≥ 92% of participants will know how to assess and manage addiction.
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≥ 92% of participants will know how to assess and manage addiction.
After completing the course, the learner will be able to:
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.
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.
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):
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.
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
Step 2 - Moderate Pain
Step 3 - Severe Pain
Principles
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.
Steps a prescriber can take include (Dowell et al., 2022; Manchikanti et al., 2023):
Tips to reduce iatrogenic harm include the following (Dowell et al., 2022; Franklin & American Academy of Neurology, 2014; Manchikanti et al., 2023):
Overdose death rates are increasing (Dowell et al., 2022). Deaths associated with synthetic opioids, such as illicitly manufactured fentanyl, have been the primary driver of the opioid crisis, with sharp increases reported. While deaths from prescription opioids have decreased since their peak, they still account for a significant portion of overdose fatalities, particularly in individuals who misuse or combine them with other substances. The combination of opioids with other drugs, such as benzodiazepines, alcohol, or stimulants, has further exacerbated overdose risks, contributing to more complex overdose scenarios. The CDC emphasizes a balanced approach to managing pain while mitigating overdose risks through education, improved prescribing practices, and the promotion of non-opioid pain management strategies (Dowell et al., 2022).
To prevent prescription drug abuse, the clinician needs to ensure (Dowell et al., 2022; Manchikanti et al., 2023):
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.
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).
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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.
Opioid antagonists and other overdose prevention treatments are critical tools in combating opioid overdoses, which have become a major public health crisis. Opioid antagonists are medications that join opioid receptors in the brain but do not activate them, thus blocking the effects of opioids like heroin, morphine, and prescription painkillers.
In addition to naloxone, overdose prevention efforts focus on harm reduction strategies and long-term treatment for OUD.
Prevention methods include the following:
Patients might be counseled on opioid antagonists and overdose prevention treatments in several key scenarios. Individuals with high-risk opioid use are the first group of patients who may benefit. Patients prescribed opioids for chronic pain management may be advised on naloxone use if they have a history of SUD or if they are prescribed high doses. People who use opioids recreationally, particularly those using street drugs (e.g., heroin or fentanyl), should be educated on naloxone and overdose risks.
Other groups that should be considered include family and caregivers of opioid users, patients in recovery, and those being discharged from medical care. Family members or caregivers of individuals at risk for opioid overdose are often provided with naloxone and trained on how to administer it in case of an emergency. Individuals undergoing treatment for OUD or who have a history of opioid addiction might be encouraged to have naloxone available to prevent accidental overdose relapses.
They may also be advised on long-term treatments like MAT, including access to buprenorphine, methadone, or naltrexone. Patients leaving the hospital after being treated for an opioid overdose are often given naloxone and information on how to access further care, including overdose prevention services. Discharged patients may also be directed to local harm reduction programs, needle exchange programs, and outpatient treatment for addiction management.
Buprenorphine is a medication commonly used as part of MAT for OUD. It helps individuals reduce or quit the use of opioids such as heroin, prescription painkillers, and other opioid substances. Buprenorphine is effective because it addresses both the physical and psychological components of opioid addiction.
Buprenorphine is a partial opioid agonist. It activates opioid receptors in the brain, but not to the same degree as full agonists like heroin or prescription opioids. Buprenorphine reduces cravings and withdrawal symptoms without generating the intense "high" associated with opioid abuse (Kumar et al., 2024). The "ceiling effect" of buprenorphine limits its potential for misuse, as higher doses do not produce greater effects beyond a certain point.
Buprenorphine is available in oral and injectable formulations. Suboxone® is a combination of buprenorphine and naloxone (the latter helps deter misuse by causing withdrawal symptoms if the medication is injected). Subutex® contains only buprenorphine and is often used in specific cases, such as pregnancy or individuals with naloxone sensitivities. Buprenorphine extended-release injections provide long-acting options that help reduce the burden of daily dosing.
The benefits of buprenorphine in MAT include reducing opioid cravings, minimizing withdrawal symptoms, improving retention in treatment, and lowering the risk of overdose (Kumar et al., 2024). It reduces opioid cravings by stimulating opioid receptors, reducing the risk of relapse. It minimizes withdrawal symptoms by alleviating the uncomfortable and often painful withdrawal symptoms, which are a significant barrier to recovery. Buprenorphine improves retention by improving engagement in treatment, which increases the chances of long-term recovery. Lastly, the partial agonist property of buprenorphine lowers the risk of overdose compared to full opioid agonists.
Buprenorphine has nuances in administration and supervision. The induction phase is typically introduced when the patient is in mild-to-moderate withdrawal from opioids to avoid triggering more severe withdrawal symptoms. In the stabilization phase, the patient’s dose is adjusted to reduce withdrawal and cravings without causing sedation or intoxication. In the maintenance phase, the optimal dose is established, and patients can remain on buprenorphine for months or even years, depending on individual needs and recovery progress. Buprenorphine can be prescribed by trained healthcare providers in an office-based setting, offering more flexibility than other treatments like methadone, which must be administered in specialized clinics.
Buprenorphine is most effective when combined with behavioral therapy and counseling. A complete methodology addresses the psychological, social, and environmental factors contributing to opioid addiction. Cognitive-behavioral therapy (CBT), contingency management, and motivational interviewing are some therapeutic methods used alongside MAT to improve outcomes.
Buprenorphine is associated with risks, including diversion/misuse, side effects, and risk in pregnancy. While buprenorphine has a lower potential for abuse, there is still some risk, particularly if not taken as prescribed. This is why formulations like Suboxone® (with naloxone) are preferred for outpatient treatment. Common side effects include headache, constipation, nausea, and insomnia (Kumar et al., 2024). Rarely, patients may experience respiratory depression if combined with other central nervous system depressants.
