Opioid Prescribing and Monitoring
How to Combat Opioid Abuse and Misuse Responsibly

Getting Addicted Patients Into Treatment

Substance use disorders are defined as “a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues using the substance despite significant substance-related problems.”1 Importantly, the presence of tolerance and withdrawal alone are not sufficient to diagnose a substance use disorder. Rather, the disorders are typically also characterized by compulsive patterns of behaviors, impairment in social and occupational functioning, recurrent use in hazardous conditions, and use despite exacerbation of physical and psychiatric problems. A patient prescribed opioids or benzodiazepines during appropriate treatment, for example, can become dependent without being addicted. Substance use disorders can be mild, moderate, or severe, based on the number of criteria met and reflecting the level of impairment for the individual (Table 1).1,2

Table 1. Diagnostic Criteria for Substance Use Disorders

A problematic pattern of substance use leading to clinically significant impairment or distress, as manifested by at least 2 of the following, occurring within a 12-month period:

  1. Substance is taken in larger amounts or over a longer period than was intended
  2. There is a persistent desire or unsuccessful efforts to cut down or control substance use
  3. A great deal of time is spent in activities necessary to obtain the substance, use it, or recover from the substance’s effects
  4. Craving, or a strong desire or urge to use the substance
  5. Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home
  6. Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance
  7. Important social, occupational, or recreational activities are given up or reduced because of substance use
  8. Recurrent substance use in situations in which it is physically hazardous
  9. Substance use is continued despite knowledge of having persistent or recurrent physical or psychological problems that are likely to have been caused or exacerbated by the substance
  10. Tolerance
  11. Withdrawal

Severity: Mild (2-3 symptoms); Moderate (4-5 symptoms);
Severe (6 or more symptoms)

Source: American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: APA; 2013.

Advances in neurobiology and neuroimaging have helped shape our understanding of the interactions between genetics, environment, drug exposure, and developmental vulnerability in the emergence of addiction. The repeated use of substances has been shown to alter neuronal circuitry involved in motivation, reward, and inhibitory control, as well as to influence the expression of neurotransmitters and receptors in the brain that contribute to the consolidation of memory, saliency of cues associated with use, and learned conditioned behaviors seen in individuals with substance use disorders. These brain changes can persist even after cessation of use. In some cases, they may not be reversible, further supporting the conceptualization of substance use disorders as a chronic disease.3-5

Tailoring Treatment

As with hypertension, diabetes, and asthma, the treatment of substance use disorders requires continuing care that is individually tailored for the patient. Comprehensive treatment plans may include education, counseling, and medications. When treating chronic diseases, adherence to treatment recommendations is the strongest predictor of treatment efficacy.6,7

Factors that can influence treatment adherence, and thus treatment efficacy, include socioeconomic status, amount of family support, and medical or psychiatric comorbidities.6-8 Indeed, relapse rates for hypertension (50% to 70%), type 1 diabetes (30% to 50%), and asthma (50% to 70%) are comparable to relapse rates for substance use disorders (40% to 60%) with nonadherence to treatment.8 Treatment for patients with substance use disorders may vary by the substance used, medical and psychiatric comorbidities, and demographics, among other factors. Any treatment plan should be monitored, assessed, and modified continuously to ensure it addresses the changing needs of the patient.9

In 2014, approximately 22.5 million people age 12 and older needed substance use treatment, but only 2.6 million people (11.6%) with substance use disorders received specialty treatment (i.e., treatment in mental health centers, or inpatient or outpatient treatment at a rehabilitation center). Among those who perceived a need for treatment, but did not receive treatment at a specialty care clinic, the most common reasons were not being ready to quit (41.2%) and inability to afford care due to a lack of health insurance coverage (30.8%).10

Primary care physicians can play an important role in identifying patients with problematic substance use and providing continuity of care to bridge the patient to the appropriate level of care.7,9 The Screening, Brief Intervention, and Referral to Treatment (SBIRT) model is an evidence-based approach for primary care physicians to help identify patients with problematic substance use behaviors in order to provide early interventions and referrals.11 Detecting problematic use of substances is the first step in preventing and reducing the negative medical and psychiatric consequences from excessive use of alcohol and other illicit substances. The goal of SBIRT is not to diagnose substance use disorders; rather, validated screening tools are used to stratify patients into low, moderate, and high risk categories for adverse health effects related to their substance use.

