Addiction Medicine Primer

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Addiction Medicine Primer: An Overview of Treatment of Substance Use Disorders

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The Addiction Medicine Primer provides a general overview about substance use disorders. It includes information about addiction medicine, diagnosis and treatment decisions for substance use disorders, effective communication strategies for talking with patients, and the role of care coordination in treating substance use disorders.

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Introduction

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According to the 2020 National Survey on Drug Use and Health (NSDUH), 40.3 million Americans, aged 12 or older, had a substance use disorder (SUD) in the past year.1 Substance use disorders continue to be an important health issue in our country.

A person is diagnosed with a SUD when patterns of symptoms resulting from the substance use are identified.2 For example, a person with a SUD might experience intense cravings for the substance because of neurobiological changes that prompt them to continue seeking and using the substance in physically hazardous situations. However, research in addiction science and treatment has produced evidence-based treatment methods to help those with a SUD recover and live healthier lives.3

What Are Substance Use Disorders?

For more information on substance use disorders and addiction, see the following:

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) describes a key feature of a substance use disorder (SUD) as “a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues using the substance despite significant substance-related problems.”2 According to the DSM-5, a diagnosis of a SUD can be applied to nine classes of drugs: alcohol; cannabis; hallucinogens; inhalants; opioids; sedatives, hypnotics or anxiolytics; stimulants; tobacco (nicotine); and other (or unknown) substances. 2 For certain substance classes, some symptoms are less prominent, and in some cases, not all symptoms apply. For example, withdrawal symptoms are not specified for inhalant use disorder. In addition, the DSM-5 describes effects of potential long-term behavioral brain changes from SUDs as shown in the following excerpt:

“An important characteristic of substance use disorders is an underlying change in brain circuits that may persist beyond detoxification, particularly in individuals with severe disorders. The behavioral effects of these brain changes may be exhibited in the repeated relapses and intense drug craving when the individuals are exposed to drug-related stimuli. These persistent drug effects may benefit from long-term approaches to treatment.”2

What Is Addiction?

For more information on the addiction medicine specialty, see the following:

The American Society of Addiction Medicine (ASAM) states, “Addiction is a treatable, chronic medical disease involving complex interactions among brain circuits, genetics, the environment, and an individual’s life experiences. People with addiction use substances or engage in behaviors that become compulsive and often continue despite harmful consequences. Prevention efforts and treatment approaches for addiction are generally as successful as those for other chronic diseases.”4 According to the DSM-5, the word addiction “ . . . is omitted from the official DSM-5 substance use disorder (SUD) diagnostic terminology because of its uncertain definition and potentially negative connotation.”2 While the term addiction is commonly used to describe serious conditions involving compulsive and habitual substance use and has historic usage in some disciplines, including addiction medicine, employing the term addiction in clinical practice or even casual conversation can worsen stigma. Tips on modeling appropriate, nonstigmatizing language are included in the section on stigma in this primer.

Addiction Medicine as a Specialty

The American Board of Medical Specialties (ABMS) recognizes two medical subspecialties that focus on providing care for patients with substance use disorders (SUDs): addiction psychiatry and addiction medicine.5

The American Board of Medical Specialties describes a practitioner of the subspecialty of addiction psychiatry as “a psychiatrist who focuses on the evaluation and treatment of individuals with alcohol, drug, or other substance-related disorders and of individuals with the dual diagnosis of substance-related and other psychiatric disorders.”6 Addiction psychiatrists are specifically trained to give evidence-based treatment to their patients, which involves not only addressing addiction but also addressing any mental disorders that might have contributed to behaviors associated with addiction. Addiction psychiatrists aim to address the underlying causes of addiction.

Female Doctor And Patient Consultation

Addiction medicine specialists provide evidence-based prevention, evaluation, diagnosis, treatment, and medical management services for patients with unhealthy substance use or substance-related health conditions. Family members who are affected by a loved one’s substance use or addiction can also seek help from addiction medicine specialists.7 Addiction medicine specialists are trained in addiction neurobiology and how to use screening and assessment tools, diagnosis and treatment planning tools, and communication strategies, including motivational interviewing. They generally have extensive experience working with patients with SUDs and have been trained in how to communicate effectively with these patients. Addiction medicine specialists work closely with other clinicians to ensure coordination of care.

Why Refer to an Addiction Medicine Specialist?

If you have a patient who might have one or more substance use disorders (SUDs), you may want to consider whether to consult with or refer your patient to an addiction medicine specialist.

