Each recommendation is identified as meriting one of three
categories of endorsement, based on the level of clinical confidence
regarding the recommendation, as indicated by a bracketed Roman
numeral after the statement. The three categories are as follows:
[I] Recommended
with substantial clinical confidence.
[II] Recommended with moderate clinical
confidence.
[III] May be recommended on the basis
of individual circumstances.
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B. General Treatment
Principles
Individuals with substance use disorders are heterogeneous
with regard to a number of clinically important features and domains
of functioning. Consequently, a multimodal approach to treatment
is typically required. Care of individuals with substance use disorders includes
conducting a complete assessment, treating intoxication and withdrawal
syndromes when necessary, addressing co-occurring psychiatric and
general medical conditions, and developing and implementing an overall
treatment plan. The goals of treatment include the achievement of
abstinence or reduction in the use and effects of substances, reduction
in the frequency and severity of relapse to substance use, and improvement
in psychological and social functioning.
A comprehensive psychiatric evaluation is essential to guide
the treatment of a patient with a substance use disorder [I].
The assessment includes 1) a detailed history of the patient's
past and present substance use and the effects of substance use
on the patient's cognitive, psychological, behavioral,
and physiological functioning; 2) a general medical and psychiatric
history and examination; 3) a history of psychiatric treatments
and outcomes; 4) a family and social history; 5) screening of blood,
breath, or urine for substance used; 6) other laboratory tests to
help confirm the presence or absence of conditions that frequently co-occur
with substance use disorders; and 7) with the patient's
permission, contacting a significant other for additional information.
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2. Psychiatric management
Psychiatric management is the foundation of treatment for
patients with substance use disorders [I]. Psychiatric
management has the following specific objectives: motivating the patient
to change, establishing and maintaining a therapeutic alliance with
the patient, assessing the patient's safety and clinical
status, managing the patient's intoxication and withdrawal
states, developing and facilitating the patient's adherence
to a treatment plan, preventing the patient's relapse,
educating the patient about substance use disorders, and reducing
the morbidity and sequelae of substance use disorders. Psychiatric
management is generally combined with specific treatments carried
out in a collaborative manner with professionals of various disciplines
at a variety of sites, including community-based agencies, clinics,
hospitals, detoxification programs, and residential treatment facilities.
Many patients benefit from involvement in self-help group meetings,
and such involvement can be encouraged as part of psychiatric management.
The specific pharmacological and psychosocial treatments reviewed
below are generally applied in the context of programs that combine
a number of different treatment modalities.
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a) Pharmacological
treatments
Pharmacological treatments are beneficial for selected patients
with specific substance use disorders [I]. The
categories of pharmacological treatments are 1) medications to treat intoxication
and withdrawal states, 2) medications to decrease the reinforcing
effects of abused substances, 3) agonist maintenance therapies,
4) antagonist therapies, 5) abstinence-promoting and relapse prevention
therapies, and 6) medications to treat comorbid psychiatric conditions.
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b) Psychosocial treatments
Psychosocial treatments are
essential components of a comprehensive treatment program [I].
Evidence-based psychosocial treatments include cognitive-behavioral
therapies (CBTs, e.g., relapse prevention, social skills training),
motivational enhancement therapy (MET), behavioral therapies (e.g.,
community reinforcement, contingency management), 12-step facilitation
(TSF), psychodynamic therapy/interpersonal therapy (IPT),
self-help manuals, behavioral self-control, brief interventions,
case management, and group, marital, and family therapies. There
is evidence to support the efficacy of integrated treatment for patients
with a co-occurring substance use and psychiatric disorder; such
treatment includes blending psychosocial therapies used to treat
specific substance use disorders with psychosocial treatment approaches
for other psychiatric diagnoses (e.g., CBT for depression).
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4. Formulation and
implementation of a treatment plan
The goals of treatment and the specific therapies chosen to
achieve these goals may vary among patients and even for the same
patient at different phases of an illness [I].
Because many substance use disorders are chronic, patients usually
require long-term treatment, although the intensity and specific
components of treatment may vary over time [I].
The treatment plan includes the following components: 1) psychiatric
management; 2) a strategy for achieving abstinence or reducing the
effects or use of substances of abuse; 3) efforts to enhance ongoing
adherence with the treatment program, prevent relapse, and improve functioning;
and 4) additional treatments necessary for patients with a co-occurring
mental illness or general medical condition.
The duration of treatment should be tailored to the individual
patient's needs and may vary from a few months to several
years [I]. It is important to intensify the monitoring
for substance use during periods when the patient is at a high risk
of relapsing, including during the early stages of treatment, times
of transition to less intensive levels of care, and the first year
after active treatment has ceased [I].
Treatment settings vary with regard to the availability of
specific treatment modalities, the degree of restricted access to
substances that are likely to be abused, the availability of general
medical and psychiatric care, and the overall milieu and treatment
philosophy.
