managing-substance-use-disorders

# Managing Substance Use Disorders

Structures SUD assessment with ASAM criteria level-of-care placement, medications for addiction treatment (MAT) protocols, and recovery planning aligned with SAMHSA and ASAM standards.

## Why This Skill Exists

Substance use disorders affect over 46 million Americans and are the leading driver of overdose deaths (over 107,000 annually). Despite this, less than 10% of people with SUD receive any treatment. The American Society of Addiction Medicine (ASAM) Criteria (Fourth Edition) is the national standard for patient placement, continued stay, and transfer/discharge in addiction treatment. CMS, state Medicaid programs, and commercial payers require ASAM criteria-based assessments for authorization of SUD treatment services. The 21st Century Cures Act and the SUPPORT Act mandate integration of SUD treatment into behavioral health and primary care settings.

Failure to use standardized assessment tools, apply evidence-based placement criteria, or offer medications for addiction treatment (particularly buprenorphine and naltrexone for opioid use disorder) constitutes a deviation from standard of care. Malpractice exposure is significant in cases of inadequate withdrawal management, failure to screen for SUD in psychiatric patients, and failure to document clinical reasoning for level-of-care decisions.

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## Checkpoint A: Pre-Draft Intake (Mandatory)

1. What substances are involved? (alcohol, opioids, stimulants, cannabis, benzodiazepines, polysubstance) — default: assess all substances
2. What is the current use pattern? (active use, early withdrawal, protracted withdrawal, stable recovery with relapse, long-term recovery) — default: assess at intake
3. Is the patient in acute withdrawal requiring medical management? — default: assess CIWA-Ar or COWS immediately
4. What is the referral context? (emergency department, inpatient medical, inpatient psychiatric, outpatient, criminal justice, self-referral) — default: outpatient
5. Is there co-occurring psychiatric illness? (dual diagnosis) — default: screen with PHQ-9, GAD-7, PCL-5, C-SSRS
6. Is the patient pregnant? (affects medication selection and urgency of treatment) — default: assess
7. Has the patient been on MAT previously? (buprenorphine, methadone, naltrexone — doses, duration, response) — default: obtain history
8. What is the patient's current insurance and authorization status? — default: verify for ASAM level placement

### Documents to Request

- PDMP query results (prescription drug monitoring program)
- Urine drug screen (UDS) results — comprehensive panel including fentanyl
- Prior SUD treatment records and discharge summaries
- ASAM criteria assessments from prior treatment episodes
- Medical records (hepatic function, HIV/HCV status, cardiac history)
- Laboratory results: CBC, CMP, LFTs, hepatitis panel, HIV, TB, pregnancy test
- Criminal justice records if mandated treatment
- Prior MAT records with dosing history
- Collateral information from family, sponsors, probation officers

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## Step 1: Comprehensive Substance Use Assessment

### Screening Tools
- **AUDIT** (Alcohol Use Disorders Identification Test): Score 0-40; ≥8 hazardous use, ≥16 harmful use, ≥20 likely dependence
- **DAST-10** (Drug Abuse Screening Test): Score ≥3 suggests problematic use
- **NIDA Quick Screen:** Single question per substance category
- **CAGE-AID:** ≥2 positive responses suggests SUD

### Substance-Specific History (for each substance)
- Substance name, route of administration, amount/frequency, cost per day
- Age of first use, age of regular use, age of problematic use
- Longest period of sobriety and what supported it
- Previous withdrawal experiences (seizures, DTs, complications)
- Previous treatment episodes (detox, residential, IOP, outpatient, 12-step, MAT)
- Current pattern: last use (date, time, amount), use in past 30 days
- Consequences: medical, psychiatric, legal, occupational, interpersonal, financial
- History of overdose (number, substances involved, naloxone administration, hospitalization)