Based on the patient’s risk category, brief interventions or referral to a higher level of care may be appropriate.11,12 Brief interventions are “in-person, time-limited efforts to provide information or advice, increase motivation to avoid substance use, or to teach behavior change skills with the aim of reducing substance use and the likelihood of experiencing negative consequences.” They are typically limited to 4 or 5 sessions, with each done during a 10- to 15-minute office visit. The focus should be on a single behavioral objective and the identification of immediate goals that will reduce the risk of harm to the patient from continued substance use.12 A common model used when administering a brief intervention is the Feedback, Responsibility, Advice, Menu of options, Empathy, and Self-efficacy (FRAMES) model (Table 2).13

Table 2. Components of Brief Interventions (FRAMES)

While brief interventions are not a replacement for specialized substance use treatment, they have been shown to be a cost-effective first-line intervention for patients with harmful patterns of substance use who are ambivalent about seeking treatment.14,15 For patients with more severe substance use disorders, or those who are already motivated and engaged in substance use treatment, brief interventions appear to be less effective.13,14,16 Linking motivational interviewing techniques with the patient’s stage of change may help patients explore ambivalence and identify discrepancies between their current substance use and their future goals (Table 3).17

Table 3. Examples of Motivational Interview Techniques: Stages of Change

Specialized Treatment

Patients at severe risk for adverse health outcomes or those who meet criteria for dependence should be referred to specialized treatment.9,11,17 Residential rehab may not be appropriate for all patients with substance use disorders. The appropriate level of care and intensity of treatment should be based on the severity of dependence and impairment in level of functioning. Decisional tools such as the American Society of Addiction Medicine (ASAM) criteria may be helpful for assessing patients across different dimensions to determine the appropriate level of care (Table 4).18,19

Table 4. ASAM Patient Placement Criteria Levels of Service

As noted, more than 80% of people who need substance use treatment do not receive it due to barriers related to lack of access to affordable treatment facilities or stigma.10 Identifying community resources and contacts that specialize in substance use treatment is the first step in facilitating “warm handoffs” to transition the patient to the appropriate level of care. “Warm handoff” strategies include describing the referral process and treatment options available to the patient, directing the patient to a specific intake coordinator at a local treatment center, having the patient make the phone call during the visit to set up an appointment, or introducing the patient to a behavioral health specialist or social worker who can help the patient address potential barriers to treatment.17 There are also a number of resources available online through the Substance Abuse and Mental Health Services Administration (SAMHSA), the National Institute of Alcohol Abuse and Alcoholism (NIAAA), and the National Institute on Drug Abuse (NIDA) websites to assist physicians in locating and engaging patients in substance use treatment facilities in their area.

Patients who are not ready for change or are not willing to engage in a higher level of care should be encouraged to continue to follow up with their primary care physician to monitor patterns of use, set treatment goals, assess progress, and reinforce motivation.17 For some patients, abstinence may not be the ultimate goal of treatment; rather, harm reduction may be a more feasible goal in early recovery. Treatment outcomes should be patient-driven and should focus on the patient’s values and other quality-of-life indicators, such as maintaining employment, repairing interpersonal relationships, and improving physical and mental health.9,19,20 Because a substance use disorder is a chronic disease, a relapsing and remitting course is expected.6,7,9,20 Patients should be encouraged to resume active participation in treatment, as research shows that length of treatment is associated with improved outcomes.9

Many support group programs, including 12-Step programs like Alcoholics Anonymous, were originally designed for the treatment of alcoholism. Over time, these programs have been adapted to address other drugs of abuse, with varying degrees of success. These programs offer another bridge to recovery for patients.

As with hypertension, diabetes, and asthma, treatment of substance use disorders is a lifelong process that requires frequent monitoring and multiple interventions addressing the biopsychosocial needs of the patient.9,19-21

Last updated on: April 29, 2019
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