Patients should be treated in the least restrictive setting
that is likely to be safe and effective [I]. Commonly
available treatment settings include hospitals, residential treatment facilities,
partial hospitalization programs, and outpatient programs. Decisions
regarding the site of care should be based on the patient's
ability to cooperate with and benefit from the treatment offered,
refrain from illicit use of substances, and avoid high-risk behaviors as
well as the patient's need for structure and support or
particular treatments that may be available only in certain settings [I].
Patients move from one level of care to another based on these factors
and an assessment of their ability to safely benefit from a different
level of care [I].
Hospitalization is appropriate for patients who 1) have a
substance overdose who cannot be safely treated in an outpatient
or emergency department setting; 2) are at risk for severe or medically
complicated withdrawal syndromes (e.g., history of delirium tremens,
documented history of very heavy alcohol use and high tolerance);
3) have co-occurring general medical conditions that make ambulatory
detoxification unsafe; 4) have a documented history of not engaging
in or benefiting from treatment in a less intensive setting (e.g.,
residential, outpatient); 5) have a level of psychiatric comorbidity
that would markedly impair their ability to participate in, adhere
to, or benefit from treatment or have a co-occurring disorder that
by itself would require hospital-level care (e.g., depression with
suicidal thoughts, acute psychosis); 6) manifest substance
use or other behaviors that constitute an acute danger to themselves
or others; or 7) have not responded to or were unable to adhere to
less intensive treatment efforts and have a substance use disorder(s)
that endangers others or poses an ongoing threat to their physical
and mental health [I].
Residential treatment is indicated for patients who do not
meet the clinical criteria for hospitalization but whose lives and
social interactions have come to focus predominantly on substance
use, who lack sufficient social and vocational skills, and who lack
substance-free social supports to maintain abstinence in an outpatient
setting [II]. Residential treatment of 
3 months is associated
with better long-term outcomes in such patients [II].
For patients with an opioid use disorder, therapeutic communities
have been found effective [II].
Partial hospitalization should be considered for patients
who require intensive care but have a reasonable probability of
refraining from illicit use of substances outside a restricted setting [II].
Partial hospitalization settings are frequently used for patients
leaving hospitals or residential settings who remain at high risk
for relapse. These include patients who are thought to lack sufficient
motivation to continue in treatment, have severe psychiatric comorbidity
and/or a history of relapse to substance use in the immediate
posthospitalization or postresidential period, and are returning
to a high-risk environment and have limited psychosocial supports
for abstaining from substance use. Partial hospitalization programs
are also indicated for patients who are doing poorly despite intensive
outpatient treatment [II].
Outpatient treatment of substance use disorders is appropriate
for patients whose clinical condition or environmental circumstances
do not require a more intensive level of care [I]. As
in other treatment settings, a comprehensive approach is optimal,
using, where indicated, a variety of psychotherapeutic and pharmacological
interventions along with behavioral monitoring [I].
Most treatment for patients with alcohol dependence or abuse can
be successfully conducted outside the hospital (e.g., in outpatient
or partial hospitalization settings) [II], although
patients with alcohol withdrawal must be detoxified in a setting
that provides frequent clinical assessment and any necessary treatments [I].
For many patients with a cocaine use disorder, clinical and research
experience suggests the effectiveness of intensive outpatient treatment
in which a variety of treatment modalities are simultaneously used
and in which the focus is the maintenance of abstinence [II].
The treatment of patients with nicotine dependence or a marijuana
use disorder occurs on an outpatient basis unless patients are hospitalized
for other reasons [I].
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6. Clinical features
influencing treatment
In planning and implementing treatment, a clinician should
consider several variables with regard to patients: comorbid psychiatric
and general medical conditions, gender-related factors, age, social
milieu and living environment, cultural factors, gay/lesbian/bisexual/transgender
issues, and family characteristics [I]. Given
the high prevalence of comorbidity of substance use disorders and
other psychiatric disorders, the diagnostic distinction between
substance use symptoms and those of other disorders should receive
particular attention, and specific treatment of comorbid disorders
should be provided [I]. In addition to pharmacotherapies
specific to a patient's substance use disorder, various
psychotherapies may also be indicated when a patient has a co-occurring
psychiatric disorder, psychosocial stressors, or other life circumstances
that exacerbate the substance use disorder or interfere with treatment [I].
A patient's cessation of substance use may also be associated
with changes in his or her psychiatric symptoms or the metabolism
of medications (e.g., altered antipsychotic metabolism via cytochrome
P450 1A2 with smoking cessation) that will necessitate adjustment
of psychotropic medication doses [I].