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).
Effective treatment of SUD requires a multifaceted approach considering the disorder's biological, psychological, and social dimensions. General treatment strategies emphasize individualized care, integrating evidence-based therapies, and fostering long-term recovery through a continuum of support.
The cornerstone of SUD treatment begins with a comprehensive assessment to determine the disorder's severity and the individual's specific needs (Swimmer & Sandelich, 2024). It typically involves evaluating the types of substances used, the time and intensity of use, co-occurring mental health conditions, and the patient’s personal and social circumstances. Based on this assessment, a personalized treatment plan is developed. Detoxification is often the first step for individuals with severe physical dependence, aimed at safely managing withdrawal symptoms under medical supervision. However, detoxification alone is insufficient for long-term recovery and must be followed by structured treatment interventions.
Behavioral therapies form the backbone of most SUD treatment programs. CBT is particularly effective, assisting individuals to identify and change patterns of thinking and behavior that contribute to substance use (Swimmer & Sandelich, 2024). Motivational interviewing is another widely used approach, focusing on enhancing a person’s motivation to change by resolving ambivalence and setting achievable goals (Chaple et al., 2024). For some, contingency management—a strategy that rewards positive behaviors like maintaining sobriety—can provide additional reinforcement. These therapies are often delivered in individual or group settings, allowing patients to share experiences and build supportive relationships (Swimmer & Sandelich, 2024).
Pharmacological treatments play a critical role, particularly for substance-specific disorders such as opioid or AUDs. Medications like methadone, buprenorphine, and naltrexone are commonly used to manage opioid dependence, reduce cravings, and prevent relapse (Nosyk et al., 2024). Similarly, medications like disulfiram, acamprosate, and naltrexone are effective for AUD (Swimmer & Sandelich, 2024). These medications are most successful when combined with behavioral therapies and continuous monitoring. Healthcare providers need to educate patients on the role of MAT and address any misconceptions that may arise.
Beyond clinical interventions, addressing the social determinants of health is essential for long-term recovery. Factors such as stable housing, employment opportunities, and access to education significantly impact treatment outcomes (Sistani et al., 2023). Programs that provide vocational training, life skills development, and peer support can empower individuals to rebuild their lives and reintegrate into society. Family involvement is also crucial, as strong support systems can enhance treatment adherence and reduce the risk of relapse. Family therapy often addresses dysfunctional dynamics and educates loved ones on how to support recovery effectively.
Relapse prevention is another critical component of SUD treatment. It involves teaching patients coping techniques to manage stress and triggers without resorting to substance use. Support groups like Alcoholics Anonymous or Narcotics Anonymous offer ongoing encouragement and accountability. Furthermore, recovery is a lifelong journey, requiring regular follow-up care to adapt strategies to evolving challenges.
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.
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.
Those who have severe OUD may be involved in illegal activity to fund their drug habit. When the disease becomes severe, engaging in activities to fund the drug habit may be a central component of the individual's existence. Many people with a drug habit who engage in illegal activity are not necessarily sociopathic. When the drug habit is controlled, patients often return to "normal" lives.
Individuals with OUD often have many health complications (Dydyk et al., 2024). Individuals may appear in poor general health, but some with a mild disorder may appear healthy. Infections are commonly associated with OUD. Injection drug users are more likely to suffer from cellulitis, abscesses, osteomyelitis, hepatitis B and C, HIV, and endocarditis. In addition, drug users are more likely to suffer from systemic bacterial infections such as tuberculosis and pneumonia. Those who chronically abuse opioids may suffer from bowel issues. Opioid use often leads to constipation and other issues such as bloating, abdominal pain, poor appetite, and ileus.
Opioid-induced hyperalgesia can result from the chronic use of opioids, a condition where there is an increased sensitivity to pain, which can be severe and chronic. Opioid-induced hyperalgesia occurs due to underlying mechanisms, such as neuroadaptive changes, central sensitization, and dysregulation of the pain modulatory system. These changes occur at the cellular and molecular levels, involving pathways like glutamate signaling, neuroinflammation, and the role of N-methyl-D-aspartate (NMDA) receptors (Mercadante et al., 2019). Clinically, these phenomena present challenges in managing chronic pain, as escalating opioid doses can exacerbate side effects without improving analgesia.
Opioid-associated liver fibrosis refers to liver damage linked to chronic opioid use, often exacerbated by coexisting factors such as hepatitis C infection, alcohol use, or metabolic syndrome (Baum et al., 2021). Opioids can directly impact liver health through mechanisms like immune modulation, oxidative stress, and alterations in gut-liver signaling. Chronic opioid use may promote inflammation and fibrosis by activating hepatic stellate cells, which are central to the fibrotic process (Seki & Schwabe, 2015). Additionally, behaviors associated with opioid use, such as needle sharing, heighten the risk of infections that accelerate liver damage. Effective management involves addressing underlying risk factors, reducing opioid use, and employing antifibrotic therapies when indicated.
Screening for OUD is a critical step in identifying patients at risk and providing timely intervention. Healthcare providers often utilize structured tools and clinical assessments to screen for OUD, focusing on patterns of opioid use and its impact on the patient's health and functioning. Key components of screening include evaluating opioid prescription use, assessing for signs of misuse, and identifying potential physical, psychological, and social consequences (Ducharme & Moore, 2019).
There are multiple commonly used screening tools, including:
A substance use history should include the amount, duration, and frequency of opioid use. When taking a history, it is helpful to determine how much of the drug is consumed. Users may describe how much of the drug is being used in a fraction of grams or number of bags. Determining when the last use occurred can help evaluate any signs of acute complications from recent drug use, such as any chance of overdose or withdrawal. It is also essential to determine what other drugs are being used, especially benzodiazepines and alcohol, as withdrawal from these agents can be life-threatening. Determine if they have any active controlled substance prescriptions and the route of ingestion. Opioids are typically consumed orally, injected, taken intranasally, or, less commonly, smoked.
