The number of diagnostic symptoms present defines the severity of the disorder, ranging from mild to severe i. Conducting a clinical assessment is essential to understanding the nature and severity of the patient's health and social problems that may have led to or resulted from the substance use. This assessment is important in determining the intensity of care that will be recommended and the composition of the treatment plan.
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After a formal assessment, the information is discussed with the patient to jointly develop a personalized treatment plan designed to address the patient's needs. Such considerations are critical for understanding the individual and for tailoring the treatment to his or her specific needs. This increases the likelihood of successful treatment engagement and retention, and research shows that those who participate more fully in treatment typically have better outcomes.
Treatment plans should be personalized and include engagement and retention strategies to promote participation, motivation, and adherence to the plan. Treatment providers can improve engagement and retention in programs by building a strong therapeutic alliance with the patient, effectively using evidence-based motivational strategies, acknowledging the patient's individual barriers, making reminder phone calls, and creating a positive environment.
Engaging, effective treatment also involves culturally competent care. For example, treatment programs that provide gender-specific and gender-responsive care are more likely to enhance women's treatment outcomes. For example, American Indians or Alaska Natives may require specific elements in their treatment plan that respond to their unique cultural experiences and to intergenerational and historical trauma and trauma from violent encounters. Substance use disorder treatment programs also have an obligation to prepare for disasters within their communities that can affect the availability of services.
A disaster can disrupt a program's ability to provide treatment services or an individual's ability to maintain treatment.
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Individuals in recovery, for example, may relapse due to sudden discontinuation of services or stress when having to cope with effects of a disaster. Individuals receiving MAT could be at risk of serious withdrawal symptoms if medications are stopped abruptly. Others may face challenges without their treatment program's support. As indicated above, the treatment of addiction is delivered in predominantly freestanding programs that differ in their setting hospital, residential, or outpatient ; in the frequency of care delivery daily sessions to monthly visits ; in the range of treatment components offered; and in the planned duration of care.
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In general, as patients progress in treatment and begin to meet the goals of their individualized treatment plan, they transfer from clinical management in residential or intensive outpatient programs to less clinically intensive outpatient programs that promote patient self-management. A typical progression for someone who has a severe substance use disorder might start with 3 to 7 days in a medically managed withdrawal program, followed by a 1- to 3-month period of intensive rehabilitative care in a residential treatment program, followed by continuing care, first in an intensive outpatient program 2 to 5 days per week for a few months and later in a traditional outpatient program that meets 1 to 2 times per month.
For many patients whose current living situations are not conducive to recovery, outpatient services should be provided in conjunction with recovery-supportive housing. In general, patients with serious substance use disorders are recommended to stay engaged for at least 1 year in the treatment process, which may involve participation in three to four different programs or services at reduced levels of intensity, all of which are ideally designed to help the patient prepare for continued self-management after treatment ends.
Brief summaries of the major levels of the treatment continuum are discussed below. Medically monitored and managed inpatient care is an intensive service delivered in an acute, inpatient hospital setting. Residential services offer organized services, also in a hour setting but outside of a hospital. These programs typically provide support, structure, and an array of evidence-based clinical services.
Partial hospitalization and intensive outpatient services range from counseling and education to clinically intensive programming. Outpatient services provide both group and individual behavioral interventions and medications when appropriate. Typically, outpatient programs are appropriate as the initial level of care for individuals with a mild to moderate substance use disorder or as continuing care after completing more intensive treatment. Regardless of the substance for which the individual seeks treatment or the setting or level of care, all substance use disorder treatment programs are expected to offer an individualized set of evidence-based clinical components.
These components are clinical practices that research has shown to be effective in reducing substance use and improving health and functioning. These include behavioral therapies, medications, and RSS. Treatment programs that offer more of these evidence-based components have the greatest likelihood of producing better outcomes. Research continues to identify new effective components of care.
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Five medications, approved by the FDA, have been developed to treat alcohol and opioid use disorders. Currently, no approved medications are available to treat marijuana, amphetamine, or cocaine use disorders. Like all other FDA-approved medications, those listed in Table 4. For these reasons, only appropriately trained health care professionals should decide whether medication is needed as part of treatment, how the medication is provided in the context of other clinical services, and under what conditions the medication should be withdrawn or terminated.
The combination of behavioral interventions and medications to treat substance use disorders is commonly referred to as MAT. Studies have repeatedly demonstrated the efficacy of MAT at reducing illicit drug use and overdose deaths, , improving retention in treatment, and reducing HIV transmission. Some medications used to treat opioid use disorders can be used to manage withdrawal and as maintenance treatment to reduce craving, lessen withdrawal symptoms, and maintain recovery.
Prescribed in this fashion, medications for substance use disorders are in some ways like insulin for patients with diabetes. Insulin reduces symptoms by normalizing glucose metabolism, but it is part of a broader disease control strategy that also employs diet change, education on healthy living, and self-monitoring. Whether treating diabetes or a substance use disorder, medications are best employed as part of a broader treatment plan involving behavioral health therapies and RSS, as well as regular monitoring.
State agencies that oversee substance use disorder treatment programs use a variety of strategies to promote implementation of MAT, including education and training, financial incentives e. These include provider, public, and client attitudes and beliefs about MAT; lack of an appropriate infrastructure for providing medications; need for staff training and development; and legislation, policies, and regulations that limit MAT implementation.