In women of childbearing age, the possibility of pregnancy
needs to be considered [I]. Each of the substances
discussed in this practice guideline has the potential to affect
the fetus, and psychosocial treatment to encourage substance abstinence
during pregnancy is recommended [I]. With some
substances, concomitant agonist treatment may be preferable to continued
substance use. In pregnant smokers, treatment with nicotine replacement
therapy (NRT) may be helpful [II]. For pregnant
women with an opioid use disorder, treatment with methadone [I] or
buprenorphine [II] can be a useful adjunct to
psychosocial treatment.
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C. Nicotine Use Disorders:
Treatment Principles and Alternatives
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1. Pharmacological
treatments
Pharmacological treatment
is recommended for individuals who wish to stop smoking and have
not achieved cessation without pharmacological agents or who prefer
to use such agents [I]. There are six medications
approved by the U.S. Food and Drug Administration (FDA) for nicotine
dependence, including five NRTs (patch, gum, spray, lozenge, and
inhaler) and bupropion. These are all first-line agents that are
equally effective in alleviating withdrawal symptoms and reducing
smoking. Any of these could be used based on patient preference,
the route of administration, and the side-effect profile [I].
Significant adverse events to NRTs, including dependence, are rare.
Although combined psychosocial and medication treatment produces
the best outcomes in treating nicotine use disorders, these medications
are effective even when no psychosocial treatment is provided [I].
Using a combination of these first-line treatments may also improve
outcome [II]. Nortriptyline and clonidine have
utility as second-line agents but appear to have more side effects [II].
Other medications and acupuncture have not been proven to be effective.
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2. Psychosocial treatments
Psychosocial treatments are
also effective for the treatment of nicotine dependence and include
CBTs [I], behavioral therapies [I],
brief interventions [II], and MET [II] provided in
individual [I], group [I], or
telephone [I] formats or via self-help materials [III] and
Internet-based formats [III]. The efficacy of
treatment is related to the amount of psychosocial treatment received.
The 12-step programs, hypnosis, and inpatient therapy have not been
proven effective.
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D. Alcohol Use Disorders:
Treatment Principles and Alternatives
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1. Management of
intoxication and withdrawal
The acutely intoxicated patient should be monitored and maintained
in a safe environment [II]. Symptoms of alcohol
withdrawal typically begin within 4–12 hours after cessation
or reduction of alcohol use, peak in intensity during the second
day of abstinence, and generally resolve within 4–5 days.
Serious complications include seizures, hallucinations, and delirium.
The treatment of patients in moderate to severe withdrawal
includes efforts to reduce central nervous system (CNS) irritability
and restore physiological homeostasis [I] and generally
requires the use of thiamine and fluids [I], benzodiazepines [I],
and, in some patients, other medications such as anticonvulsants,
clonidine, or antipsychotic agents [II]. Once
clinical stability is achieved, the tapering of benzodiazepines
and other medications should be carried out as necessary, and the
patient should be observed for the reemergence of withdrawal symptoms
and the emergence of signs and symptoms suggestive of co-occurring
psychiatric disorders [I].
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2. Pharmacological
treatments
Specific pharmacotherapies for alcohol-dependent patients
have well-established efficacy and moderate effectiveness. Naltrexone
may attenuate some of the reinforcing effects of alcohol [I],
although data on its long-term efficacy are limited. The use of
long-acting, injectable naltrexone may promote adherence, but published
research is limited and FDA approval is pending. Acamprosate, a 
-aminobutyric acid (GABA)
analog that may decrease alcohol craving in abstinent individuals,
may also be an effective adjunctive medication in motivated patients
who are concomitantly receiving psychosocial treatment [I].
Disulfiram is an effective adjunct to a comprehensive treatment
program for reliable, motivated patients whose drinking may be triggered
by events that suddenly increase alcohol craving [II].
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3. Psychosocial treatments
Psychosocial treatments found effective for some patients
with an alcohol use disorder include MET [I],
CBT [I], behavioral therapies [I],
TSF [I], marital and family therapies [I],
group therapies [II], and psychodynamic therapy/IPT [III].
Recommending that patients participate in self-help groups, such
as Alcoholics Anonymous (AA), is often helpful [I].
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E. Marijuana Use
Disorders: Treatment Principles and Alternatives
Studies of treatment for marijuana use disorders are limited.
No specific pharmacotherapies for marijuana withdrawal or dependence
can be recommended [I]. In terms of psychosocial
therapies, an intensive relapse prevention approach that combines
motivational interventions with the development of coping skills
may be effective for the treatment of marijuana dependence [III],
but further study of these approaches is necessary.
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F. Cocaine Use Disorders:
Treatment Principles and Alternatives
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1. Management of
intoxication and withdrawal
Cocaine intoxication is usually self-limited and typically
requires only supportive care [II]. However, hypertension,
tachycardia, seizures, and persecutory delusions can occur with
cocaine intoxication and may require specific treatment [II].
