioma, palmar erythema, telangiectasias, gynecomastia, or testicular atrophy
• Elevated blood pressure
• New heart murmur
• Other cardiac diseases, including heart failure or cardiomyopathy
• Abscess – suggestive of methicillin-resistant Staphylococcus aureus
• Genitourinary abnormalities suggestive of sexually transmitted infection, as many individuals with SUD engage in high-risk behaviors
• Abdominal tenderness/organomegaly – suggestive of hepatitis or pancreatitis
• Findings of anemia, such as fatigue or conjunctival pallor, may suggest complications of alcohol use
• Memory loss suggestive of dementia
• Pulmonary symptoms such as wheezing or a cough may suggest lung damage 

Assessment should include basic laboratory tests if indicated to evaluate any disease states, but no specific laboratory test is indicated for addiction other than drug testing. Drug testing plays a crucial role in the assessment, diagnosis, and monitoring of individuals with SUDs. It provides objective evidence of recent substance use, helping to confirm self-reported information or detect undisclosed use. Commonly used in clinical, occupational, and legal settings, drug testing can support treatment planning by identifying specific substances being used. Tests typically analyze urine, blood, saliva, hair, or sweat, with urine tests being the most common due to their non-invasive nature and ability to detect a wide range of substances. Drug testing is particularly valuable in monitoring treatment adherence and identifying relapse, enabling timely intervention. However, the utility of drug testing must be balanced against limitations, such as false positives or negatives, variability in detection windows, and the potential for individuals to tamper with samples. Clinicians must use drug testing as part of a comprehensive evaluation, considering behavioral, psychological, and social factors alongside test results. Furthermore, it is crucial to approach drug testing with sensitivity and confidentiality to foster trust and encourage individuals to engage in treatment. When used appropriately, drug testing is a valuable tool for improving outcomes in SUD treatment and recovery.

Individuals with a family history of SUD are at higher risk of developing a SUD. Twin and family studies consistently show that genetic factors explain about 50% of the risk of developing SUDs (Deak & Johnson, 2021). Heritability estimates for AUD and OUD are around 50% (Gerring et al., 2024), while estimates for cocaine use disorder are as high as 72% (Ducci & Goldman, 2012).

Social history is another important part of the assessment of SUD. Risk factors for SUD include those who have friends with SUD, living environment (e.g., poverty, high-violence community), or having a romantic partner with a SUD (Swimmer & Sandelich, 2024). In addition, individuals with SUD often have complicated lives with adverse social events such as violent behavior, financial problems, failure to fulfill social responsibilities, and abnormal social relationships.

Detoxification, also known as medically supervised opioid withdrawal, is the use of pharmacotherapy to reduce the signs/symptoms of withdrawal in individuals who are using opioids. Detoxification aims to help the patient safely move to continued treatment and maintain abstinence from opioids. Detoxification alone does not lead to abstinence, but it is the first step.

Abstinence requires the patient to address ongoing cravings and many of the psychosocial factors that lead to addiction. Addressing the consequences of addiction is another important key factor in the treatment of addiction. Consequences include the addiction's damage to personal relationships, finances, mental/physical health, and employment. Detoxification is only fully realized when a patient is off all opioids or transitioned to naltrexone. Patients maintained on buprenorphine or methadone are still dependent on opioids.

There are many reasons a person may abruptly stop taking opioids. When opioids are stopped abruptly, detoxification may be done to relieve suffering. Reasons people may stop abruptly include a patient being hospitalized for an acute illness and unable to obtain the illicit opioid, the patient running out of access to the drug or money to purchase the drug, a person presenting for treatment of OUD, legal issues (e.g., getting incarcerated), the provider who supplied the medication is no longer prescribing the medication, or the user wants to stop using the drug.