There are several good reasons to do so, which include the following:

  • Expertise: Credentialed addiction medicine specialists have clinical expertise in prevention, evaluation, diagnosis, and treatment of patients with one or more SUDs and associated health conditions. Addiction medicine specialists provide education to patients, other providers, community members, and policy makers.
  • Experience: Addiction medicine specialists are experienced with the various levels of care and treatment options available to help patients with one or more SUDs and are familiar with when to apply them.
  • Network: Addiction medicine specialists routinely collaborate with other clinicians in specialized fields to provide coordinated care. They generally have well-developed networks that enable them to coordinate services to patients and their families and share appropriate information to achieve safer and more effective care.
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Diagnosis and Treatment Decisions

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Diagnosing a substance use disorder (SUD) requires a comprehensive evaluation of a patient’s cognitive, behavioral, and physiological symptoms. For example, a clinician may ask the patient questions about their life, addictive behavior, and patterns of misuse. It’s also important to address SUDs in a non-stigmatizing manner, using language that respects the dignity of all people who use substances. An evaluation may also include obtaining the results of urine drug testing (UDT) and data from prescription drug monitoring program (PDMP) reports. Urine drug testing is a common tool used in assessment and treatment monitoring. The PDMP should also be reviewed to identify any additional prescriptions for controlled substances including opioids, benzodiazepines, and stimulants. Clinicians can use the diagnostic information to determine whether a patient is experiencing symptoms consistent with a SUD and, if so, in what range of severity.

No single approach to treatment of a SUD successfully enables every individual to reach recovery; however, evidence-based guidelines can help clinicians guide their patients to the best treatment options for their specific recovery needs. These guidelines help clinicians systematically evaluate a patient’s clinical needs and situation to match them with the right level of care in the most appropriate available setting. The American Society of Addiction Medicine (ASAM) levels of care continuum can be used to determine which treatment options are appropriate based on individual risks and needs as well as strengths, skills, and resources.

For more information on diagnosis and treatment, see the following:

Effective Communication

To treat a substance use disorder (SUD) with the goal of recovery, clinicians must communicate effectively with their patients. Talking to patients and families about a SUD can be a difficult topic to address. It is important to establish trust and express empathy.

Acknowledging that a SUD is a chronic but treatable medical disorder can be the first step to reducing the stigma often associated with SUDs and can facilitate open and honest communication between patients and their clinicians. Addressing a patient as a whole person when talking about a SUD can provide them with hope and a more positive outlook.

Doctor And Patient Hands On Table

Demonstrate empathy and understanding. Remember to let patients know that recovery is possible and that paths to recovery look different for different people. Here are a few techniques that convey empathy:

  • Actively listen to the patient.
  • Engage with the patient in a nonjudgmental way.
  • Treat the patient with respect and address their SUD as the medical disorder that it is.
  • Help the patient understand that you intend to help them get the treatment they need. This reinforces the possibility of recovery.
For more information on effective communication, see the following:

Stigma

Doctor Sitting And Touching Hand

A person with a substance use disorder (SUD) is unfortunately still regarded by many as having a moral failing and problems that any strong individual should be able to overcome. The associated shame felt by patients and families can create a significant barrier to treatment access and effectiveness. Patients may see acknowledging and receiving treatment for their illness as a sign of personal failure and weakness. This can make pursuing and accepting treatment very difficult.

As a clinician, you can set an example and reduce stigma around SUD with simple changes in language. Model appropriate, nonstigmatizing language for your patients, their families, and fellow healthcare professionals by avoiding slang and using clear, clinically accurate language. For example:

  • Use person-first language. Describe people as having a condition or illness, not being a condition. Say, “person with a substance use disorder (or refer to the specific disorder such as opioid or alcohol use disorder).” Don’t say “addict,” “junkie” or “user.” Such slang can be dehumanizing.
  • Say “drug use” or “unhealthy use” if referring to prescription medications. Don’t say “drug abuse.”
  • Say “substance use disorder.” Don’t say “drug habit.” Using the word “habit” undermines the seriousness of a SUD. It also inaccurately implies that a person is choosing to use substances or can choose to stop.
  • Avoid terms with negative implications, like “abuse” and “abuser.” They can impact the quality of medical care while also reducing the patient’s willingness to self-disclose or engage in treatment.
  • Avoid the term “addiction” when caring for and communicating with patients. Instead, consider language that frames every SUD as a health problem and shows respect for people affected by it.
  • When discussing screening results, say “tested negative for a particular substance” or “tested positive for a particular substance.” Depending on what the patient has shared regarding their use, the results could be described as “expected” or “unexpected.” Don’t say “dirty” or “clean,” which can diminish a patient’s sense of empowerment for change.