Acutely agitated patients may benefit from sedation with benzodiazepines [III].
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2. Pharmacological
treatments
Pharmacological treatment is not ordinarily indicated as an
initial treatment for patients with cocaine dependence. In addition,
no pharmacotherapies have FDA indications for the treatment of cocaine
dependence. However, for individuals who fail to respond to psychosocial
treatment alone, some medications (topiramate, disulfiram, or modafinil)
may be promising when integrated into psychosocial treatments.
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3. Psychosocial treatments
For many patients with a cocaine use disorder, psychosocial
treatments focusing on abstinence are effective [I].
In particular, CBTs [I], behavioral therapies [I],
and 12-step-oriented individual drug counseling [I] can
be useful, although efficacy of these therapies varies across subgroups
of patients. Recommending regular participation in a self-help group
may improve the outcome for selected patients with a cocaine use
disorder [III].
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G. Opioid Use Disorders:
Treatment Principles and Alternatives
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1. Management of
intoxication and withdrawal
Acute opioid intoxication of a mild to moderate degree usually
does not require specific treatment [II]. However,
severe opioid overdose, marked by respiratory depression, may be fatal
and requires treatment in an emergency department or inpatient setting [I].
Naloxone will reverse respiratory depression and other manifestations
of opioid overdose [I].
The treatment of opioid withdrawal is directed at safely ameliorating
acute symptoms and facilitating the patient's entry into
a long-term treatment program for opioid use disorders [I].
Strategies found to be effective include substitution of methadone
or buprenorphine for the opioid followed by gradual tapering [I];
abrupt discontinuation of opioids, with the use of clonidine to
suppress withdrawal symptoms [II]; and clonidine-naltrexone detoxification [II].
It is essential that the treating physician assess the patient for
the presence of other substances, particularly alcohol, benzodiazepines,
or other anxiolytic or sedative agents, because the concurrent use
of or withdrawal from other substances can complicate the treatment
of opioid withdrawal [I]. Anesthesia-assisted
rapid opioid detoxification (AROD) is not recommended because of
lack of proven efficacy and adverse risk-benefit ratios.
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2. Pharmacological
treatments
Maintenance treatment with methadone or buprenorphine is appropriate
for patients with a prolonged history (>1 year) of opioid dependence [I].
The goals of treatment are to achieve a stable maintenance dose
of opioid agonist and facilitate engagement in a comprehensive program
of rehabilitation [I]. Maintenance treatment with
naltrexone is an alternative strategy [I], although
the utility of this strategy is often limited by lack of patient adherence
and low treatment retention.
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3. Psychosocial treatments
Psychosocial treatments are effective components of a comprehensive
treatment plan for patients with an opioid use disorder [II].
Behavioral therapies (e.g., contingency management) [II],
CBTs [II], psychodynamic psychotherapy [III],
and group and family therapies [III] have been
found to be effective for some patients with an opioid use disorder.
Recommending regular participation in self-help groups may also
be useful [III].
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II. General Treatment Principles
Although many of the principles presented in this section
apply to all substances reviewed in this guideline (i.e., nicotine,
alcohol, marijuana, cocaine, and opioids), not all principles are
applicable to the treatment of every substance use disorder. This
is particularly true for nicotine dependence treatment, as nicotine
dependence rarely causes the behavioral or social harm seen with
other substance dependencies.
Individuals with substance use disorders are heterogeneous
with regard to a number of clinically important features:
The number and type of substances
used
The individual's genetic vulnerability for
developing a substance use disorder(s)
The severity of the disorder, the rapidity with which
it develops, and the degree of associated functional impairment(s)
The individual's awareness of the substance
use disorder as a problem
The individual's readiness for change and motivation
to enter into treatment for the purpose of change
The associated general medical and psychiatric conditions
(either co-occurring or induced by substance use)
The individual's strengths (protective and
resiliency factors) and vulnerabilities
The social, environmental, and cultural context in which
the individual lives and will be treated
It is clinically helpful when assessing patients to use a
spectrum that includes use, misuse, abuse, and dependence. The
latter two terms represent formal diagnostic categories. Use of
a substance may or may not be clinically significant. If use of
a substance is thought to be potentially clinically significant
but does not meet diagnostic criteria for abuse or dependence, it
may be characterized as "misuse," although this
is not a formal diagnostic category. Even when functional impairment
is absent or limited, substance misuse can be an early indicator
of an individual's vulnerability to developing a chronic
substance use disorder. Brief early interventions can effectively
reduce this progression (1–3), although follow-up reinforcement
appears necessary for sustained utility. Most individuals presenting
or referred for treatment of a substance use disorder, however,
have been unable to stop using substances on their own. They often
exhibit functional impairments across many categories (e.g., health,
social and family, occupa