OUD during pregnancy requires specialized treatment to ensure the health of both the mother and the developing fetus. The CDC (2025b) emphasizes that creating a comprehensive treatment plan can significantly enhance pregnancy outcomes. Abrupt discontinuation of opioids during pregnancy is not recommended due to risks such as preterm labor, fetal distress, and miscarriage (CDC, 2025b). Instead, medication for OUD, including methadone and buprenorphine, is advised as first-line therapy. Combined with behavioral therapy and medical services, these medications improve outcomes and reduce relapse risk (CDC, 2025b). Pregnant individuals with OUD must collaborate closely with healthcare providers to manage care during and after pregnancy. Coordination between prenatal care providers and specialists in opioid use ensures comprehensive support. While medication for OUD may lead to neonatal abstinence syndrome (NAS) in newborns, this condition is manageable, and the benefits often outweigh the risks. Healthcare providers should not withhold medication for OUD due to concerns about NAS alone (CDC, 2025b).

Monitoring patients going through opioid withdrawal should be done with a structured instrument and a thorough physical assessment, which will help guide medical management. A standard tool used is the Clinical Opioid Withdrawal Scale (COWS) (Wesson & Ling, 2003). It rates 11 signs/symptoms on a 0-5 scale and has a high interrater correlation coefficient. Testing should be repeated during withdrawal to monitor for progression or improvement.

Detoxification aims to manage withdrawal symptoms safely and is often the first step in addressing OUD. While detoxification alone does not constitute comprehensive treatment, several medications are critical in managing withdrawal:

• Methadone: A long-acting opioid agonist that alleviates withdrawal symptoms and cravings by stabilizing opioid levels in the brain. It is administered in specialized clinics and is effective for detoxification and maintenance therapy.
• Buprenorphine: A partial opioid agonist that minimizes withdrawal symptoms and cravings without generating the full euphoric effects of opioids. It has a ceiling effect, lowering the risk of misuse and overdose. It is available in formulations like Suboxone® (combined with naloxone) and can be prescribed in office-based settings.
• Clonidine: A non-opioid medication that mitigates withdrawal symptoms such as anxiety, sweating, and agitation. It is not FDA-approved for OUD but is used off-label as an adjunct during detoxification.
• Naltrexone: An opioid antagonist used after detoxification to prevent relapse. It blocks opioid receptors, reducing the effects of any opioids taken post-detox.

Combined with counseling and behavioral therapies, these medications enhance the likelihood of successful recovery.

In Kentucky, Advanced Practice Registered Nurses (APRNs) are authorized to prescribe buprenorphine for MAT of OUD under specific professional standards outlined in 201 KAR 20:065 (Kentucky General Assembly, 2025). This regulation establishes comprehensive guidelines to ensure safe and effective prescribing practices.

In order to prescribe, the APRN must hold a current, active license with prescriptive authority in Kentucky (Kentucky General Assembly, 2025). They are required to complete eight hours of continuing education training on managing OUD and other SUDs to prescribe buprenorphine. Before initiating buprenorphine therapy, APRNs must conduct a thorough patient evaluation, including a comprehensive medical and psychiatric history, physical examination, and appropriate laboratory testing (which may include a CBC, comprehensive drug screen, liver function tests, HIV testing, and hepatitis serology). A written treatment plan should be developed, outlining objectives, counseling requirements, and criteria for treatment success.

During treatment with buprenorphine for OUD, drug testing should ensue. At least eight drug screens should occur every twelve months. The patient should be screened for buprenorphine, methadone, alcohol, opioids, benzodiazepines, THC, amphetamines, and cocaine. Two of the drug screens should be random, and a pill count should coincide. At least one of these two drug screens should be confirmed by gas or liquid chromatography/mass spectrometry. A positive drug screen should be incorporated into the decision to continue or modify treatment (Kentucky General Assembly, 2025).

Buprenorphine is often used in acute detoxification because it has many benefits, such as:

• It is safer in overdose than methadone
• It has a high affinity for the mu-opioid receptor
• It slowly dissociates from the receptor
• It has a long duration of action

Caution must be used with buprenorphine as it can bring on or exacerbate withdrawal from opioids. The patients must be in a mild to moderate withdrawal state before taking the first dose of buprenorphine (COWS score of 10-12). The dose will reverse the withdrawal symptoms as it leads to opioid agonism.

While buprenorphine can lead to respiratory depression, it is much less likely to cause this than methadone (Kumar et al., 2024). It is a partial agonist of the mu-opioid receptors, reducing the likelihood of severe respiratory depression. It is more likely to be fatal in overdose if combined with alcohol or benzodiazepines or if it is injected.

