Updated: Dec 3, 2021
Guidelines (American Psychiatric Association)
The American Psychiatric Association is the association of US psychiatrists, as well as the largest and most authoritative in the world for the category. The APA works to promote improvement in the treatment of mental disorders, including substance abuse treatment, and this aim is pursued by promoting guidelines on case management and informed decision on the most effective treatment in light of current scientific evidence.
Research has shown that the use of pharmacotherapy for substance use disorders may be limited unless it is given in conjunction with psychotherapy (APA, 2010).
A. General Principles of Processing
1. Treatment Goals
A multimodal approach is usually required, as individuals with a substance use disorder are clinically and functionally heterogeneous. The main purpose of treatment of substance use disorder includes motivating the patient to change and helping him develop, practice and internalize changes in attitudes and behaviors that tend to prevent relapse. Additional purposes of the intervention include:
Help the patient reduce substance use or achieve complete abstinence.
Abstinence is associated with the best long-term outcomes.
Many patients are unable or unwilling to achieve abstinence and just want to reduce usage to a controlled level.
Controlled use can lead to a decrease in associated disorders but is unrealistic for many patients and can dissuade them from working towards abstinence.
Help the patient reduce the frequency and severity of substance use episodes.
Improve psychological and social functioning.
Repair cracked relationships and improve family and interpersonal relationships that can foster an abstinent lifestyle.
Develop social and professional skills.
Obtain information from the patient and, with their permission, from other sources (e.g. family, friends, current or former professionals, employers) as long as appropriate.
If necessary, depending on the clinical problem and the patient's motivation, conduct an assessment in several sessions.
Recognize that a group of people may have an increased risk of developing a substance use disorder (e.g., gay or bisexual people with nicotine addiction or patients with schizophrenia) or of having an undiagnosed substance use disorder (e.g., older people).
Include in the assessment what is listed in Table 1.
Consider using empirically validated substance use disorder screening tools for (e.g. CAGE [have you ever felt the need to cut down on drinking, have been annoyed [Annoyed] by others' criticism of your drink, have you ever felt guilty [Guilty] because you drink, have you ever needed a glass first thing in the morning to open your eyes( [Eye opener], the Alcohol Use Identification Test or the Drug Abuse Screening Test) such as help in identifying unrecognized substance use disorders.
Consider using qualitative or quantitative blood, breath, or urine screening tests to identify recent substance uses.
Evaluate whether or not the use of diagnostic tests are indicated for monitoring the presence or absence of pregnancy (in women of childbearing potential) or for general medical conditions common among people with a substance use disorder.
Table 1: what to include in the assessment
A detailed history of the patient's present and past including:
Types of substances used (including nicotine, caffeine and over-the-counter drugs) and possible use of different substances in combination;
Method of use, quantity, frequency, duration, method of administration and contexts of use of the substance (e.g., where, with whom);
Date and quantity of the last use;
Associated degree of intoxication, withdrawal and subjective effects of all substances used.
History of prior drug use treatments (e.g., setting, context, modality, duration, and adherence), efforts to discontinue use and results (e.g., duration of abstinence, subsequent substance use, reasons for relapse, level of social and occupational functioning achieved).
Degree of readiness for change, including:
Awareness of the substance as a problem,
Plans to finish using it,
Reasons for using the substance, including desired effects,
Obstacles to treatment and abstinence,
Expectations and preferences for the next treatment,
Effects on cognitive, psychological, behavioral, social, occupational and physiological functioning.
General medical and psychiatric history and mental status examination for
3. Family History of Substance Use or Psychiatric Disorders
Social history (including relationships with family and peers, financial and legal problems) and psychosocial support (including the influences of close friends or other family members in supporting or undermining past attempts at abstinence).
Educational and occupational history, including school or work adaptation and identification of high-risk occupation of substance use.
4. Formulation and Implementation of the Treatment
Develop and implement a strategy to achieve abstinence.
If abstinence is not the patient's goal, use a motivational approach to encourage abstinence in the future.
Use specific pharmacological and psychosocial interventions in the context of an organized treatment program that combines different modalities
Apply the principles of psychiatric management to coordinate the use of different clinics and modalities used in individual, group, family and self-help settings.
Customize the intervention plan based on personal needs and preferences.
