Understanding Substance Use Disorder: A helpful guide for health professionals

Substance Use Disorder (SUD) is a health condition involving a patient's uncontrolled use of a substance, such as alcohol, drugs, and medications, that affects an individual's daily life by impairing their physical and mental health, along with social functioning. There are about 20 million people in the US (approximately 6% of the total population) living with substance use disorder. Despite how common it is, people with substance use disorder have a lot of stigma, discrimination, and criminalization directed at them. It's important to remember that addiction isn't a character defect or weakness but a chronic disease. The great news is that SUD is a treatable condition. 

As a health professional, it's crucial you're able to recognize the symptoms of SUD, understand how to offer support, and know how to get patients the treatment they need, whether it's in your office or through a referral to specialized care. 

Understanding Substance Use Disorder  

Several factors lead to the development of substance use disorder; let's take a look at the causes and risk factors. Causes fall into two categories: environment (nurture) and genetics (nature). Environmental factors include patient peer groups, who may encourage them to try a substance, as well as family members' beliefs and attitudes towards substance use. Genetics also play a role in substance use disorder and the development of addiction. Addiction is the compulsive use of a substance in search of the pleasurable effects despite the negative consequences. Multiple genes may either accelerate or delay the development of addiction to a substance, such as the genes involved with drug metabolism and the information transfer between neurons.  

Risk factors associated with substance use disorder include: 

• Use of a highly addictive drug 
• Family history of addiction  
• Peer pressure, especially in younger individuals 
• Lack of a family bond or family involvement in an individual's life 
• Living with a mental health disorder and using substances as a coping mechanism  
• Use of substances at an early age can affect the brain and predispose an individual to addiction 

Now that we've discussed the different factors that can contribute to the development of substance use disorder let's look at the types of substances that are commonly used: 

• Tobacco 
• Alcohol 
• Cannabis 
• Opioids (Either prescription or illegal use) 
• Hallucinogens (Phencyclidine or PCP, LSD) 
• Inhalants (glue, nitrous oxide) 
• Sedatives (benzodiazepines, barbiturates) 
• Anti-anxiety medications (anxiolytics) 
• Stimulants (cocaine, amphetamine, methylphenidate) 

As a health professional, you probably recognize some of these substances as medications. Being mindful that patients may develop a dependence or an inability to feel stable without using the substance, or even an addiction, is essential because it helps you remain vigilant for signs of substance abuse to intervene early and get patients treatment swiftly. 

Substance use disorder can have many detrimental effects on a patient's physical and mental health. Though the effects tend to vary depending on which substance, the consequences to physical health are: 

• Increased risk for infection  
• Nausea and abdominal pain 
• Stroke  
• Seizure 
• Brain damage 
• Lung disease 
• Heart conditions 
• Memory loss 
• Liver damage 
• Liver failure 
• HIV 

The potential impact on behavioral health include: 

• Aggression 
• Depression 
• Hallucinations 
• Paranoia 
• Impulsivity 
• Loss of self-control 
• Suicidal thoughts 
• Impaired judgment  

The potential long-term effects of substance use disorder are very concerning, making it even more important for clinicians to have a better understanding of how substance use impacts the brain. Generally speaking, these substances affect the reward area of the brain, causing the release of a large amount of dopamine, leading to feelings of pleasure, euphoria, or deep calm. Repeated substance use can change an individual's brain chemistry and lead to tolerance. When a person develops a tolerance to a substance, the receptors in their brain become less sensitive to the substance, and they'll need more of it to feel similar effects of the dopamine release. As time progresses, this can lead to dependency and, eventually, addiction.  

Recognizing Substance Use Disorder in Your Patients

The signs and symptoms of each substance type vary depending on the drug. However, the following symptoms and behaviors can help you identify a substance use disorder: 

• A need to use the substance daily 
• Very strong urges to use substance 
• Development of tolerance 
• Need more of the substance to get the desired effect  
• Spending money on substances, even if it causes financial issues 
• Withdrawal from social or recreational activities 
• Disinterest in school or work 
• Diminished school or work performance 
• Neglecting physical appearance 
• Requests for money that seem out of the ordinary 
• Stealing items or money from family members or friends 
• Low energy or lack of motivation 
• Continuous use of substances despite the detrimental effects 
• Being involved in risky activities that can impair decision-making 

Next, let's discuss the screening and assessment techniques available to identify substance use disorder. Screening, Brief Intervention, and Referral to Treatment (SBIRT) is a reliable way to screen individuals for substance abuse. The universal screening included in SBIRT steers the conversation regarding substance use in a way that motivates patients to set goals to improve their health (reduce harm), think about their values, address their substance use, and provide referrals to specialized support services for substance use treatment.  

There are pre-screening tools with minimal questions to identify problematic substance use. If additional information is needed, patients can proceed to a full screening that can be self-administered or done through a verbal interview. Different screening tools exist for adolescents, adults, older adults, and pregnant women. More information about each of the screening tools can be found here. 

Urine, breathalyzers, saliva, and hair follicle tests are also screening tools to help identify the type of substance a person has ingested to aid health professionals in forming an individualized treatment plan. 

Treatment and Interventions  

The first step to recovery for someone with substance use disorder is to admit that they have a problem. Detoxification or withdrawal therapy is one of the most important aspects of recovery. There can be a gradual reduction of the use of the substance or a temporary substitution with medications such as methadone, buprenorphine, or a combination of naloxone and buprenorphine to prevent severe withdrawal symptoms. Inpatient detoxification is often more effective than outpatient detoxification due to the continuous access to care during this difficult process. Patients can enter an inpatient rehabilitation program to help monitor withdrawal symptoms and provide strategies to avoid abusing substances again. 