Part of the assessment is to determine if the patient has been using larger doses over time to determine if tolerance is present, as it is one criterion for SUD (American Psychiatric Association, 2022). Patients with tolerance are more likely to develop withdrawal if they abruptly stop opioids. Many people initially use heroin to get high, but then need it to avoid withdrawal.
The assessment should include an evaluation of any occupational, psychological, or social issues from drug use. Determining treatment history helps determine the degree of the OUD. The assessment should include evaluating the type of treatment, including supervised withdrawal, counseling, self-help groups, MAT, residential treatment, or inpatient treatment.
The physical examination can detect signs of opioid use and physical consequences of use. Signs of chronic intravenous opioid use include track marks (calluses or scars over subcutaneous veins from repeated injections), and a perforated nasal septum may indicate intranasal drug use. The physical consequences of use may include infections. A heart murmur may suggest subacute bacterial endocarditis, and hepatomegaly may suggest acute hepatitis. Opioid withdrawal may be suggested by yawning, runny nose, muscle twitching, watery eyes, piloerection, and hyperactive bowel sounds.
Laboratory evaluation of a patient with OUD is crucial for diagnosis, monitoring, and managing complications. Initial tests often include a urine drug screen to detect opioids and other substances. Immunoassays are commonly used for initial screening, but confirmatory tests like gas chromatography-mass spectrometry or liquid chromatography-mass spectrometry provide greater specificity (Kale, 2019).
Additional tests assess the health consequences of opioid use. Liver function tests evaluate potential hepatic damage, often linked to infections or coexisting conditions like hepatitis C. Complete blood counts (CBC) and electrolyte panels can reveal signs of infection, anemia, or dehydration. HIV and hepatitis panel testing are essential due to the risk of infections from needle sharing. Testing for syphilis and tuberculosis may also be warranted based on risk factors.
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):
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.).
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).
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.
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.
Long-term cannabis use can have significant physical, cognitive, and psychological effects. The extent of these effects depends on factors like frequency, dose, age of onset, and individual susceptibility.
A good screening question is asking, "How often did you use cannabis in the last year?" An answer of less than monthly helps rule out CUD. The one-question screening tool is a good starting point as it helps identify patients without the disease, but does not accurately predict patients with the disease (Matson et al., 2022).
Evaluate for signs/symptoms of CUD, such as social, academic, or work impairment or worsening underlying mental health issues. Physical exam findings suggesting CUD include chronic conjunctival injection, tachycardia, yellowing of the fingertips, and cannabis odor on the clothes. Drug testing is not typically used for screening purposes in primary care, but may be used in high-risk populations or places of employment. All positive screening tests should be evaluated further, including screening for other drugs of abuse.
CUD, as defined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), involves a problematic pattern of cannabis use leading to significant impairment or distress. Diagnosis requires at least two of 11 criteria within 12 months (American Psychiatric Association, 2022).
Diagnostic criteria can be classified under the subheadings of impaired control, social impairment, risky use, and pharmacological dependence (American Psychiatric Association, 2022). Impaired control includes consuming more cannabis than intended, unsuccessful efforts to cut down, and spending excessive time obtaining, using, or recovering from its effects. Craving, or an intense desire to use cannabis, is also included. Social impairment is marked by failure to meet obligations at work, school, or home, continued use even in the presence of social or interpersonal problems, and giving up important activities. Risky use includes using cannabis in situations where it poses a physical hazard and continued use despite awareness of physical or psychological harm caused by cannabis. Pharmacological dependence involves tolerance (needing increased amounts to achieve the same effect) and withdrawal symptoms such as irritability, anxiety, sleep disturbances, or appetite changes when cannabis use ceases.
The severity of CUD is classified as mild (2-3 symptoms), moderate (4-5 symptoms), or severe (6 or more symptoms). These criteria emphasize the impact of cannabis use on various aspects of life, guiding clinicians in diagnosis and treatment planning (American Psychiatric Association, 2022).
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.
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.
When a patient is identified as having unhealthy substance use, an entire substance use assessment should ensue. When substance use risk is high in some situations, it is more appropriate to perform a complete assessment instead of screening, including in mental health facilities or correctional settings.
SUD is a new diagnosis in DSM-5. It is subclassified depending on the type of abused substance (e.g., OUD). It is defined as substance use with considerable impairment or anguish that presents with at least two of the following characteristics (Table 2) over 12 months (American Psychiatric Association, 2022).
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The number of present features determines the severity of the disease. When two to three features are present, it is considered a mild disease; if four to five are present, then it is moderate disease, and if six or more are present, severe disease is the diagnosis (American Psychiatric Association, 2022).
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.
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:
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.
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.
The COWS is an eleven-item scale that a healthcare provider gives. It evaluates the signs and symptoms of opioid withdrawal. The scores are tallied to help determine the severity of opiate withdrawal and evaluate how dependent the patient is on opioids. The tool rates each category on a scale from zero to five and looks at clinical features such as heart rate, gastrointestinal (GI) upset, sweating, tremor, restlessness, yawning, pupil size, anxiety or irritability, bone or joint aches, runny nose, or tearing. The scale can be found here (Wesson & Ling, 2003). |
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.
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).
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.
For patients who prefer opioid-free detoxification or are not candidates for opioid replacement therapy, symptom management is key. Withdrawal can bring a bevy of other symptoms, such as nausea, diarrhea, abdominal cramping, myalgia, anxiety, restlessness, and insomnia. Medications can be given to manage these symptoms.
