7.5 Substance Use Disorder

What Is Substance Use Disorder?

A substance use disorder (SUD) is the disorder that occurs when the repeated use of alcohol and/or other drugs significantly impairs a person’s health and results in an inability for them to meet major responsibilities at work, school, or home (Substance Abuse and Mental Health Services Administration, 2022). SUDs can occur with various drugs, including alcohol, cannabis, hallucinogens, inhalants, opioids, sedatives, hypnotics, anxiolytics, stimulants, and tobacco. SUD can be classified as mild, moderate, or severe.

The most severe form of SUD, addiction, happens when there is continued use of the substance despite negative consequences. It is important to note that addiction is a medical disease and not a description of someone’s character. As such, persons with SUDs should not be referred to as abusers, addicts, alcoholics, or medication seekers, because these terms are negative and stigmatizing. Stigma associated with SUDs can be isolating and demoralizing, and it can hinder persons from seeking treatment. To reduce the stigma, instead focus on the medical diagnosis and specific SUD at hand.

Although SUD is defined as a chronic, treatable disease, recovering from an SUD can be difficult. Most persons with an SUD cannot simply stop taking the problematic drug, because changes to their usage can result in devastating withdrawal symptoms. In some cases, a different drug can be substituted to help wean the patient off the problematic one; these include methadone, buprenorphine, and naltrexone, all of which are used to treat patients addicted to stronger opioids. Patients may also participate in programs, such as twelve-step facilitation therapy, outpatient counseling to understand addiction and triggers, or inpatient rehabilitation at a full-time facility that provides a supportive environment for recovery without distractions or temptations. Providers use evidence-based guidelines to select a treatment plan that best meets the clinical needs of the patient.

Use of pain medications, particularly opioids, has the potential to become a SUD. One SUD, opioid use disorder (OUD), is caused by a problematic pattern of opioid use. Because opioids activate the release of endorphins in the brain, resulting in feelings of pleasure, they are highly addictive. Unlike other causes of SUD, OUD is typically associated with a higher risk of physical dependence, which is when the person feels like they cannot function without the use of the substance. Dependence is not to be confused with tolerance, which is when the body requires more of a drug over time to achieve the same level of pain relief. If someone who is dependent on a drug reduces their dosage or stops taking it altogether, withdrawal symptoms will occur. Symptoms of withdrawal include sweating, confusion, enlarged pupils, loss of appetite, diarrhea, vomiting, cramps, tremors, yawning, and flu-like symptoms.

SUD has become a grave concern within the United States. According to the CDC (2023), approximately 1.6 million people in the United States suffer from OUD. Often, OUD results in opioid overdose. The frequency of drug overdose deaths increased by 30 percent from 2019 to 2020, with nearly 75 percent of drug overdose deaths involving an opioid (CDC, 2022a). It is estimated that 187 people die every day from opioid overdoses (CDC, 2022a). Considering the frequency of opioid deaths, the U.S. government declared the opioid crisis to be an epidemic and public health emergency in 2017 (Centers for Medicare & Medicaid Services, 2022). The severity of the opioid epidemic is illustrated by the data captured in Figure 7.8.

Figure 7.8 These data, from 2019 to 2020, show the number of people in the United States affected in different ways by the opioid epidemic. (credit: “Opioids by the Numbers” by U.S. Department of Health and Human Services/U.S. Department of Health and Human Services, Public Domain)

Preventing SUD and Addiction

Prevention is critical for reducing the prevalence of SUDs and addiction. The most effective way to prevent OUD is to reduce the frequency of prescribing opioids; if opioids are not prescribed, then they are much less likely to cause addiction. Education and awareness around the harms of substance use is also critical to gain the support of friends, families, and communities. People also need to be educated about ways to safely store and dispose of opioids.

The 2022 CDC Clinical Practice Guideline for Prescribing Opioids for Pain recommends providers review a patient’s history of controlled substance prescriptions prior to prescribing opioids (CDC, 2022b). To do so, the provider can view the patient’s history of prescribed opioid use via a prescription drug monitoring program (PDMP), an electronic database that tracks controlled substance prescriptions. PDMPs also inform providers of any other medications that a patient is taking that may place the patient at risk for overdose from an opioid. PDMPs can be very beneficial when the patient is transitioning to a new provider or the patient’s medication history is unavailable. The PDMP should be checked prior to prescribing opioids and at least every three months when continuing opioid therapy.

Managing Pain in Patients with SUD

Managing pain in patients with SUD can be tricky. All patients, regardless of whether they have an SUD, have the right to be treated with respect and to have their pain managed adequately. Each condition, both pain and SUD, requires a multifactorial, patient-centered approach that may involve both pharmacological and nonpharmacological interventions. The SUD and the cause of the pain should be treated independently.

For patients with an OUD, maximize nonpharmacological therapies and nonopioid medications prior to treating the pain with opioids. Examples of nonpharmacological therapies that may be effective include therapeutic exercise, physical therapy, and CBT, as well as complementary and alternative medicines. Examples of nonopioid medications that may be used include NSAIDs, topical analgesics, and adjuvant medications, such as serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants, and antipsychotics.

If pain levels necessitate opioid use, then do not withhold opioids from a patient with an OUD. Just as for any patient, it is important to establish shared goals and known risks, form a treatment agreement, and ensure close monitoring with routine follow-up visits to reassess pain. Opioid doses should be titrated by starting with a low dose and increasing the dose slowly, as needed. Treatment agreements outline the course of action for the treatment, as mutually agreed upon by the patient and the provider. As always, the patient should be an active participant in the collaborative approach to determine a treatment plan that meets the needs of the individual. A sample treatment agreement is shown in Figure 7.9.

Figure 7.9 A pain medication treatment agreement establishes clear guidelines and expectations for the safe and responsible use of prescription pain medications. (credit: “ Rx Pain Medications KNOW THE OPTIONS • GET THE FACTS” by Substance Abuse and Mental Health Services Administration/helpandhopewv.org, Public Domain)