Stigma among healthcare professionals may contribute to the problem. Discomfort with discussing a SUD may lead to inadequate screening and diagnosis. Education in the science of addiction coupled with training in patient communication will help reduce stigma.

Care Coordination

Doctor Sitting And Touching Hand

Care coordination is critical in treating a substance use disorder (SUD) to achieve positive patient outcomes. Coordinating treatment for related and unrelated comorbidities, including mental health conditions, is an integral part of treating a SUD. For example, medications are available to treat possible mental health disorders, such as depression or anxiety, that may be co-occurring with the person’s SUD.

In Treatment Approaches to Drug Addiction Drug Facts, the National Institute on Drug Abuse (NIDA) lists principles of effective treatment including:

  • Effective treatment addresses all the patient’s needs, not just his or her drug use.
  • Treatment should address other possible mental disorders.
  • Treatment programs should test patients for HIV/AIDS, hepatitis B and C, tuberculosis, and other infectious diseases, as well as teach them about steps they can take to reduce their risk of these infections. 8

Addiction medicine specialists generally have extensive networks with different types of healthcare professionals that enable them to develop treatment plans that address the wider needs of patients and their families. This network may include licensed clinical social workers, behavioral specialists, counselors, psychologists, psychiatrists, addiction psychiatrists, state health workers, community and faith-based programs, and treatment centers.

For more information on care coordination, See the following:

About the Addiction Medicine Toolkit

The Addiction Medicine Primer is one of several products designed to provide education and resources for the treatment of substance use disorders (SUDs). Other products in the Addiction Medicine Toolkit include the following:

E-learning modules and patient cases:

  • Treatment of Substance Use Disorders: An Overview of Addiction Medicine
  • Treatment Options for Substance Use Disorders
  • Effective Communication in Treating Substance Use Disorders
  • Care Coordination in Treatment of Substance Use Disorders
  • Patient Cases

Conversation starters: Short guides that offer strategies for communication surrounding treatment of SUDs including motivational interviewing techniques, the use of non-stigmatizing language, and patient anxiety reduction:

  • Motivational Interviewing to Help Your Patients Seek Treatment
  • Remove Stigma – Talk with Your Patients About Substance Use Disorder
  • Empathy—Talking to Patients About Substance Use Disorder

Addiction medicine checklist: A checklist that clinicians can use to build a reference document to help treat patients with SUDs. The checklist consists of three sections: Treatment Considerations, Patient Confidentiality Considerations, and Harm Reduction Considerations. Within each section, a list of reminders gives the clinician specific items to consider when treating a patient. Clinicians can customize the information to meet their clinical needs and the needs of their patients.

References

1 Substance Abuse and Mental Health Services Administration. (2020). Key Substance Use and Mental Health Indicators in the United States: Results from the 2020 National Survey on Drug Use and Health. https://www.samhsa.gov/data/sites/default/files/reports/rpt35325/NSDUHFFRPDFWHTMLFiles2020/2020NSDUHFFR1PDFW102121.pdf

2 American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Arlington, VA, American Psychiatric Association, 2013.

3 National Institute on Drug Abuse. (2018, Jan). Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition) Preface. Retrieved April 9, 2021, from https://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third-edition/preface

4 American Society of Addiction Medicine. Definition of Addiction. Retrieved April 9, 2021, from https://www.asam.org/Quality-Science/definition-of-addiction

5 Nunes, E. V., Kunz, K., Galanter, M., & O’Connor, P. G. (2020). Addiction Psychiatry and Addiction Medicine: The Evolution of Addiction Physician Specialists. The American Journal on Addictions, 29(5), 390–400. https://doi.org/10.1111/ajad.13068

6 American Board of Medical Specialties. (2020). ABMS Guide to Medical Specialties. https://www.abms.org/wp-content/uploads/2020/11/ABMS-Guide-to-Medical-Specialties-2020.pdf

7 National Institute on Drug Abuse. (2018). About the Addiction Medicine Subspecialty. Retrieved August 20, 2021, from https://www.drugabuse.gov/nidamed-medical-health-professionals/health-professions-education/adm-fellow-toolkit/about-addiction-medicine-subspecialty

8 National Institute on Drug Abuse. (2019, January). Treatment Approaches for Drug Addiction DrugFacts. Retrieved April 26, 2021, from https://www.drugabuse.gov/publications/drugfacts/treatment-approaches-drug-addiction

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Page last reviewed: March 2, 2022
Content source: Centers for Disease Control and Prevention, National Center for Injury Prevention and Control