Here are some adjunctive treatments used (many of them are used off-label):
Alpha-2 adrenergic agonists can significantly reduce signs and symptoms of withdrawal. Common agents in this class include lofexidine and clonidine. They help treat the symptoms of diarrhea, nausea, abdominal cramping, sweating, irritability, and anxiety, and are less effective for insomnia, cravings, and muscle aches. These agents are not typically used as primary agents in opioid withdrawal in favor of buprenorphine or methadone. They are often used as adjunctive treatments to help manage symptoms.
In settings where opioids are restricted (such as prisons), alpha-2 adrenergic agonists are often used as a first-line agent. These agents are very sedating and sometimes abused for this purpose, but the risk is low. In addition, these medications reduce anxiety by lowering noradrenaline levels and reduce withdrawal symptoms by reducing hyperactivity in the locus coeruleus (SAMHSA, n.d.; Shah & Huecker, 2023).
Pregnancy, hypotension, psychosis, renal insufficiency, and cardiac instability are contraindications to the use of alpha-2 adrenergic agonists.
After medical detoxification, relapse rates are high. Therefore, continued treatment is critical to prevent patients from returning to their old lifestyle. Treatment after detoxification includes psychosocial interventions, pharmacotherapy, clinical monitoring, education, and take-home naloxone.
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:
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.
Psychotherapies are often used in the management of addiction. CBT is a widely recognized and evidence-based approach to treating OUD. It aims to address the psychological and behavioral patterns contributing to substance use while equipping individuals with coping mechanisms to maintain long-term recovery (LeBlanc et al., 2024). OUD is a chronic condition often characterized by compulsive opioid use despite harmful consequences, with CBT focusing on reducing these behaviors by modifying thought patterns and developing healthier behavioral responses.
CBT for OUD incorporates several core principles, including identifying and restructuring maladaptive thought patterns, managing cravings, and developing alternative coping strategies. One of the foundational techniques is cognitive restructuring, where individuals learn to recognize and challenge distorted thinking patterns, such as beliefs that opioids are necessary to cope with stress or manage pain (LeBlanc et al., 2024; Miller, 2022). By addressing these cognitions, CBT helps patients reduce their psychological dependence on opioids, a critical step toward recovery.
Behavioral components of CBT include skill-building exercises to manage triggers, such as stress or exposure to environments associated with past drug use. Patients are taught to recognize high-risk situations and employ alternative behaviors, like engaging in physical activities or relaxation techniques, to manage these challenges effectively.
Another integral aspect of CBT in treating OUD is relapse prevention. It involves preparing patients for potential setbacks and helping them develop strategies to address these challenges without resorting to substance use. Therapists work collaboratively with patients to identify early warning signs of relapse and create detailed action plans to counteract them. Techniques such as mindfulness and stress management are also incorporated to enhance emotional regulation, reducing relapse likelihood (Carroll & Weiss, 2017).
The efficacy of CBT for OUD has been well-documented in research. Studies suggest that CBT is particularly effective when combined with MAT, which addresses the physiological aspects of opioid dependence (LeBlanc et al., 2024; Shi et al., 2019).
Addiction counseling is often used in drug and AUD and can be done in group settings or individually. It includes education and a variety of psychotherapies. Other key components are based on the principle of 12-step programs, helping patients avoid risky situations, encouraging self-help groups, and encouraging healthy social activities. Critical components to addiction counseling include adoption of the 12-step belief, addressing any ambivalence the patient has, focusing on the present, planning free time, setting a goal of abstinence, avoiding individuals and situations that are associated with use, participation in drug counseling, self-help groups, managing anger, addressing guilt/shame over previous use, employment services, and managing money and focusing on short term behavioral goals (SAMHSA, 2006).
Addiction counselors may get frequent urine samples for drug testing. The patient should also be asked about drug use. If any drug use is identified, evaluate the precipitating factors and strategies to avoid drug use in the future.
Twelve-step programs encourage the use of mutual health groups that include Alcoholics Anonymous and Narcotics Anonymous. However, some people prefer CBT to a 12-step program, including individuals who dislike the group setting or the spiritual aspect of 12-step programs.
Utilizing the community reinforcement approach looks to help those with OUD maintain sobriety by providing intervention to help the patient function better. It includes employment counseling, fostering healthy social networks, and helping patients access social services.
Mutual help groups are effective in the treatment of OUD. Increasing participation can be accomplished by education, helping patients find meetings, working with patients through the first few steps, and linking patients to program participants.
Methadone, a Schedule II drug, is a full opioid agonist and has been a foundational treatment for OUD since the mid-20th century. By binding to the same receptors in the brain as other opioids, methadone mitigates withdrawal symptoms and reduces cravings without producing the euphoric high associated with opioid misuse (Durrani & Bansal, 2024). Methadone helps patients stabilize their lives, engage in therapy, and pursue recovery goals. However, methadone's efficacy is closely tied to its administration in regulated clinical settings, such as opioid treatment programs, due to its potential for misuse and the risk of respiratory depression at higher doses. Regular monitoring and structured dosing schedules within these programs ensure patient safety and adherence to treatment protocols (Ghanem et al., 2022).
Overdose death is one risk with methadone, and those taking benzodiazepines at the same time are at increased risk of overdose. Therefore, methadone has a higher risk of overdose than buprenorphine, and all patients who have OUD should be educated about overdose and should be given naloxone.
Methadone has multiple drug-to-drug interactions, so extreme caution should be used with methadone in individuals on other medications.
Methadone is typically dosed once a day. Ten to 30 mg is typically given on the first day of treatment. After that, increase the dosage in 5 to 10 mg increments every 3-5 days. Patients are closely monitored for signs of oversedation, respiratory depression, or continued withdrawal symptoms. The gradual titration reduces the risk of methadone accumulation and overdose, particularly in individuals with slower metabolism (The ASAM National Practice Guideline for the Treatment of Opioid Use Disorder, 2020; Durrani & Bansal, 2024).