In most cases, the APRN should recommend an in-office observed induction. If it is not inducted in the office, the APRN should document why it was not and implement an appropriate home-based induction as recommended by the Substance Abuse and Mental Health Services (SAMHSA) or the American Society of Addiction Medicine. In addition, the utilization of any opioid withdrawal protocol should be documented with a standardized tool (e.g., COWS) (Kentucky General Assembly, 2025).

Detoxification from opiates can be done with buprenorphine, methadone, and non-opioid options. Opiate detoxification involves managing withdrawal symptoms while transitioning the patient to a stable and safer condition, which can be done using opioid agonists (methadone), partial agonists (buprenorphine), or non-opioid medications. The choice depends on factors such as the severity of dependence, patient preference, and medical history.

Buprenorphine is a partial opioid agonist, meaning it activates opioid receptors but with a ceiling effect, reducing the risk of overdose. It helps ease withdrawal symptoms while minimizing cravings. In the induction Phase, the patient must be in mild-to-moderate withdrawal (e.g., COWS ≥ 8-12) before starting buprenorphine.

The traditional approach to starting buprenorphine requires patients to be in mild to moderate opioid withdrawal before starting buprenorphine to minimize the risk of precipitated withdrawal. Precipitated withdrawal occurs when buprenorphine displaces full opioid agonists from receptors, leading to acute withdrawal symptoms. Patients are typically advised to abstain from short-acting opioids for 12–24 hours and long-acting opioids for 24-48 hours before induction. The COWS is often used to assess withdrawal severity, with a score of 8-12 indicating readiness for induction. The initial buprenorphine dose is usually 2-4 mg, followed by additional doses every 1-2 hours based on withdrawal symptoms, up to 8 mg on the first day. Maintenance doses are adjusted over subsequent days (León-Barriera et al., 2023).

Methadone is a full opioid agonist, meaning it prevents withdrawal and cravings but can be addictive if misused. It is only prescribed in federally approved clinics for opioid detox. In the induction phase, the initial dose is 10-30 mg once daily; reassess in 3-4 hours and provide a 5-10 mg additional dose if needed—the maximum first-day dose is 40 mg (Kumar et al., 2024; Office of Addiction Services and Supports, 2019). In the stabilization phase, the dose is adjusted to suppress withdrawal without sedation. In the tapering phase, which occurs over 7-10 days, the dose is reduced by 5 mg daily. In some cases, a long-term taper occurs over weeks to months by decreasing the dose by 5-10% per week for better tolerance (Nosyk et al., 2024; Office of Addiction Services and Supports, 2019).

Quick withdrawal, often seen when precipitated by naltrexone or buprenorphine, may be more severe and lead to more severe complications such as cardiomyopathy or delusions (Shah & Huecker, 2023). These complications can also occur in an unassisted detoxification withdrawal. Other complications include suicide, dehydration (often caused by insufficient oral intake), and electrolyte abnormalities. Another complication is opioid overdose. If the patient abandons treatment and uses his typical dose of opioids with a reduced tolerance, an overdose may occur.

Individuals with OUD are likely to relapse after withdrawal, especially in the absence of a maintenance treatment program. MAT and other treatments significantly reduce the risk of relapse (Kumar et al., 2024; Office of Addiction Services and Supports, 2019).

Pharmacotherapy combined with psychosocial treatment is often used long-term to prevent relapse of OUD. Pharmacotherapy typically consists of an opioid agonist (methadone), a partial agonist (buprenorphine), or an opioid antagonist (naltrexone). Before prescribing medications, it is essential to determine if the patient is physiologically addicted, and if so, modification of treatment may be indicated.

A non-pregnant adult who is not addicted to opioids is a candidate for addiction counseling and possibly long-acting injectable naltrexone. For the adult who is physically dependent but is post-withdrawal, long-acting injectable naltrexone may also be considered. Before starting naltrexone, withdrawal must be complete. However, withdrawal does not have to be complete before starting methadone or buprenorphine. Naltrexone is typically used by a highly motivated patient who has mild OUD.