MAT for patients with a chronic opioid use disorder must be delivered for an adequate duration in order to be effective. Patients who receive MAT for fewer than 90 days have not shown improved outcomes. Methadone is a synthetic opioid agonist that has been used to treat the symptoms of withdrawal from heroin and other opioids. A chemical substance that binds to and activates certain receptors on cells, causing a biological response.
Fentanyl and methadone are examples of opioid receptor agonists. Long-term methadone maintenance treatment for opioid use disorders has been shown to be more effective than short-term withdrawal management, and it has demonstrated improved outcomes for individuals including pregnant women and their infants with opioid use disorders.
The use of methadone to treat opioid use disorders has much in common with treatments for other substance use disorders and other chronic illnesses. However, it has one significant structural and cultural difference. Under regulations dating back to the early s, the federal government created special methadone programs for adults with opioid use disorders. The use of opioid agonist medications to treat opioid use disorders has always had its critics. Such views are not scientifically supported; the research clearly demonstrates that MAT leads to better treatment outcomes compared to behavioral treatments alone.
Moreover, withholding medications greatly increases the risk of relapse to illicit opioid use and overdose death. Decades of research have shown that the benefits of MAT greatly outweigh the risks associated with diversion.
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Drug diversion. A medical and legal concept involving the transfer of any legally prescribed controlled substance from the person for whom it was prescribed to another person for any illicit use. OTPs are predominantly outpatient programs approximately 95 percent that provide pharmacotherapy in combination with behavioral therapies and other RSS. Buprenorphine and naltrexone may also be provided in OTPs. Individuals receiving medication for opioid use disorders in an OTP must initially take their doses daily under observation.
Buprenorphine is available as a sublingual tablet and a sublingual or buccal film. In addition, in May , an implantable formulation of buprenorphine was approved by the FDA. For individuals who are already on a stable low to moderate dose of buprenorphine, the implant delivers a constant low dose of buprenorphine for 6 months. Buprenorphine is associated with improved outcomes compared to placebo for individuals including pregnant women and their infants with opioid use disorders, and it is effective in reducing illegal opioid use.
Buprenorphine is a partial opioid agonist, meaning that it binds to and activates opioid receptors but with less intensity than full agonists. As a result, there is an upper limit to how much euphoria, pain relief, or respiratory depression buprenorphine can produce. Clinical experience and research protocols indicate that buprenorphine initiation and stabilization during the induction period is an important part of successful treatment for individuals with opioid use disorder. However, if the combined medication is injected, the naloxone component can precipitate an opioid withdrawal syndrome, and in this way serves as a deterrent to misuse by injection.
Buprenorphine may be prescribed by physicians who have met the statutory requirements for a waiver in accordance with the Controlled Substances Act 21 U. This patient limit does not apply to OTPs that dispense buprenorphine on site because the OTP operating in this capacity is doing so under 21 U. When they first receive their waiver, physicians can provide buprenorphine treatment for only up to 30 individuals.
After the first year they can request to treat up to Although approximately , primary care physicians practice medicine in the United States, only slightly more than 30, have a buprenorphine waiver, and only about half of those are actually treating opioid use disorders. CARA temporarily expands eligibility to prescribe buprenorphine-based drugs for MAT for substance use disorders to qualifying nurse practitioners and physician assistants through October 1, Naltrexone is an opioid antagonist that binds to opioid receptors and blocks their activation; it produces no opioid-like effects and is not abusable.
It prevents other opioids from binding to opioid receptors so that they have little to no effect. It also interrupts the effects of any opioids in a person's system, precipitating an opioid withdrawal syndrome in opioid-dependent patients, so it can be administered only after a complete detoxification from opioids.
There is also no withdrawal from naltrexone when the patient stops taking it. Because naltrexone is not a controlled substance, it can be prescribed or administered by any physician, nurse practitioner, or physician assistant with prescribing authority. Naltrexone comes in two formulations: oral and extended-release injectable. Extended-release injectable naltrexone, which is administered on a monthly basis, addresses the poor compliance associated with oral naltrexone since it provides extended protection from relapse and reduces cravings for 30 days. A number of factors should be weighed in determining the need for medication when treating an individual for an alcohol use disorder, such as the patient's motivation for treatment, potential for relapse, and severity of co-existing conditions.
Each has a distinct effectiveness and side effect profile. Prescribing health care professionals should be familiar with these side effects and take them into consideration before prescribing. Research studies on the efficacy of medications to treat alcohol use disorders have demonstrated that most patients show benefit, although individual response can be difficult to predict.
Disulfiram is a medication that inhibits normal breakdown of acetaldehyde which is produced by the metabolism of alcohol, thus rapidly increasing acetaldehyde in the blood which produces an aversive response. Thus, once disulfiram is taken by mouth, any alcohol consumed results in rapid buildup of acetaldehyde and a negative reaction or sickness results.
The intensity of this reaction is dependent on the dose of disulfiram and the amount of alcohol consumed. Disulfiram was the first medication approved by the FDA to treat alcohol use disorder and its efficacy has been widely studied. Disulfiram is most effective when its use is supervised or observed, which has been found to increase compliance. Thus, an individual who wants to reduce, but not stop, drinking is not a candidate for disulfiram.
Disulfiram should also be avoided in individuals with advanced liver disease. Naltrexone is the opioid antagonist described above that is used to treat opioid use disorder. Because it blocks some opioid receptors, naltrexone counteracts some of the pleasurable aspects of drinking.