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Practice Guideline for the Treatment of Patients With Substance Use Disorders, Second Edition

DOI: 10.1176/appi.books.9780890423363.141077
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Work Group on Substance Use Disorders

Herbert D. Kleber, M.D., Chair

Roger D. Weiss, M.D., Vice-Chair

Raymond F. Anton Jr., M.D.

Tony P. George, M.D.

Shelly F. Greenfield, M.D., M.P.H.

Thomas R. Kosten, M.D.

Charles P. O'Brien, M.D., Ph.D.

Bruce J. Rounsaville, M.D.

Eric C. Strain, M.D.

Douglas M. Ziedonis, M.D.

Grace Hennessy, M.D. (Consultant)

Hilary Smith Connery, M.D., Ph.D. (Consultant)

This practice guideline was approved in December 2005 and published in August 2006. A guideline watch, summarizing significant developments in the scientific literature since publication of this guideline, may be available.

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Guide to Using This Practice Guideline

The Practice Guideline for the Treatment of Patients With Substance Use Disorders, 2nd Edition, consists of three parts (A, B, and C) and many sections, not all of which will be equally useful for all readers. The following guide is designed to help readers find the sections that will be most useful to them.

Part A, "Treatment Recommendations for Patients With Substance Use Disorders," is published as a supplement to the American Journal of Psychiatry and contains general and specific treatment recommendations. Section I summarizes the key recommendations of the guideline and codes each recommendation according to the degree of clinical confidence with which the recommendation is made. Section II, "General Treatment Principles," provides a general discussion of the formulation and implementation of a treatment plan as it applies to the individual patient. Section II.G, "Clinical Features Influencing Treatment," discusses a range of clinical considerations that could alter the general recommendations discussed in Section I. Sections III, IV, V, VI, and VII provide specific recommendations for the treatment of patients with nicotine-, alcohol-, marijuana-, cocaine-, and opioid-related disorders, respectively.

Part B, "Background Information and Review of Available Evidence," and Part C, "Future Research Needs," are not included in the American Journal of Psychiatry supplement but are provided with Part A in the complete guideline, which is available in print format from American Psychiatric Publishing, Inc. (http://www.appi.org) and online through the American Psychiatric Association (http://www.psych.org). Part B provides an overview of substance use disorders, including general information on their natural history, course, and epidemiology. It also provides a structured review and synthesis of the evidence that underlies the recommendations made in Part A. Part C draws from the previous sections and summarizes areas for which more research data are needed to guide clinical decisions.

To share feedback on this or other published APA practice guidelines, a form is available at http://mx.psych.org/survey/reviewform.cfm.

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Development Process

This practice guideline was developed under the auspices of the Steering Committee on Practice Guidelines. The development process is detailed in "APA Guideline Development Process," which is available from the APA Department of Quality Improvement and Psychiatric Services. The key features of this process with regard to this document include the following:

  • A comprehensive literature review to identify all relevant randomized clinical trials as well as less rigorously designed clinical trials and case series when evidence from randomized trials was unavailable

  • The development of evidence tables that summarized the key features of each identified study, including funding source, study design, sample sizes, subject characteristics, treatment characteristics, and treatment outcomes

  • Initial drafting of the guideline by a work group that included psychiatrists with clinical and research expertise in substance use disorders

  • The production of multiple revised drafts with widespread review (23 organizations and 70 individuals submitted significant comments)

  • Approval by the APA Assembly and Board of Trustees

  • Planned revisions at regular intervals

Relevant updates to the literature were identified through a MEDLINE literature search for articles published since the initial guideline edition, published in 1995. Thus MEDLINE was searched, using PubMed, between 1995 and 2002 using the keywords "substance use disorder OR substance use disorders OR substance use OR substance withdrawal OR substance intoxication OR substance abuse OR substance dependence OR alcohol abuse OR alcohol dependence OR cocaine abuse OR cocaine dependence OR cocaine use OR marijuana use OR marijuana abuse OR marijuana dependence OR opiate abuse OR opiate dependence OR opiate use OR opioid abuse OR opioid dependence OR opioid use OR heroin abuse OR heroin dependence OR heroin use OR cigarette OR cigarettes OR smoking OR tobacco OR tobacco use OR tobacco use disorder OR tobacco use cessation OR smoking cessation." This search yielded 89,231 references, of which 4,373 were controlled clinical trials; randomized, controlled trials; or meta-analyses; 4,101 of the 4,373 references were studies in humans, were written in the English language, and had abstracts. Evidence tables were developed for these results. Later in the development process, a second MEDLINE literature search, using PubMed, on the same keywords for the period 2003 to February 2005 yielded an additional 25,003 references, of which 1,114 were controlled clinical trials; randomized, controlled trials; or meta-analyses; 1,063 of these 1,114 references were studies in humans, were written in the English language, and had abstracts. Additional, less formal literature searches were conducted by APA staff and individual members of the Work Group on Substance Use Disorders. The Cochrane databases were also searched for relevant meta-analyses.

The summary of treatment recommendations is keyed according to the level of confidence with which each recommendation is made (indicated by a bracketed Roman numeral). In addition, each reference is followed by a bracketed letter that indicates the nature of the supporting evidence.

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Part A: Treatment Recommendations for Patients With Substance Use Disorders

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I. Executive Summary

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A. Coding System

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.

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1. Assessment

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.

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3. Specific treatments

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].

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5. Treatment settings

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.