MAT is a first-line treatment instead of psychosocial treatment alone when the patient suffers from moderate to severe OUD. Research suggests that less opioid use is reported with methadone than buprenorphine, but urine drug testing for opioid use showed no difference between groups (Nielsen et al., 2022).

Psychosocial treatment alone can be used in a handful of conditions (SAMHSA, 2021; The ASAM National Practice Guideline for the Treatment of Opioid Use Disorder, 2020). These include:

• Patients who refuse, lack access, or have contraindications to MAT
• Patients who had a sustained prior response to psychosocial treatment
• A patient who has a strong preference for psychosocial treatment despite education regarding MAT
• A patient who has mild disease, is very motivated, and has good premorbid function and a robust social support network

Shared decision-making is a crucial aspect in determining which treatment option is the best to maintain. First, a discussion regarding the risks and benefits of each treatment option should be laid out to the patient, and then a shared decision about the best treatment option should be made.

The use of MAT is considered the first-line treatment for OUD. Treatment can help patients regain their lives and become productive members of society. MAT may be done with opioid agonists (methadone), partial opioid agonists (buprenorphine), or an opioid antagonist (naltrexone). When opioid agonists are used, patients are physically dependent on methadone or buprenorphine. Still, these patients do not have the negative behaviors associated with dependence/addiction to other opioids and are effective in OUD (Nielsen et al., 2022).

The duration of MAT for OUD varies based on individual needs, treatment goals, and clinical guidelines. Research and clinical consensus suggest that many patients benefit from long-term or indefinite MAT to reduce the risk of relapse and improve outcomes (Carter et al., 2023). MAT has no set time limit, and treatment duration should be individualized. Some patients may require MAT for months, while others may benefit from years of treatment or choose to stay on it indefinitely, as discontinuing prematurely can lead to a heightened risk of relapse. Studies have consistently shown that maintaining MAT for at least one to two years provides substantial benefits, including reduced opioid use, lower overdose rates, and improved social functioning (National Academies of Sciences, Engineering, and Medicine, 2019). Ultimately, decisions about the length of treatment should be made collaboratively between the patient and the healthcare provider, considering the patient’s progress, stability, and preferences.

A 22-year-old male is seen in the clinic accompanied by his mother. His mother reports that he has been unable to eat and has had diarrhea for the last 24 hours. After dropping out of college, he recently moved home to live with his mother. He reports that he was using prescription opiates for the last six months after a knee injury and then moved on to illicit fentanyl use.

The patient reports he is restless, nauseous, has diarrhea, has a runny nose, yawning, and sweating. He is noted to have a blood pressure of 146/88 millimeters of mercury (mmHg) on physical exam, a heart rate of 116, he is noticeably restless, has beads of sweat on his forehead, and has a noticeable tremor. The COWS score is 19, which puts him in moderate withdrawal.

The APRN who evaluates the patient has a DEA certification to prescribe controlled substances to treat OUD. As part of the examination, the APRN takes a history of presenting illness, a medical and psychiatric history, a drug use history, and a social and family history. In addition, the APRN performs a focused physical exam.

Labs were drawn, demonstrating a normal CBC, negative HIV screen, normal kidney function, and electrolytes; alanine aminotransferase (ALT) was increased two times above the normal limit. The comprehensive drug screen was positive for opioids. The APRN contacted the prescription drug monitoring program, reviewed prescriptions for the last 12 months, and confirmed a prescription for hydrocodone with acetaminophen and a lorazepam prescription.

The patient signed a release of information to get a copy of his medical records from the provider prescribing opiates for his knee and the emergency room evaluations he had over the last year.

The APRN discussed treatment options with the patient and obtained informed consent to use buprenorphine for acute withdrawal. In addition, the APRN prescribed bismuth for diarrhea and ondansetron for nausea.

After documenting the presence of opioid withdrawal symptoms and the COWS score of 19, the patient was given buccal buprenorphine 2.1 mg/naloxone 0.3 mg for in-office observed induction. After two hours, the patient was better, but the COWS score was 12, so a repeat dose was given. After one hour, the patient has a COWS score of 6 and is only slightly sedated. He is sent home and returns to the clinic the next day. At that point, he has a COWS score of 16 and is given buprenorphine 4.2 mg and naloxone 0.7 mg as a one-time dose. He is observed for two hours in the clinic and is noted to have a COWS score of 5 after those two hours.