Intensify monitoring of substance use and consider whether adjustments are needed during periods of high risk of relapse.
Consider including family members or support people as part of the intervention.
Consider recommending participation in self-help groups.
5. Pharmacological Treatment
For selected patients, the drugs can be used for the following purposes:
Treatment of intoxication states.
Decrease or eliminate withdrawal symptoms in order to reduce craving and the risk of relapse.
Substitute an agonist for the specific class of substances used (e.g., methadone or buprenorphine’s for opioids, nicotine replacement therapies for tobacco, benzodiazepines for alcohol).
Consider using other drugs that may also reduce withdrawal symptoms (e.g., clonidine for opioid withdrawal).
Reduce the strengthening effect of the substance of abuse.
Evaluate the use of drugs that block the subjective and physiological effect of subsequently administered substances (e.g., the opioid antagonist naltrexone to block the effect of opioids).
To promote abstinence and prevent relapses.
Evaluate the use of medications such as:
Disulfiram, which can discourage alcohol use by the patient's awareness of the unpleasant interaction between the drug and the substance.
Naltrexone, which decreases the craving for alcohol likely through the effects on opioid receptors in mediating the strengthening effect of alcohol.
Acamprosate, which is thought to promote alcohol withdrawal by reducing nervous hyperexcitability.
Bupropion, which decreases the craving for nicotine and the need to smoke.
Treat co-existing psychiatric conditions
Address comorbid psychiatric disorders to improve adherence and treatment success for substance use disorder.
6. Psychosocial Treatment
Psychosocial treatments are an essential part of a comprehensive treatment program. Integrating or mixing psychosocial interventions can be helpful when patients show substance use alongside another psychiatric disorder. Depending on the type of specific substance use disorder being treated (see next sections), the availability of specific psychosocial treatment, and the patient's preferences, choose from the following interventions:
TCC and Cognitive Therapies
Purpose of TCC:
Modify dysfunctional cognitive processes that lead to dysfunctional behaviors.
Intervening in the chain of events leads to the use of substances.
Help reduce chronic and acute craving.
Promote and enhance the development of effective social behaviors and skills.
Types of TCC:
Standard cognitive therapy - changing maladaptive thought patterns to reduce negative emotions and behaviors (e.g., substance use).
Social skill training - improve the person's ability to communicate effectively and meaningfully by listening to others, imagining the thoughts and emotions of others, monitoring their non-verbal communication, adapting to circumstances to maintain relationships and being assertive.
Relapse prevention - uses cognitive and behavioral techniques to help patients develop greater self-control and avoid relapse.
Therapy to Improve Motivation
Motivate the patient to change by empathically asking about the pros and cons of specific behavior and exploring the patient's goals and associated ambivalence.
Contingency management to enforce abstinence (e.g., with vouchers) or punish substance use (e.g., with notifications to the trial court, employer, or family members) as measured by monitoring random and supervised urine, saliva or hair follicles.
Community reinforcement provides the patient with natural and alternative reinforcements to abstinence through involvement in the social community (e.g., in the family, with peers).
Exposure to stimuli and relaxation techniques expose the patient to craving-inducing stimuli while preventing the use of substances to facilitate the extinction of a conditioned craving response.
Facilitation to 12 Steps
Promote abstinence by using a short, structured and supervised manualized intervention to improve patient motivation and facilitate participation in 12-step programs.
Psychodynamic and Interpersonal Therapies
They can facilitate withdrawal, especially when combined with other modalities of intervention (e.g., drug therapy and self-help groups).
It can be supportive, therapeutic and educational.
Increase responsibility by giving the group the opportunity to respond to prodromal signs of relapse.
Dysfunctional families are associated with poorer patient outcomes in the short and long term. Family therapy goals include:
Encourage the family to support the patient for withdrawal.
Obtain clinical information about the patient.
Maintain marital relations.
Acting on interpersonal and family interactions that lead to conflict or substance use.
Reinforce behaviors that can help prevent relapses and improve recovery expectations.
Self-help and 12-step Oriented Groups
Alcoholics Anonymous (AA) and other 12-step-oriented programs provide tools to help participants stay sober, including the 12-step, group identification, mutual help and sharing of experiences, strengths and hope with each other.