### DSM-5-TR Diagnostic Criteria
Document at least 2 of 11 criteria within a 12-month period for each substance:
1. Taken in larger amounts or longer than intended
2. Persistent desire or unsuccessful efforts to cut down
3. Great deal of time spent obtaining, using, or recovering
4. Craving or strong desire to use
5. Recurrent use resulting in failure to fulfill obligations
6. Continued use despite persistent social/interpersonal problems
7. Important activities given up or reduced
8. Recurrent use in physically hazardous situations
9. Continued use despite knowledge of physical/psychological problem
10. Tolerance (increased amounts needed or diminished effect)
11. Withdrawal (characteristic syndrome or substance used to avoid withdrawal)

Severity: 2-3 criteria = mild, 4-5 = moderate, 6+ = severe

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## Step 2: Withdrawal Assessment and Medical Stabilization

### Alcohol Withdrawal — CIWA-Ar (Clinical Institute Withdrawal Assessment for Alcohol, Revised)
- Score 0-67; assess every 4-8 hours initially
- <10: Mild withdrawal — supportive care, thiamine, folate, multivitamin
- 10-18: Moderate — symptom-triggered benzodiazepine protocol (chlordiazepoxide or lorazepam)
- >18: Severe — aggressive benzodiazepine dosing, consider ICU monitoring
- DT risk factors: prior DTs, prior withdrawal seizures, CIWA-Ar >15, concurrent medical illness, age >65

### Opioid Withdrawal — COWS (Clinical Opiate Withdrawal Scale)
- Score 0-48; assess before MAT induction
- 5-12: Mild withdrawal
- 13-24: Moderate (minimum score for buprenorphine induction with standard protocol)
- 25-36: Moderately severe
- ≥37: Severe
- Buprenorphine induction: Wait for COWS ≥8-12 (traditional) or use low-dose/micro-dosing protocol to avoid precipitated withdrawal

### Benzodiazepine Withdrawal
- Prolonged taper required (reduce 10-25% every 1-2 weeks)
- Seizure risk is significant — never discontinue abruptly
- Convert to equivalent long-acting benzodiazepine (diazepam or chlordiazepoxide) for taper
- Monitor with CIWA-B or clinical assessment

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## Step 3: ASAM Criteria Level-of-Care Determination

Apply the ASAM Criteria across six dimensions:

1. **Acute intoxication / withdrawal potential:** Current intoxication, withdrawal risk, need for medical monitoring
2. **Biomedical conditions:** Active medical problems affecting treatment or requiring monitoring
3. **Emotional, behavioral, or cognitive conditions:** Psychiatric comorbidity, cognitive impairment, emotional stability
4. **Readiness to change:** Motivation, engagement, stage of change (precontemplation, contemplation, preparation, action, maintenance)
5. **Relapse, continued use, or continued problem potential:** Relapse history, coping skills, triggers, recovery environment
6. **Recovery/living environment:** Housing stability, social support, recovery capital, environmental risks

### ASAM Levels of Care
- **0.5:** Early intervention
- **1.0:** Outpatient services (<9 hours/week)
- **2.1:** Intensive outpatient (IOP, 9-19 hours/week)
- **2.5:** Partial hospitalization (≥20 hours/week)
- **3.1:** Clinically managed low-intensity residential
- **3.3:** Clinically managed population-specific high-intensity residential
- **3.5:** Clinically managed high-intensity residential
- **3.7:** Medically monitored intensive inpatient
- **4.0:** Medically managed intensive inpatient

Document the rating for each dimension and how the composite profile determines the recommended level of care. Document when the patient's clinical presentation crosses dimensions at different levels and how the highest-acuity dimension drives placement.

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## Step 4: Medications for Addiction Treatment (MAT)

### Opioid Use Disorder
- **Buprenorphine (Suboxone/Sublocade):** First-line outpatient. Induction: 2-4mg SL, titrate to 16-24mg/day. X-waiver eliminated as of 2023; all DEA-licensed prescribers can prescribe.
- **Methadone:** OTP (opioid treatment program) setting only. Start 20-30mg/day, titrate by 5-10mg every 5-7 days. Target: 80-120mg/day.
- **Naltrexone (Vivitrol):** Extended-release IM monthly. Requires 7-14 days opioid-free. Effective for highly motivated patients.