Methadone is typically given in liquid form, but is also available in tablet form. Dosing can be variable, and 20 to 30 mg may be enough to prevent withdrawal but not enough to stop craving or block the euphoria from other opioids. Dosing is different for OUD when compared to pain management. The target dose is often 60-80 mg a day. Some patients with OUD are effectively managed on doses of 80-120 mg (Durrani & Bansal, 2024; The ASAM National Practice Guideline for the Treatment of Opioid Use Disorder, 2020).
Buprenorphine is a partial opioid agonist, and while it is associated with respiratory depression and euphoria, these effects are considerably weaker than full opioid agonists (Kumar et al., 2024). It is associated with a lower level of misuse, reduces cravings and withdrawal, and is safer in overdose. Buprenorphine is a Schedule III-controlled substance. APRNs are being called on to participate in patient care with addiction disorders.
Buprenorphine is a partial mu-opioid agonist and comes in multiple formulations, including an injection, tablet, and film for sublingual/buccal use (Kumar et al., 2024). It is often combined with naloxone (even though naloxone has poor bioavailability, sublingually), which reduces the risk of abusing buprenorphine. Adding naloxone to buprenorphine causes withdrawal symptoms if the medication is dissolved and injected.
Side effects of buprenorphine include insomnia, dry mouth, dizziness, tremors, palpitations, constipation, nausea, vomiting, headache, fatigue, myalgia, fever, sweating, blurry vision, and dilated pupils (Kumar et al., 2024). More severe side effects include overdose, respiratory depression, dependence, withdrawal, and adrenal insufficiency.
Buprenorphine has proven to be effective in the management of OUD. Mortality rates are reduced in OUD when patients are treated with buprenorphine-naloxone compared to being off the medication. In addition to overall death rates, mortality was reduced due to reduced drug use and accidental poisoning. The same study showed that mortality rates were lower on buprenorphine-naloxone when compared to methadone (Pearce et al., 2020).
Before starting buprenorphine, the patient must refrain from opioids for at minimum 12-24 hours and be in the initial stages of opioid withdrawal. If a patient is given buprenorphine when there are opioids in the system or the patient is not in the early stages of withdrawal, an acute withdrawal state may ensue (Kumar et al., 2024). During withdrawal, buprenorphine will alleviate the symptoms of withdrawal.
Before buprenorphine is prescribed for OUD or supervised withdrawal, the APRN must thoroughly evaluate the patient and the patient’s record. The evaluation should include the patient’s history of present illness, history of drug use, social and family history, medical/psychiatric history, a physical exam, and laboratory testing. The evaluation should include obtaining medical records and discussing and documenting prior treatments.
Appropriate laboratory tests include a drug screen, liver function tests (LFTs), metabolic panel, CBC, HIV screening, and hepatitis serology. The APRN should review the prescription drug monitoring program and obtain a report if the patient has been prescribed a controlled substance in the last 12 months (Kentucky General Assembly, 2025).
Buprenorphine should not be used with other opioids, stimulants, benzodiazepines, or other sedative-hypnotics unless there is consultation with a certified physician in psychiatry or addiction medicine, an APRN certified in addiction therapy, or a psychiatric-mental health nurse practitioner. For no more than 30 days, an APRN may prescribe buprenorphine, without consultation, to an individual who is also on another opioid, stimulant, benzodiazepine, or other sedative-hypnotics when the provider is addressing a “documented extraordinary and acute medical need” (Kentucky General Assembly, 2025).
The APRN should talk with the patient and discuss alternative treatment options. In addition, the APRN should discuss the risks and benefits of treatment with buprenorphine. Before treatment, informed consent should be obtained. The treatment plan may include participation in a behavioral modification program that may include a 12-step program or counseling (Kentucky General Assembly, 2025).
The starting dose for buprenorphine should be no more than 4 mg (Kentucky General Assembly, 2025). The initiation of buprenorphine treatment requires careful assessment and timing to ensure safety and efficacy. Patients must exhibit moderate withdrawal symptoms, typically with a COWS score of 8–12 or higher, to avoid precipitated withdrawal caused by buprenorphine's partial opioid agonist properties. For short-acting opioids like heroin or oxycodone, induction should begin 12–24 hours after the last use, while long-acting opioids like methadone require a 24-72-hour delay. The patient is closely monitored for 1–2 hours to evaluate symptom relief and detect adverse effects. If withdrawal symptoms persist, an additional 2–4 mg may be administered later on the same day (Kumar et al., 2024; Office of Addiction Services and Supports, 2019).
Subsequent dosing adjustments occur over the following days to achieve a stable maintenance dose that effectively manages withdrawal symptoms and cravings. This cautious approach minimizes risks and supports successful treatment initiation. If any withdrawal symptoms are noted, the dose may be increased to 16 mg of buprenorphine in 4 mg steps. Continue titration until the patient reaches a stable dose that suppresses cravings and withdrawal without causing side effects. Eight to 16 mg will stabilize most patients, but responses are variable (Kumar et al., 2024; Office of Addiction Services and Supports, 2019).
Visits for patients with OUD should be scheduled frequently in the first two months. The first visit should be within ten days and at least every ten days for the first month. For the second month, visits should occur no more than every 14 days. After the second month, the patient should be seen monthly for two years if the patient shows positive progress and every three months after two years of compliance (Kentucky General Assembly, 2025).