Encouraging participation in self-help groups can be an important addition to treatment for some but not all patients.
Refusal to participate does not indicate resistance to treatment in general.
Patients requiring psychoactive drugs (e.g., lithium or antidepressants) should be referred to groups that encourage these treatments.
Self-guided therapies that monitor alcohol and tobacco use may be useful for a general health care population but tend to be less useful for patients who come to specialized programs for the treatment of substance use disorders.
7. Clinical Aspects Influencing the Treatment
Consider whether the treatment plan needs to be modified based on the individual patient characteristics.
Show sensitivity to cultural differences and incorporate cultural beliefs about healing and recovery to improve outcomes within ethnic minorities.
Recognize that poly abuse is common and can complicate assessment and treatment.
Consider whether the treatment plan needs changes based on the coexistence of general medical conditions.
Consider the benefits and risks to individual patients when choosing medications to treat comorbid disorders.
Change your treatment plan for substance use disorder to address other comorbid psychiatric disorders as well.
Addressing the increased risk of suicide and aggressive behavior during an intoxication or abstinence period in individuals with comorbidities with other psychiatric disorders.
Incorporate the psychosocial therapies indicated together with the drug therapies for each disorder.
Consider whether the initial phase of treatment requires increased intensity when treating individuals suffering only from substance use disorder (e.g., early use of nicotine substitutes, supplemental use of nicotine patches with other replacement therapies or groups or individual behavioral therapy for smoking cessation).
Assess the potential effects that withdrawal may have on symptoms of comorbid psychiatric disorders when synchronizing treatment efforts.
Coping with insomnia, which is a common problem and can predict relapses although the evidence is limited, TCC or psychotropic drugs (e.g., trazodone or gabapentin) may be considered.
Address the factors most likely to affect patient adherence with comorbid disorders (e.g., concerns about drug interactions, cognitive impairment, poor motivation, or lack of social support).
Assess whether treatment can be made more effective through the integration of community-based assertiveness interventions, staged motivation models and recovery-oriented perspectives.
Encourage attending groups that follow the 12-step program and support appropriate use of psychotropic drugs.
Assess the possibility of pregnancy as part of the treatment planning process for women of childbearing age.
In the case of pregnant women, modify the treatment to maximize patient and fatal well-being.
Choose treatments for pregnant women based on an assessment of the risks and benefits of treatment for the fetus as well as for the patient.
B. Psychiatric Management
Motivate the patient to change.
Establish and maintain a therapeutic alliance.
Assess patient safety and clinical status.
Reduce the severity and sequelae of substance use disorders.
Develop and facilitate treatment adherence.
Use relapse prevention strategies.
Facilitate access to services and coordinate resources between mental health services, general medicine and social services.
Appendices on specific substances
C. Nicotine Addiction
Provide drug treatments for people who wish to quit smoking and have not succeeded without drugs or who prefer to use them.
The five NRTs (patches, gums, lozenges, nasal spray or inhaler) and bupropion are the first-line treatments that are as effective in relieving withdrawal symptoms as they are in reducing smoking.
The choice of first-line treatment is based on patient preference, method of administration and side effects.
Significant side effects of NRTs, including addiction, are rare.
Using a combination of these first-line treatments can improve outcomes (e.g., two NRTs or one NRT together with buprioprion).
If abstinence continues, additional NRTs should be considered (e.g., a higher dose or greater number of NRTs, different formulation producing higher nicotine levels).
Combining psychosocial and pharmacological interventions produce the best results.
Nortriptyline and clonidine are useful as second-line agents but appear to have more side effects.
Other medications and acupuncture have not been shown to be effective.
Providing psychosocial treatments as an essential component of a comprehensive treatment program as well as for individuals who prefer these approaches.
Such treatments are usually provided in a multimodal package that includes providing information to the patient on quitting smoking, helping the patient decide when to plan to quit smoking, warning against coffee and alcohol use, helping the patient to develop skills to stop smoking. avoid relapse and help him set a date to quit (quitting abruptly is preferable to tapering off).
The effects of the treatment are improved by follow-up visits one to three days after the patient has quit smoking.
When given in individual, group, telephone, or self-help (written, video, or internet) formats, potentially useful psychosocial treatments include:
Short interventions. They include behavioral supportive smoking cessation counselling with aspects of motivational enhancement therapy (MET).
