Management of Substance Use Disorder

Publication Date: January 1, 2015
Last Updated: March 14, 2022

Recommendations

A. Screening

For patients in general medical and mental healthcare settings, we recommend screening for unhealthy alcohol use annually using the three-item Alcohol Use Disorders Identification Test-Consumption (AUDIT-C) or Single Item Alcohol Screening Questionnaire (SASQ). (Strong for)
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B. Brief Alcohol Intervention

For patients without documented alcohol use disorder who screen positive for unhealthy alcohol use, we recommend providing a single initial brief intervention regarding alcohol-related risks and advice to abstain or drink within nationally established age and gender-specific limits for daily and weekly consumption. (Strong for)
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C. Determination of Treatment Setting

For patients with a diagnosis of a substance use disorder, we suggest offering referral for specialty substance use disorder care based on willingness to engage in specialty treatment. (Weak for)
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For patients with substance use disorders, there is insufficient evidence to recommend for or against using a standardized assessment that would determine initial intensity and setting of substance use disorder care rather than the clinical judgment of trained providers. ()
(N/A)
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D. Treatment

a. Alcohol Use Disorder

i. Pharmacotherapy
For patients with moderate-severe alcohol use disorder, we recommend offering one of the following medications:
  • Acamprosate
  • Disulfiram
  • Naltrexone- oral or extended release
  • Topiramate
(Strong for)
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For patients with moderate-severe alcohol use disorder for whom first-line pharmacotherapy is contraindicated or ineffective, we suggest offering gabapentin. (Weak for)
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ii. Psychosocial Interventions
For patients with alcohol use disorder we recommend offering one or more of the following interventions considering patient preference and provider training/competence:
  • Behavioral Couples Therapy for alcohol use disorder
  • Cognitive Behavioral Therapy for substance use disorders
  • Community Reinforcement Approach
  • Motivational Enhancement Therapy
  • 12-Step Facilitation
(Strong for)
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b. Opioid Use Disorder

i. Pharmacotherapy

For patients with opioid use disorder, we recommend offering one of the following medications considering patient preferences:

  • Buprenorphine/naloxone
  • Methadone in an Opioid Treatment Program
(Strong for)
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In pregnant women with opioid use disorder for whom buprenorphine is selected, we suggest offering buprenorphine alone (i.e., without naloxone) considering patient preferences. (Weak for)
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For patients with opioid use disorder for whom buprenorphine is indicated, we recommend individualizing choice of appropriate treatment setting (i.e., Opioid Treatment Program or office-based) considering patient preferences. (Strong for)
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For patients with opioid use disorder for whom opioid agonist treatment is contraindicated, unacceptable, unavailable, or discontinued and who have established abstinence for a sufficient period of time (see narrative), we recommend offering:
  • Extended-release injectable naltrexone
(Strong for)
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There is insufficient evidence to recommend for or against oral naltrexone for treatment of opioid use disorder. ()
(N/A)
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At initiation of office-based buprenorphine, we recommend addiction-focused Medical Management (see narrative) alone or in conjunction with another psychosocial intervention. (Strong for)
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ii. Psychosocial Interventions With or Without Pharmacotherapy
For patients in office-based buprenorphine treatment, there is insufficient evidence to recommend for or against any specific psychosocial interventions in addition to addiction-focused Medical Management. Choice of psychosocial intervention should be made considering patient preferences and provider training/competence. ()
(N/A)
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In Opioid Treatment Program settings, we suggest offering individual counseling and/or Contingency Management, considering patient preferences and provider training/competence. (Weak for)
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For patients with opioid use disorder for whom opioid use disorder pharmacotherapy is contraindicated, unacceptable or unavailable, there is insufficient evidence to recommend for or against any specific psychosocial interventions. ()
(N/A)
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c. Cannabis Use Disorder

i. Pharmacotherapy

There is insufficient evidence to recommend for or against the use of pharmacotherapy in the treatment of cannabis use disorder. ()
(N/A)
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ii. Psychosocial Interventions

For patients with cannabis use disorder, we recommend offering one of the following interventions as initial treatment considering patient preference and provider training/competence:
  • Cognitive Behavioral Therapy
  • Motivational Enhancement Therapy
  • Combined Cognitive Behavioral Therapy/Motivational Enhancement Therapy
(Strong for)
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d. Stimulant Use Disorder

i. Pharmacotherapy

There is insufficient evidence to recommend for or against the use of any pharmacotherapy for the treatment of cocaine use disorder or methamphetamine use disorder. ()
(N/A)
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ii. Psychosocial Interventions

For patients with stimulant use disorder, we recommend offering one or more of the following interventions as initial treatment considering patient preference and provider training/competence:
  • Cognitive Behavioral Therapy
  • Recovery-focused behavioral therapy
    • General Drug Counseling
    • Community Reinforcement Approach
  • Contingency Management in combination with one of the above
(Strong for)
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E. Promoting Group Mutual Help Involvement

For patients with substance use disorders in early recovery or following relapse, we recommend promoting active involvement in group mutual help programs using one of the following systematic approaches considering patient preference and provider training/competence:
  • Peer linkage
  • Network support
  • 12-Step Facilitation
(Strong for)
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F. Co-occurring Mental Health Conditions and Psychosocial Problems