It is difficult to get through opioid withdrawal, and therefore, opioid agonists (instead of antagonists) can manage symptoms of opioid withdrawal (Lee et al., 2018). A recent systematic review suggested that buprenorphine significantly reduces opioid cravings, with comparable efficacy to methadone and superiority over placebo. Compared to extended-release naltrexone, buprenorphine demonstrated a faster onset of craving reduction during the induction phase, though both medications were effective in maintenance treatment. The study highlights the partial agonist properties of buprenorphine as a key mechanism in suppressing cravings while minimizing overdose risk. It concludes that buprenorphine is a highly effective option for managing opioid cravings in patients with OUD and emphasizes the importance of individualized treatment plans to optimize outcomes (Baxley et al., 2023)
In a study, 570 people with OUD were given an injection of long-acting naltrexone or daily transmucosal buprenorphine for 24 weeks. The study concluded that buprenorphine was 94% successful in inducing (moving the user from an abused opioid to a dose of buprenorphine, which will offer relief from withdrawal), and naltrexone induced only 72%. In addition, those assigned to naltrexone were more likely to relapse when compared to those on buprenorphine. However, there was no significant difference in relapse when comparing naltrexone and buprenorphine in those who were successfully induced onto their respective medications, with rates for both groups being slightly above 50% (Lee et al., 2018).
A recent study compared the effectiveness of buprenorphine/naloxone and methadone in treating OUD. The research found that within a 24-month period, the rate of treatment discontinuation was higher among patients receiving buprenorphine/naloxone compared to those on methadone. This suggests that methadone may be more effective in retaining patients in treatment over the long term. However, both medications are considered effective for OUD, and the choice between them should be individualized, considering factors such as patient preference, accessibility, and potential side effects (Nosyk et al., 2024).
The risk of overdose is much more significant with methadone when compared to buprenorphine. Methadone is much more challenging to use as it requires daily clinic monitoring, and it may lead to an increased risk of respiratory depression and lethal overdose. As a partial opioid agonist, buprenorphine is much less likely to cause respiratory depression. All patients who are prescribed either methadone or buprenorphine must be educated regarding overdose.
Less research is available regarding treatment efficacy on mild OUD than on moderate to severe OUD. Naltrexone is often recommended for mild OUD. It blocks the mu-opioid receptor, so if a patient takes another opioid, there will be no euphoria. It is also not associated with withdrawal if stopped. Unlike methadone and buprenorphine, it does not lead to physiological dependence. It is easier to switch from naltrexone to methadone or buprenorphine, but switching from buprenorphine or methadone to naltrexone requires up to ten days to withdraw from the medication (Singh & Saadabadi, 2023).
Specific interventions may be helpful in certain situations. For example, those who continue to use opioids or do not participate in treatment may benefit from motivational interviewing. In addition, nonadherence can be remedied by the supervised taking of the medication or using long-acting injections of naltrexone or buprenorphine.
The use of methadone, buprenorphine, and naltrexone for OUD in pregnancy is guided by considerations of maternal and fetal safety, as well as treatment efficacy. Methadone, a full opioid agonist, has been the historical standard treatment for pregnant individuals with OUD due to its ability to stabilize opioid levels and reduce illicit use, though it requires daily visits to opioid treatment programs (Rodriguez & Klie, 2019).
Buprenorphine is increasingly preferred as research has found that buprenorphine use was associated with a lower risk of adverse neonatal outcomes compared to methadone. Specifically, infants exposed to buprenorphine had a reduced incidence of NAS and preterm birth. These findings suggest that buprenorphine may offer more favorable neonatal outcomes than methadone in the treatment of OUD during pregnancy (Suarez et al., 2022).
Buprenorphine-naloxone combinations are generally avoided during pregnancy due to limited data on safety, although monotherapy has been widely studied. Naltrexone, an opioid antagonist, is less commonly used in pregnancy because data on its safety and efficacy are limited, and discontinuation risks during pregnancy can lead to relapse (Committee Opinion No. 711, 2017). Individualized care, including close monitoring of the pregnancy and coordination with obstetric and addiction specialists, is crucial to optimizing outcomes for both the pregnant individual and the fetus.
Females of childbearing age being considered for MAT should have a pregnancy test. If the test is positive, then the patient should be counseled regarding the risk of NAS. In addition, before buprenorphine is prescribed to a pregnant or breastfeeding patient, the APRN should consult a maternal-fetal medical specialist or obstetrician to help manage the patient (Kentucky General Assembly, 2025).
Recent guidelines and research emphasize that the duration of MAT for OUD should be individualized, with no predetermined endpoint. The CDC states that there is no recommended duration limit for treatment with buprenorphine or methadone, noting that discontinuation is associated with an elevated risk of relapse and overdose (Dowell et al., 2022). Similarly, the American Society of Addiction Medicine advises that the length of MAT should be tailored to each patient's needs, potentially extending to lifelong treatment (The ASAM National Practice Guideline for the Treatment of Opioid Use Disorder, 2020).
Limited data is available to help clinicians whose patients had an inadequate response to OUD treatment. For patients who had an unsuccessful response to an opioid agonist/partial agonist, utilization of the other opioid agonist/partial agonist could be considered. For example, if a patient has an unsuccessful response to transmucosal buprenorphine, switching to a long-acting injection of buprenorphine can be considered. When taking buprenorphine and an inadequate response is obtained, one could consider a switch to methadone. When methadone is used as the first agent, and the patient has an inadequate response, it is a little more complicated to switch to buprenorphine. The patient may need to be off methadone for a few days, so there is no precipitated withdrawal when starting the buprenorphine.
Patients who continue to use opioids despite treatment with opioid agonists could be considered for naltrexone injection if they can tolerate a supervised withdrawal from the opioids. For patients who do not respond to oral naltrexone, a long-acting injection of naltrexone could be considered. Intensifying psychosocial therapies should also be considered.