A follow-up appointment is set for one week, and he is given a one-week prescription of buprenorphine/naloxone. He is then scheduled every week for the next month and then every two weeks for the following months. The patient does well, has not gone back to opioid use, and has no ill effects of buprenorphine/naloxone. He is scheduled for monthly evaluations for the next two years. For the first year, he has a drug screen at each of the visits.

As part of the initial plan, the patient must see a mental health counselor with expertise in addiction and join a 12-step program.

Effective treatment for AUD often involves a combination of behavioral therapies, medications, and mutual support groups. Behavioral treatments, such as CBT and motivational enhancement therapy, aim to change drinking behaviors through counseling. Medications approved by the FDA for AUD include naltrexone, acamprosate, and disulfiram, each working through different mechanisms to support recovery. Mutual support groups like Alcoholics Anonymous provide peer support and can complement professional treatment. It is important to note that treatment plans should be individualized, as the effectiveness of each approach can vary based on personal circumstances.

Managing alcohol withdrawal is a critical first step in treating AUD and ensuring patient safety. Alcohol withdrawal symptoms, which can range from mild anxiety and tremors to severe complications like seizures and delirium tremens, occur when heavy or prolonged alcohol use is suddenly reduced or stopped. Medical supervision is often necessary, especially for individuals at risk of severe withdrawal, to prevent life-threatening complications. Benzodiazepines are commonly used to manage symptoms, reduce the risk of seizures, and stabilize patients during detoxification. Supportive care, including hydration, nutritional support, and monitoring, plays a vital role in recovery. Proper management of alcohol withdrawal not only ensures a safer detox process but also sets the foundation for long-term treatment and recovery, emphasizing the importance of comprehensive care tailored to individual needs.

CUD involves the problematic consumption of cannabis, leading to significant impairment or distress (Patel & Marwaha, 2024). Effective treatment typically combines behavioral therapies and, in some cases, pharmacological interventions.

Behavioral therapies include CBT, motivational enhancement therapy, contingency management (CM), and family-based interventions (Adams et al., 2023; Patel & Marwaha, 2024). CBT is among the most evaluated methods in treating cannabis dependence, helping individuals recognize and modify maladaptive thoughts and behaviors associated with cannabis use. MET focuses on enhancing an individual's motivation to change their cannabis use by exploring and resolving ambivalence. CM provides tangible rewards to reinforce positive behaviors, such as abstinence from cannabis. Family-based intervention approaches like multidimensional family therapy involve family members in therapy sessions to address systemic issues contributing to cannabis use, which is particularly effective among adolescents.

Currently, there are no FDA-approved medications specifically for CUD. However, research has explored several pharmacological options, including medications targeting withdrawal symptoms and agonist substitution therapies. Research is ongoing in cannabis withdrawal treatment targeting alleviating withdrawal symptoms, such as irritability and dysphoric mood, though no medication has been broadly and consistently effective. Compounds like dronabinol, a synthetic THC, have been studied to reduce withdrawal symptoms and cravings by mimicking cannabis's effects in a controlled manner (Adams et al., 2023; Patel & Marwaha, 2024).

Combining behavioral therapies with pharmacological interventions may enhance treatment outcomes. For instance, integrating CBT with medications aimed at reducing withdrawal symptoms could provide comprehensive support for individuals seeking to reduce or cease cannabis use.

Given the complex nature of CUD, treatment plans should be individualized, considering factors such as the severity of dependence, co-occurring mental health conditions, and the patient's readiness to change. Ongoing research continues to explore more effective treatment modalities to support individuals affected by CUD.

Treatment goals of CUD may be abstinence or reduction in use until problems do not occur secondary to cannabis use. Reduction in use is a more common goal in those with mild CUD. Motivational interviewing is a critical aspect of the early treatment of CUD. The patient needs to identify the benefits and harms of cannabis use.