Behavioral therapies. They include contingency management, exposure to stimuli and aversive approaches such as "rapid smoking".
Cognitive and behavioral therapies. They are aimed at cognitive coping styles, such as identifying dysfunctional thoughts, questioning them, and replacing them with more effective thought processes to prevent a slip from becoming a relapse (e.g., not catastrophizing a slip) and behavioral coping styles such as walking away risk situations, replace other behaviors (walking, exercise) and use skills to manage triggers (assertiveness, ability to refuse, time management).
Social support. It appears to be as beneficial as a specific intervention or support provided by a spouse.
Psychosocial treatments that have not been proven effective include residential treatment, hypnosis, and 12-step program-oriented groups.
D. Alcohol Use Disorder
Management of alcohol withdrawal intoxication
Evaluate symptoms of intoxication and withdrawal.
Consider using standardized withdrawal symptom scales such as the Clinical Institute Withdrawal Assessment of Alcohol Scale-Revised to measure the level and change in withdrawal symptoms.
Laboratory tests should be used to determine whether other substances contribute to the clinical presentation.
Withdrawal symptoms generally begin within 4-12 hours of stopping or reducing alcohol use, peak in intensity on the second day of abstinence, and generally resolve within four to five days.
In mild to moderate abstinence, gastrointestinal problems, anxiety, irritability, high blood pressure, tachycardia, and autonomic hyperactivity occur.
Severe withdrawal symptoms occur in less than 5% of patients and include delirium, hallucinations, grand mal seizure, respiratory alkalosis, and fever.
Determine if risk factors for withdrawal are present.
The presence of each of the following is associated with significant withdrawal risks:
Previous history of delirium tremens and / or alcohol withdrawal.
Documented history of very important alcohol use and high tolerance.
Including abuse of other substances.
General medical conditions or comorbid psychiatric disorders.
Repeated unsuccessful attempts at detoxification in an outpatient setting.
Choose a setting appropriate for the treatment.
For acute poisoning monitor and maintain in a safe environment.
For mild to moderate withdrawal, provide general support, reassurance, and frequent monitoring. For most patients with mild to moderate withdrawal symptoms, this may occur in an outpatient setting that provides frequent clinical assessments and any necessary clinical treatment.
For moderate to severe abstinence, organize an appropriate setting based on the patient's signs and symptoms, past history, co-existing medical and psychiatric conditions, and social support network. Residential treatment and hospitalization may be required, particularly for patients experiencing delirium tremens.
Treat moderate to severe withdrawal with pharmacotherapy.
Restoring physiological homeostasis (e.g., glucose, thiamine, and fluids).
Reduce CNS irritability with benzodiazepines.
Administer a benzodiazepine orally, e.g., chlordiazepoxide (50 mg every 2-4 hours), diazepam (10-20 mg every 2-4 hours), oxazepam (60 mg every 2-4 hours) or lorazepam (1-4 mg every 2-4 hours), as needed based on withdrawal signs and symptoms.
Calculate the total number of benzodiazepine milligrams needed for the first 24 hours and use this value to determine the following daily doses.
Reduce benzodiazepines over the next 2-5 days. (Patients in severe withdrawal and those with a history of withdrawal-related symptoms may take up to 10 days for benzodiazepines to be completely disposed of.)
Use an anticonvulsant agent (in addition) to prevent withdrawal attacks. Evidence is emerging for the use of anticonvulsants as alternatives to benzodiazepines, particularly for patients with previous withdrawal crises or multiple medical alcohol detoxes and in outpatient detox settings.
Beta-blockers or clonidine can be used short-term in combination with benzodiazepines to reduce withdrawal symptoms; however, such use can complicate the choice of benzodiazepine dosage by masking withdrawal symptoms.
Use an additional antipsychotic agent for a short time for delirium or psychosis.
Observe if withdrawal symptoms recur and relapse when medications are tapered.
Observe for recurring signs and symptoms of a comorbid psychiatric disorder.
Evaluate Drug Treatment
The following pharmacotherapies for patients with alcohol dependence have effectiveness (efficacy) and well demonstrated moderate effectiveness (effectiveness), in particular as part of a broader treatment program.
Naltrexone can lessen some