Key points of patient education with buprenorphine include:
Buprenorphine has misuse potential, and the addition of naloxone to buprenorphine reduces its chance of being abused.
Injectable buprenorphine has emerged as a significant advancement in the treatment of OUD, offering an alternative to daily oral medications. Sublocade®, approved in 2017, is administered monthly and requires a loading dose with at least seven days of prior oral buprenorphine treatment to stabilize the patient before transitioning. It delivers a steady medication level, effectively reducing cravings and withdrawal symptoms over a 30-day period (U. S. Food and Drug Administration [FDA], 2021).
In May 2023, the FDA approved Brixadi®, an extended-release buprenorphine injection for subcutaneous use designed to treat moderate to severe OUD. Brixadi is available in weekly and monthly formulations, providing flexibility in treatment plans. Both medications enhance adherence by eliminating the need for daily dosing and reducing diversion risks. The use of long-acting injectable buprenorphine can positively influence patients' relationships and social interactions, as it minimizes the daily reminder of medication intake, which reduces the stigma associated with OUD treatment.
When managing patients who are transferred from another treatment provider and have previously experienced withdrawal without relapse, 201 KAR 20:065 offers guidance. The APRN must document the patient's history of withdrawal, educate them about the potential for precipitated withdrawal, and continue maintenance treatment at the same or lower dosage as previously established. The APRN must schedule visits at the same frequency as the previous provider or more frequently if necessary. After the initial induction of buprenorphine, the APRN must prescribe an amount that minimizes craving and withdrawal without causing sedation, ensuring the dosage does not exceed FDA-approved limits (Kentucky General Assembly, 2025).
An APRN may initiate buprenorphine in an emergency (emergency department or urgent care setting) or when a patient is an inpatient with OUD without meeting the above criteria (Kentucky General Assembly, 2025). Before prescribing, the APRN must ensure no harmful interaction with another medication. Medications that may interact include benzodiazepines or muscle relaxers.
Naltrexone blocks the euphoric effects of opioids. The patient should not be withdrawing when the medication is started, as it may cause the patient to go into more severe withdrawal. When starting naltrexone, it should be medically supervised to assess for withdrawal.
Naltrexone is given as a daily pill or a monthly injection. Oral naltrexone is started at 25 mg daily for 2-3 days and then increased to 50 mg daily (Singh & Saadabadi, 2023). The medication should not be started until at least one week after the last time an opiate was taken. In some situations, a naloxone challenge test (Table 4) can ensure the safety of starting the medication sooner. Injection of naltrexone is given at a dose of 380 mg once a month.
A naloxone challenge test can be done to ensure the patient is wholly withdrawn from opioids. Before starting the test, the patient should not have any apparent signs of opioid withdrawal. Before administering naloxone, a set of vital signs is taken. The patient is watched for one hour and monitored for any signs/symptoms of withdrawal using a standardized scale; if the patient demonstrates any withdrawal, pulse, or blood pressure increase, the patient fails the challenge. |
MAT is the recommended standard of care for managing OUD during pregnancy due to its effectiveness in reducing opioid use, improving maternal and neonatal outcomes, and decreasing the risks associated with illicit drug use, including preterm birth and low birth weight (Committee Opinion No. 711, 2017; Zhao et al., 2020). The primary medications used in MAT for pregnant individuals are methadone and buprenorphine, as these have demonstrated safety and efficacy in this population (Committee Opinion No. 711, 2017).
Methadone is a long-standing treatment for OUD in pregnant women, recognized for its effectiveness in stabilizing maternal opioid levels and reducing illicit opioid use. Its use during pregnancy is associated with improved adherence to prenatal care and decreased obstetric complications (Sanjanwala et al., 2023).
However, methadone crosses the placenta, and its use can lead to NAS, a condition where newborns experience withdrawal symptoms. Infants exposed to methadone in utero should be monitored for NAS and managed accordingly (Sanjanwala et al., 2023).
While methadone is effective, it requires daily administration under supervision, which can pose challenges for some pregnant women. Alternative treatments, such as buprenorphine, have been associated with lower risks of NAS and may offer more flexibility (Suarez et al., 2022). Nonetheless, methadone remains a viable and often necessary option for many pregnant women with OUD.
Buprenorphine, a partial opioid agonist, is increasingly recognized as a safe and effective alternative to methadone in pregnancy. A recent study suggested buprenorphine was consistently associated with improved birth weight and gestational age compared to methadone (Kinsella et al., 2022). However, these results should be interpreted with caution due to potential biases. These findings suggest that buprenorphine may offer certain advantages over methadone in managing OUD during pregnancy, particularly concerning neonatal outcomes.
Maintenance treatment should be sustained for pregnant women with OUD, with buprenorphine as a preferred option due to its reduced likelihood of causing neonatal sedation. Recent research indicates that buprenorphine use during pregnancy is linked to a lower risk of adverse neonatal outcomes compared to methadone. However, both medications present similar risks of adverse effects for the mother (Durrani & Bansal, 2024). Combination formulations with naloxone are generally avoided during pregnancy due to limited safety data on naloxone exposure.
MAT during pregnancy is complemented by comprehensive prenatal care and psychosocial support to address the multifaceted needs of the patient. This includes regular monitoring of maternal and fetal health, behavioral therapy, and addressing co-occurring mental health disorders. Discontinuing opioids abruptly, or “detoxification,” is generally not recommended during pregnancy due to the risks of miscarriage, preterm labor, and fetal distress (Committee Opinion No. 711, 2017).
While MAT significantly improves outcomes, barriers such as stigma, limited access to treatment, and inadequate provider training can hinder its implementation. Addressing these challenges requires education and advocacy to promote evidence-based care and support for pregnant individuals with OUD.