Cannabis withdrawal encompasses a range of psychological and physical symptoms that emerge following the abrupt cessation or significant reduction of cannabis use, particularly in regular or heavy users. Common psychological symptoms include anxiety, irritability, anger or aggression, disturbed sleep with vivid dreaming, depressed mood, and loss of appetite. Physical manifestations may involve chills, headaches, physical tension, sweating, and stomach pain. Typically, these symptoms begin within 24 to 48 hours after stopping cannabis use, peak between days two and six, and can persist for up to three weeks or more in heavy users (Connor et al., 2022). The primary clinical concern with cannabis withdrawal is its potential to trigger relapse, as individuals may resume use to alleviate discomfort. Management strategies focus on supportive counseling and psychoeducation, with pharmacological interventions considered when necessary to address specific symptoms. However, no medications are currently approved specifically for treating cannabis withdrawal, and further research is needed to establish effective pharmacological treatments.

If one intervention does not work alone, combining the treatments should be considered using mutual help groups, such as Marijuana Anonymous. If psychosocial interventions are ineffective, medications may be tried, but no medication has shown significant efficacy (Connor et al., 2022). A meta-analysis has shown that those receiving psychosocial interventions were twice as likely to abstain or reduce cannabis use at 3-4 months as those with no intervention (Patnode et al., 2020).

A 32-year-old incarcerated male is being released from prison after a 12-month sentence for possession of illegal substances. He is generally healthy, but he was diagnosed with AUD, OUD, and hepatitis C while incarcerated.

Before release, he worked with recovery services in the prison system, going through programming, receiving individual counseling, and participating in mutual-help groups (Alcoholics Anonymous and Narcotics Anonymous). When visiting with his drug counselor, he lets her know that he would like some medication to help him with his alcohol and drug use after release from prison.

He is referred to the APRN for evaluation to determine what/if any medication can help him. After a conversation with the patient, it was determined that naltrexone would be the best option as it is effective for both opioid and AUDs. He is concerned regarding his ability to take daily medication, so it was determined that the monthly naltrexone injection would be the best option.

Naltrexone is often used in correctional settings for OUD as it is an opioid antagonist, does not have analgesic activity, and essentially has no abuse potential. In addition, it is best used in patients who are detoxified from opiates, which this patient has not used since he has been incarcerated.

The APRN is concerned that naltrexone may further damage his liver, given his hepatitis C and history of alcohol use and injection drug use. Naltrexone is associated with low rates of liver enzyme elevation, and rarely does it lead to liver injury; only 1% of patients have a liver enzyme rise more significant than three times the upper limit of normal (National Institute of Diabetes and Digestive and Kidney Diseases, 2012).

The liver quickly metabolizes naltrexone to its inactive form, and the etiology of hepatic injury is unknown, but it may be dose-dependent. If liver enzymes are significantly increased, discontinuing therapy typically reverses the levels, but in many cases, it reverses even if therapy is continued. While naltrexone is potentially a hepatotoxic agent, it has not been definitively linked to hepatotoxicity (National Institute of Diabetes and Digestive and Kidney Diseases, 2012).

After a follow-up evaluation from the APRN, where the liver enzymes are reviewed and deemed appropriate for therapy, he is given the naltrexone injection. He is scheduled to be released from prison two weeks later.

He comes back to the medical department two days after the injection with insomnia, dizziness, headache, nausea, and mild diarrhea. He is thoroughly evaluated, and the exam is benign. It is explained to him that these are common side effects of naltrexone.

The recovery service team set up an appointment for the patient with an addiction treatment center in the community after release to assist with psychosocial services to help keep him off opioids, alcohol, and other drugs. In addition, he is set up for an appointment in two more weeks for another naltrexone injection.

Addiction is a debilitating disease that is associated with significant brain pathology. Addiction can result from many substances, including alcohol, opiates, and cannabis. It can lead to significant morbidity and even mortality. Clinicians need to be well-versed in the evaluation, diagnosis, and treatment of multiple types of addiction.

Opioid addiction has become a significant problem in recent years. Fortunately, the literature has become much more robust regarding the evaluation and treatment of addiction to opioids. Many good treatment options are now available in the treatment of OUD, including buprenorphine. While buprenorphine is very effective in the management of OUD, it is associated with risks. It is important that healthcare providers review risks and benefits and understand that treatment is individualized.

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