### Alcohol Use Disorder
- **Naltrexone:** 50mg PO daily or 380mg IM monthly. Reduces heavy drinking days. Contraindicated with opioid use.
- **Acamprosate:** 666mg TID. Supports abstinence maintenance. Renally cleared, no hepatic metabolism.
- **Disulfiram:** 250mg daily. Aversion therapy — causes severe reaction with alcohol. Requires reliable adherence.
- **Gabapentin:** 900-1800mg/day in divided doses. Off-label but supported by evidence, particularly for insomnia and anxiety symptoms in early recovery.

### Tobacco Use Disorder
- **Varenicline:** 0.5mg daily x 3 days, 0.5mg BID x 4 days, then 1mg BID x 12 weeks
- **Bupropion SR:** 150mg daily x 3 days, then 150mg BID x 12 weeks
- **Nicotine replacement therapy:** Patch, gum, lozenge, inhaler, nasal spray (combination therapy recommended)

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## Step 5: Recovery Planning and Relapse Prevention

Develop a comprehensive recovery plan addressing:

- Continued MAT with monitoring schedule
- Psychotherapy: Motivational Enhancement Therapy (MET), CBT for relapse prevention, Contingency Management, Community Reinforcement Approach
- Mutual support groups: AA/NA, SMART Recovery, Refuge Recovery, LifeRing
- Peer recovery support services
- Housing (sober living, recovery housing)
- Vocational/educational support
- Legal assistance if applicable
- Naloxone distribution and overdose prevention education (for all opioid-involved patients and their families)
- Infectious disease screening and treatment (HCV, HIV, TB)
- Continuing care plan with step-down schedule

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## Checkpoint B: Post-Draft Alignment (Mandatory)

1. Are all substances assessed with DSM-5-TR severity classification?
2. Is the withdrawal assessment documented with validated tool scores (CIWA-Ar, COWS)?
3. Are all six ASAM dimensions rated with supporting clinical data?
4. Is MAT offered for opioid and alcohol use disorders with documentation of the discussion?
5. Does the recovery plan include relapse prevention, peer support, and continuing care?

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## Quality Audit

- [ ] Comprehensive substance use history obtained for all substances
- [ ] DSM-5-TR criteria documented with severity specifier for each SUD
- [ ] PDMP queried and documented
- [ ] Urine drug screen obtained and interpreted
- [ ] Withdrawal assessment completed with validated tool (CIWA-Ar or COWS)
- [ ] All six ASAM dimensions assessed and rated
- [ ] ASAM level-of-care recommendation documented with rationale
- [ ] MAT discussed and offered (or documented reason for not offering — patient preference, contraindication)
- [ ] Co-occurring psychiatric disorders screened and addressed
- [ ] Naloxone prescribed or provided for opioid-involved patients
- [ ] Infectious disease screening ordered (HCV, HIV, TB)
- [ ] Pregnancy test for women of childbearing potential
- [ ] Safety assessment (overdose risk, suicidal ideation, DUI/impaired driving)
- [ ] Recovery plan includes mutual support, housing, and vocational components

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## Guidelines

1. Always offer MAT for opioid use disorder — withholding buprenorphine or methadone when clinically indicated is a deviation from standard of care per ASAM, APA, and WHO guidelines.
2. Never discharge a patient from opioid agonist therapy for positive urine drug screens alone — continued substance use is a symptom of the disease, not a treatment contract violation.
3. Screen every psychiatric patient for substance use — co-occurrence rates exceed 50% for mood disorders, anxiety disorders, and psychotic disorders.
4. Document ASAM dimension ratings with clinical specificity, not just numeric scores — payers require narrative justification for level-of-care placement.
5. For pregnant patients with opioid use disorder, buprenorphine or methadone is the standard of care — medically supervised withdrawal during pregnancy increases relapse risk and fetal distress.
6. Always provide naloxone (Narcan) prescriptions and overdose prevention education for patients with opioid use disorder and their families.
7. Benzodiazepine withdrawal requires a gradual taper — abrupt discontinuation risks seizures and death. Do not apply opioid withdrawal protocols to benzodiazepine dependence.