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.
The FDA has approved three primary medications for AUD treatment (Nehring et al., 2024). Naltrexone reduces the pleasurable effects of alcohol by blocking opioid receptors, thereby decreasing cravings and heavy drinking. It is available in both oral and extended-release injectable forms. Acamprosate helps maintain abstinence by stabilizing brain chemistry disrupted by chronic alcohol consumption. It is typically administered orally in multiple daily doses. Disulfiram acts as an aversive agent by inhibiting the enzyme acetaldehyde dehydrogenase, leading to unpleasant reactions (e.g., flushing, nausea) when alcohol is consumed. This deterrent effect supports abstinence. Additionally, medications like gabapentin and topiramate have shown promise in treating AUD, though they are not FDA-approved for this specific indication.
Selecting the appropriate medication requires a comprehensive evaluation of the patient's medical history, drinking patterns, and treatment goals. Combining pharmacotherapy with behavioral interventions often yields the most effective outcomes.
For AUD, oral naltrexone is usually started at 50 mg/day but can be increased to 100 mg/day (Singh & Saadabadi, 2023). For patients with poor adherence to daily treatment, the use of long-acting naltrexone can be considered. The long-acting form is dosed at 380 mg intramuscularly monthly. Naltrexone can be started when the patient is drinking.
Naltrexone must be used cautiously. It is associated with hepatotoxicity, especially with high doses. Naltrexone cannot be used in those on an opioid, but can be used effectively for those with both OUD and AUD.
Acamprosate modulates neurotransmitter systems, particularly by modulating the NMDA and gamma-aminobutyric acid (GABA) receptors (Kalk & Lingford-Hughes, 2014). This dual action helps stabilize the brain's chemical balance disrupted by chronic alcohol consumption, thereby reducing the risk of relapse.
Clinical evidence supports the efficacy of acamprosate in promoting abstinence. A systematic review and meta-analysis, encompassing 118 clinical trials with 20,976 participants, found that acamprosate significantly improved alcohol consumption-related outcomes compared to placebo. The number needed to treat to prevent one person from returning to any drinking was 11 (McPheeters et al., 2023).
Adherence to acamprosate is crucial for its effectiveness. However, challenges with medication compliance can limit its full benefit. Research indicates that poor adherence may diminish the therapeutic outcomes of acamprosate, underscoring the need for strategies to support consistent use (Donoghue et al., 2023).
Acamprosate is generally well-tolerated. Diarrhea is a commonly reported side effect. Unlike some other AUD medications, acamprosate is not associated with liver toxicity, making it a suitable option for individuals with liver concerns. However, it is primarily excreted unchanged by the kidneys, so caution is advised in patients with severe renal impairment.
Disulfiram is another medication that helps with AUD. When taken, it is associated with adverse effects when mixed with alcohol. It is meant to help individuals maintain abstinence. The dose for disulfiram is 125 to 500 mg a day (Stokes et al., 2024). Naltrexone can be started without the need to detox the patient. Drinking should not occur when patients are on acamprosate or disulfiram. When acamprosate is started, it will inhibit the desire to go back to drinking. Disulfiram will lead to adverse effects when alcohol is consumed.
After treatment is started, close follow-up should occur. During these visits, the patient should be assessed and supported, and family members engaged (if indicated). In addition, patients should be monitored for treatment effectiveness, adherence, side effects, and any relapse signs.
There is limited data on the safety of these medications in pregnant women. However, pregnant patients with heavy alcohol use are at high risk of damage to the fetus, and medication should be considered for those who continue drinking. Only those with expertise should treat AUD in pregnancy (Kelty et al., 2021)
Patients often continue with psychosocial treatment for six to twelve months, but the length of time in treatment is not linked to long-term alcohol abstinence rates (Kramer Schmidt et al., 2018). Medication treatment for AUD is often three to six months (Crowley, 2015). Longer treatment is often done, and the exact length of time to maintain treatment is unknown. Treatment with naltrexone, acamprosate, and disulfiram can be stopped abruptly, and no taper is needed. Continued monitoring should occur after treatment when medication is discontinued.
Certain factors require greater urgency to control AUD. Those at high risk for suicide or pregnant women need to be assessed to ensure treatment is effective quickly. Individuals who do not have an adequate initial response may benefit from increasing the frequency or intensity of interventions—for example, going to more groups per week, moving from outpatient treatment to day treatment, or adding medication.
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).
Test | Value | Normal |
---|---|---|
Alanine Aminotransferase (ALT) | 54 international units (IU)/liter (L) | 0-44 IU/L |
Aspartate Aminotransferase (AST) | 36 IU/L | 0-40 IU/L |
Urine Drug Screen | Negative | Negative |
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.
CEUFast, Inc. is committed to furthering diversity, equity, and inclusion (DEI). While reflecting on this course content, CEUFast, Inc. would like you to consider your individual perspective and question your own biases. Remember, implicit bias is a form of bias that impacts our practice as healthcare professionals. Implicit bias occurs when we have automatic prejudices, judgments, and/or a general attitude towards a person or a group of people based on associated stereotypes we have formed over time. These automatic thoughts occur without our conscious knowledge and without our intentional desire to discriminate. The concern with implicit bias is that this can impact our actions and decisions with our workplace leadership, colleagues, and even our patients. While it is our universal goal to treat everyone equally, our implicit biases can influence our interactions, assessments, communication, prioritization, and decision-making concerning patients, which can ultimately adversely impact health outcomes. It is important to keep this in mind in order to intentionally work to self-identify our own risk areas where our implicit biases might influence our behaviors. Together, we can cease perpetuating stereotypes and remind each other to remain mindful to help avoid reacting according to biases that are contrary to our conscious beliefs and values.