Among patients in early recovery from substance use disorders or following relapse, we suggest prioritizing other needs through shared decision making (e.g., related to other mental health conditions, housing, supportive recovery environment, employment, or related recovery-relevant factors) among identified biopsychosocial problems and arranging services to address them. (Weak for)
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G. Follow-up

We suggest assessing response to treatment periodically and systematically, using standardized and valid instrument(s) whenever possible. Indicators of treatment response include ongoing substance use, craving, side effects of medication, emerging symptoms, etc. (Weak for)
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For patients who have initiated an intensive phase of outpatient or residential treatment, we recommend offering and encouraging ongoing systematic relapse prevention efforts or recovery support individualized on the basis of treatment response. (Strong for)
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For patients in substance use disorders specialty care, we recommend against automatic discharge from care for patients who do not respond to treatment or who relapse. (Strong against)
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H. Stabilization and Withdrawal

a. Assessment

For patients with alcohol or opioid use disorder in early abstinence, we suggest using standardized measures to assess the severity of withdrawal symptoms such as Clinical Institute Withdrawal Assessment for Alcohol (revised version) (CIWA-Ar) for alcohol or Clinical Opiate Withdrawal Scale (COWS) for opioids. (Weak for)
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We recommend inpatient medically supervised alcohol withdrawal management for patients with any of the following conditions:
  • History of delirium tremens or withdrawal seizures
  • Inability to tolerate oral medication
  • Co-occurring medical conditions that would pose serious risk for ambulatory withdrawal management (e.g., severe coronary artery disease, congestive heart failure, liver cirrhosis)
  • Severe alcohol withdrawal (i.e., Clinical Institute Withdrawal Assessment for Alcohol [revised version] [CIWA-Ar] score ≥20)
  • Risk of withdrawal from other substances in addition to alcohol (e.g., sedative hypnotics)
(Strong for)
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We suggest inpatient medically supervised withdrawal for patients with symptoms of at least moderate alcohol withdrawal (i.e., Clinical Institute Withdrawal Assessment for Alcohol [revised version] [CIWA-Ar] score ≥10) and any of the following conditions:
  • Recurrent unsuccessful attempts at ambulatory withdrawal management
  • Reasonable likelihood that the patient will not complete ambulatory withdrawal management (e.g., due to homelessness)
  • Active psychosis or severe cognitive impairment
  • Medical conditions that could make ambulatory withdrawal management problematic (e.g., pregnancy, nephrotic syndrome, cardiovascular disease, lack of medical support system)
(Weak for)
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b. Alcohol Use Disorder Stabilization and Withdrawal

We recommend using one of the following pharmacotherapy strategies for managing alcohol withdrawal symptoms:
  • A predetermined fixed medication tapering schedule with additional medication as needed
  • Symptom-triggered therapy where patients are given medication only when signs or symptoms of withdrawal occur (e.g., as needed dosing)
(Strong for)
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For treatment of moderate to severe alcohol withdrawal, we recommend using benzodiazepines with adequate monitoring because of documented efficacy and high margin of safety. (Strong for)
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For managing mild to moderate alcohol withdrawal in patients for whom risks of benzodiazepines outweigh benefits (e.g., inadequate monitoring available, abuse liability, or allergy/adverse reactions), we suggest considering carbamazepine, gabapentin, or valproic acid as an alternative. (Weak for)
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We recommend against using alcohol as an agent for medically supervised withdrawal.

(Strong against)
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c. Opioid Use Disorder Stabilization and Withdrawal

For patients not yet stabilized from opioid use disorder, we recommend against withdrawal management alone due to high risk of relapse and overdose. (Strong against)
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Among patients with opioid use disorder for whom maintenance agonist treatment is contraindicated, unacceptable, or unavailable, we recommend using a methadone (in Opioid Treatment Program only) or buprenorphine taper for opioid withdrawal management. (Strong for)
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For patients with opioid use disorder for whom methadone and buprenorphine are contraindicated, unacceptable, or unavailable, we recommend offering clonidine as a second-line agent for opioid withdrawal management. (Strong for)
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d. Sedative Hypnotic Use Disorder Stabilization and Withdrawal

For patients in need of withdrawal management for sedative hypnotics, we suggest one of the following:
  • Gradually taper the original benzodiazepine
  • Substitute a longer acting benzodiazepine then taper gradually
  • Substitute phenobarbital for the addicting agent and taper gradually
(Weak for)
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Recommendation Grading

Overview

Title

Management of Substance Use Disorder

Authoring Organization

Veterans Health Administration / Department of Defense

Endorsing Organization

American Psychiatric Association

Publication Month/Year

January 1, 2015

Last Updated Month/Year

January 10, 2024

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Male, Adolescent, Adult, Older adult

Health Care Settings

Ambulatory, Correctional facility

Intended Users

Social worker, psychologist, counselor, addiction treatment specialist, nurse, nurse practitioner, physician, physician assistant

Scope

Counseling, Assessment and screening, Rehabilitation, Management, Treatment

Diseases/Conditions (MeSH)

D019966 - Substance-Related Disorders

Keywords

Behavioral Treatment, Substance use disorders, Opioid, Stimulant

Supplemental Methodology Resources

Methodology Supplement, Data Supplement, Data Supplement

Methodology

Number of Source Documents
327
Literature Search Start Date
January 1, 2015
Literature Search End Date
June 30, 2020