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CPG Substance Use Disorder Clinical Practice Guideline Subject: Substance Use Disorder Policy Number: 474 Effective Date: November 2005 Updated: February 2021 This Clinical Practice Guideline is subject to the terms in the IMPORTANT NOTICE at the end of this document _________________________________________________________________ OVERVIEW The National Survey on Drug Use and Health (NSDUH) for 2016 1 found that among Americans age 12 and over 51.3 million were current cigarette smokers, 65.3 million reported binge alcohol use (4+ drinks for women and 5+ drinks for men on the same occasion) and 16.3 million reported heavy alcohol use (binge drinking on 5 or more days in the past 30 days) in the past month, and 28.6 million used an illicit drug in the past 30 days. In 2016, an estimated 11.8 million people misused opioids in the past year, including 11.5 million pain reliever misusers and 948,000 heroin users. According to data from the NIAAA 31, more than 10% of children in the United States live with a parent with alcohol problems. About 88,000 people (approximately 62,000 men and 26,000 women) die from alcohol-related causes annually, making alcohol the third leading preventable cause of death in the United States. The first is tobacco, and the second is poor diet and physical inactivity. In 2014, alcohol-impaired driving fatalities accounted for 9,967 deaths (31 percent of overall driving fatalities). In 2010, alcohol misuse cost the United States $249 billion. Three- quarters of the total cost of alcohol misuse is related to binge drinking. A 2011 estimate of Substance Use Disorders Costs to the American Economy is over $700 billion. 7 All health care professionals, therefore, are likely to come in contact with individuals who abuse or are dependent upon substances and are in a unique position to evaluate for these conditions and motivate patients to seek appropriate treatment interventions. Despite the growing diversity of treatment options, however, only 14.6% of people with alcohol abuse or dependence receive treatment according to the data from the NIAAA’s 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions 27. In 2009, an estimated 7 million Americans were abusing prescription drugs, more than the number abusing cocaine, heroin, hallucinogens and inhalants combined. Emergency-room visits related to non-medical use of opioids rose 111% between 2004 and 2008. Between 1998 and 2008 the rate of opioid prescription misuse is estimated to have increased 400%. According to the National Institute of Drug Abuse (NIDA) young adults (age 18-25) are the biggest abusers of prescription opiate pain relievers, stimulants and anxiolytics. In 2010 almost 3000 young adults died (8 persons per day) as a result of prescription drug overdoses (mostly opiates) and that is more than overdoses with any other drug, including heroin and cocaine combined. Many more required emergency care (for every death due to Rx drug overdose, there were 17 treatment admissions and 66 emergency room visits). In 1 the United States, drug overdose is now the leading cause of accidental death, as well as the leading cause of death in those under 50. According to CDC, drug-poisoning deaths involving opioids have quadrupled from 1999 (1.4/ 100000) to 2011 (5.4/100000). Benzodiazepines were involved in 31% of such poisonings in 2011 (a 13% increase from 1999). DIAGNOSTIC CONSIDERATIONS Substance Use Disorder Substance use disorder is defined as a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues using the substance despite significant substance-related problems. These maladaptive pattern of behaviors leading at the minimum to clinically significant impairment or distress, as manifested by at least two of the following: IMPAIRED CONTROL larger amounts taken or over a longer period than was originally intended persistent desire to cut down or regulate use and may report multiple unsuccessful efforts to decrease or discontinue use great deal of time to obtain, use or recovering from its effects craving: defined as a manifestation by an intense desire or urge for the drug that may occur at any time but is more likely when in an environment where the drug previously was obtained or used SOCIAL IMPAIRMENT Recurrent substance abuse resulting in a failure to fulfill major role obligations at work, school, or home Continued substance use despite persistent or recurrent social or interpersonal problems related to the substance. Important social, occupational, or recreational activities may be given up or reduced because of substance use RISKY USE Recurrent substance use in situations in which it is physically hazardous Failure to abstain from substances despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance 2 PHARMACOLOGICAL CRITERIA Tolerance – either requiring a markedly increased dose of the substance or the chemical group the substance belongs to, for achievement of desired effect or a markedly reduced effect when usual dose is used Withdrawal – a symptom cluster that occurs characteristic for that substance or the chemical group the substance belongs to, potentially requiring a similar chemical substance to be taken to relieve or avoid the withdrawal SEVERITY and SPECIFIERS *Based on a number of above symptom criteria, use as a general estimate to quantify severity: MILD- presence of two or three symptoms MODERATE- four or five symptoms SEVERE- six or more symptoms Substance-Induced Disorders includes Intoxication, Withdrawal and Other Substance/MEDICATION Induced Mental Disorders and medical complications. Substance Intoxication: Development of a reversible substance specific syndrome due to the recent use of a substance followed by: Psychological changes attributable to physiological effects of the substance on the Central Nervous System (CNS) such as disturbance in perception, wakefulness, attention, thinking, judgment, psychomotor activity and/ or interpersonal relatedness. Changes occur during or shortly after the use of the substance, and could not be readily explained by another mental disorder nor attributable to another medical condition. NOTE: This does not apply to tobacco. Withdrawal: Physiological and psychological effects of cessation or reduction in heavier and prolonged use of a specific substance. Clinically significant distress that may be associate with impairment in social, occupational and/ or other areas of functioning. Symptoms could not be readily explained by another mental disorder nor attributable to another medical condition. *Note: Tolerance and Withdrawal criteria do NOT count if it applies only to medication (opioids, sedatives, stimulants) taken under appropriate medical supervision Substance/Medication-Induced Mental Disorder: Potentially severe, usually temporary, but sometimes persisting CNS syndrome developing in the context of the effects of substances of abuse, medications or several toxins. All substance/medication-induced mental disorders may be induced by the 10 classes of substances use disorders or by variety of medications used in medical treatment. Common characteristics and features are described below: Clinically significant symptomatic presentation of a relevant mental disorder. 3 Evidence from the history, physical examination, or laboratory findings of both of the following; Disorder developed during or within 1 month of substance intoxication or withdrawal or taking a medication; AND Involved substance/medication is capable of producing a mental disorder Disorder is not better explained by an independent mental disorder which includes the following: The disorder preceded the onset or severe intoxication or withdrawal or exposure to the medication; OR The full mental disorder persisted for a substantial period of time (e.g. at least 1 month) after the cessation of acute withdrawal or severe intoxication or taking the medication or hallucinogen persisting perception disorder, which persist beyond the cessation of acute intoxication or withdrawal. Delirium is not the cause Disorder causes clinically significant distress or impairment in social, occupational and/or other areas of functioning. Assessment Given the statistical data cited above, it is clear that patients of all ages should be screened for substance use. When assessing for substance use disorders (SUD), it is important to ask very specific questions. Patients will often downplay their use of substances. Obtaining information from additional sources (family, employer, medical) can be helpful. The following are factors that should be assessed to determine the severity of SUD and the appropriate level of care. (Nicotine dependence as a primary substance use disorder will be considered elsewhere.) Include the Primary substances of choice and method of administration following in the Onset and history of use assessment: All current substances used, including prescriptions, over-the- counter medications and supplements, and substances obtained from illicit sources or over the Internet Level and pattern of current use History of attempts to stop or control use Psychosocial assessment, including current support systems Medical Examination to rule out comorbid medical conditions, including screening of blood, breath or urine for substances used Psychiatric Evaluation to rule out comorbid psychiatric conditions and potential consequences of drug use on cognition Evaluate readiness for
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