Another type of SUD treatment is a form of psychotherapy called cognitive behavioral therapy (CBT). Individuals learn ways to deal with cravings to prevent relapse, how to work through a relapse if it occurs, and how to deal with other mental health conditions they may need to treat.  

Maintaining sobriety can be tough. Involvement in support groups allows individuals to voice their struggles, celebrate victories, find resources, and build community. For many people in the process of recovery, a combination of medication and psychotherapy, whether it be group or individual, is the most effective.  

Early intervention services aim to decrease the harm caused by substance abuse, lessen risky behaviors, prevent injury, improve health, and prevent the progression of substance misuse due to substance use disorder. Early intervention services often serve as the middle ground between prevention and treatment. When individuals with serious substance use issues are identified through early intervention services, they can be referred to treatment. 

As a health professional, having nonjudgemental conversations regarding substance misuse can motivate patients to acknowledge their behavior and decrease their substance use. When risky behaviors are identified during early intervention, providing patients with counseling that's both educational and specific to their issues can also be effective in helping patients take the next step toward recovery.  

Support for Patients with Substance Use Disorder 

A strong support system is vital for patients with substance use disorder. Both family and social support improve treatment adherence and help patients change their behaviors for better outcomes. Family therapy is a valuable way to involve a patient's family in their recovery process and improve communication. It provides everyone involved with a better understanding of what to expect during treatment, reduces conflict, and helps loved ones build strategies to support their loved ones and help prevent relapse. Community-based initiatives also help support patients with substance use disorder, so involving the community in prevention and treatment is imperative. For example, training community and family members on how to administer can reduce overdose incidents and save lives. 

Relapses Are Common and Should Be Anticipated 

It's often said that relapse is a part of the recovery process for patients with substance use disorder. While that can be discouraging to hear, there are four strategies to prevent relapse: therapy, medications, monitoring, and peer support. 

As previously discussed, CBT is effective in the treatment of substance use disorder because patients can identify maladaptive behaviors and thinking patterns while they learn new skills and behaviors that support their recovery. Unfortunately, some patients relapse due to the discomfort from withdrawal symptoms. Depending on which substance patients use, there are different medications to support the recovery process that mitigate uncomfortable withdrawal symptoms and reduce cravings.

Monitoring patients through drug testing is another key strategy in relapse prevention. Urine drug screens are the most common method because they can detect a wide array of substances. Hair follicle drug tests, saliva tests, and breathalyzers are also testing options, but they're limited in what substances they screen for.  

The final relapse prevention strategy is peer support. Peer support programs include self-help, support groups such as 12-step programs, and recovery coaches. Peer support groups emphasize attending meetings, following a structured program, and receiving guidance from a mentor. Recovery coaches are individuals who've personally dealt with substance abuse and addiction themselves, have maintained sobriety for at least a year, and have completed a certification course. While there's no one-size-fits-all approach to relapse prevention, the goal is to provide patients with effective tools and support so they can stay sober. 

Collaborative care is essential for patients with SUD, making multidisciplinary teams key in helping patients recover and prevent relapse. Primary care providers are often the first health professionals to engage with SUD patients, which makes it vital for providers to be aware of the signs and symptoms to best counsel patients, monitor treatment, and look for signs of relapse. It's also crucial for pharmacists to report any concerns to the medical team regarding the type of medications prescribed, dosing, or interactions. 

Resources for Health Professionals 

If you identify a patient who needs a referral to an SUD specialist, it's important to use strategies to motivate patients to accept the referral and follow up. Providers use the SBIRT screening tool to refer patients to a specialist for a clinical assessment and an individualized treatment plan. Before making a referral, discuss the effectiveness of treatment, consider the patient's financial situation and ability to pay for treatment, and work to reduce stigma. You can also share resources for community support groups and networks. Take the time to stay up-to-date regarding new research about substance use disorder and how to help patients. Also, consider exploring continuing education opportunities to develop your knowledge of the condition. 

Developing a Compassionate, Collaborative Approach to Recovery

Substance use disorder is a complex condition, but thankfully, it's a treatable one. A compassionate approach to care fosters open discussions, while evidence-based treatments and developing a solid support system enhance recovery. As a member of a multidisciplinary team, we encourage you to take some time to learn about causes, risk factors, and impacts at both the primary care and community levels. By addressing stigma and promoting collaborative care, you can improve the lives of those affected by SUD while contributing to a more humane society.

References 

• https://www.psychiatry.org/patients-families/addiction-substance-use-disorders  
• https://health.gov/healthypeople/objectives-and-data/browse-objectives/addiction  
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10168177/  
• https://www.cdc.gov/overdose-prevention/treatment/index.html  
• https://www.mayoclinic.org/diseases-conditions/drug-addiction/symptoms-causes/syc-20365112  
• https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10168177/  
• https://www.cdc.gov/overdose-prevention/treatment/index.html  
• https://www.gatewayfoundation.org/about-gateway-foundation/faqs/effects-of-drug-abuse/  
• https://oasas.ny.gov/sbirt  
• https://www.ncbi.nlm.nih.gov/books/NBK551500/ 
• https://www.nami.org/about-mental-illness/common-with-mental-illness/substance-use-disorders/  
• https://medlineplus.gov/ency/article/001522.htm  
• https://www.psychiatry.org/patients-families/addiction-substance-use-disorders/what-is-a-substance-use-disorder  
• https://www.ncbi.nlm.nih.gov/books/NBK424859  
• https://www.niaaa.nih.gov/health-professionals-communities/core-resource-on-alcohol/make-referrals-connect-patients-alcohol-treatment-meets-their-needs#pub-toc6  
• https://nida.nih.gov/nidamed-medical-health-professionals/health-professions-education/cmece-activities