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Surgeon General’s Report Summary – Chapter 4

Surgeon General’s Report Summary – Chapter 4
Surgeon General’s Report Summary – Chapter 4

Well-supported scientific evidence shows that substance use disorders can be effectively treated, with recurrence rates no higher than those for other chronic illnesses such as diabetes, asthma, and hypertension. With comprehensive continuing care, recovery is now an achievable outcome. – Key Findings, Pg. 4-2

Overview

As stated in chapter 4 of this Report, changes are being made in the prevention, diagnoses, and treatment of Substance Use Disorders. It has been found that, while treatment for severe SUD’s should be handled by specialized treatment facilities, those with mild to moderate substance use problems or disorders can receive adequate treatment in a general health care setting.

While efforts are being made to provide screening for alcohol and substance use disorders in the general health care settings, this transition has been partially delayed by lack of training, resources, and staff.

The terms Substance Use Disorder Treatment and Continuum of Care are used through this chapter to describe the diverse types of treatment available.

Substance Use Disorder Treatment: A service or set of services that may include medication, counseling, and other supportive services designed to enable an individual to reduce or eliminate alcohol and/or other drug use, address associated physical or mental health problems, and restore the patient to maximum functional ability. Pg. 4-3, Key Terms side bar

Continuum of Care. An integrated system of care that guides and tracks a person over time through a comprehensive array of health services appropriate to the individual’s need. A continuum of care may include prevention, early intervention, treatment, continuing care, and recovery support. Pg. 4-3, Key Terms side bar

Recommended Populations Who Should Receive Early Intervention

As this report suggests, early intervention has proven useful in deterring substance use problems from becoming Substance Use Disorders. While interventions can be helpful to everyone, certain groups are at higher risk, and therefore would benefit more, from early intervention strategies.

Those groups are as follows:

  • Adolescents and adults who are at risk of, or are showing signs of substance misuse or mild substance use disorder
  • People who binge drink (I.E. – Men who have consumed at least 5 drinks, and women who have consumed at least 4 drinks in one sitting, at least once, in the past 30 days
  • People who drink or use substances while driving
  • Women who drink or use substances while pregnant
  • Pg. 4-5

After screening, and early intervention measures in primary care settings, follow-up efforts should be addressed with individuals showing signs of risk for, or evidence of, a substance use disorder. This follow-up effort should include brief advice or counseling offered in a non-judgmental way; emphasis on the importance of substance use reduction and the individual’s capacity for accomplishing the goal; and, later, evaluating whether the screening and intervention has proven effective or not. At this point, the necessity of treatment can be discussed if screening and intervention has proven un-effective.

Populations Who Need Treatment, But Aren’t Receiving It

As discussed in Chapter 1, many people who meet the criteria for a Alcohol Use Disorder or Substance Use Disorder do not receive treatment. According to a survey by National Survey of Drug Use and Health (NSDUH) in 2015, only around 2.2 million people with a SUD, or 1 in 10 individuals, received any type of treatment in the year before the survey was administered. Pg. 4-8

Of the survey participants, over 7 million women, and more than 1 million adolescents aged 12 to 17 needed treatment, but did not receive it. Thirteen million participants were non-Hispanic or non-Latino Whites, 3 million were Hispanics or Latinos, and 3 million were non-Hispanic Blacks or African Americans who did not receive treatment. Pg. 4-8

Alcohol was shown to be the most prevalent substance reported, followed by misuse of prescription pain relievers, methamphetamines, marijuana, and cocaine. Roughly 1 in 10 individuals reported use of more than one substance.

Also, among those individuals with a SUD, over 8 million or 40 percent stated a mental disorder diagnosis in the year before the survey was administered. Only 6.8 percent received treatment for both conditions, and 52 percent did not receive treatment at all.

Many individuals with substance use disorders also have related physical health problems. Substance use can contribute to medical issues, such as an increased risk of liver, lung, or cardiovascular disease, as well as infectious diseases such as Hepatitis B or C, and HIV/AIDS, and can worsen these health outcomes. Pg. 4-9

Reasons For Not Seeking Treatment

There are varying reasons why people do not seek substance abuse treatment. Some are unmindful that they need treatment. Some have never been told they have a SUD. And, some do not think they have a problem. This Report stresses the importance of screening for substance use disorders in the general health care setting because of the reasons stated above.

For those who think they need treatment for a SUD, many do not seek this treatment. The most common reasons for this are:

  • They are not ready to stop using. Due to substance-induced changes in the brain (as discussed in Chapter 2), many individuals underestimate the severity of their problem, over-estimate their ability to control it, or both
  • No health care coverage/ couldn’t afford it
  • Treatment may have negative effect on job, stigma in neighborhood/ community
  • Do not know where to go to receive treatment, or desired type of treatment isn’t available
  • No transportation, proximity to programs is too great, inconvenient hours
  • Pg. 4-9

Other barriers to receiving treatment are availability of insurance coverage, cost of that coverage, and what said coverage does or does not cover. This Report states that while increasing the number of individuals with insurance can help, it ultimately depends on the insurance companies as to what will be covered, and what will not. Coverage such as types or components of SUD treatments, specifically medications. These barriers to treatment are compounded more when treatment services are difficult to reach because of proximity to said services, and expenses incurred through time and travel.

Common Types of Treatment Settings

Medically Monitored and Managed Inpatient Care

This type of care is delivered while the patient is in the hospital. Individuals who would benefit from this type of treatment are those who:

  • Need assistance with alcohol or substance withdrawal
  • Need care that is delivered by a doctor or nursing staff
  • Those who have been diagnosed with a co-occurring mental disorder
  • Those who are in poor health

Residential services

This type of treatment is delivered in a specialty housing setting, specifically designed for those in recovery. Individuals who would benefit from this type of treatment are those who:

  • Are bodily and mentally able to take care of themselves
  • Do not have access to housing that facilitates recovery
  • Have a history of repeated use after receiving treatment
  • Have an illness that coincides with a substance use disorder

Partial Hospitalization and Intensive Outpatient Services

Partial hospitalization and intensive outpatient services range from counseling and education to clinically intensive programming. Partial hospitalization programs are used as a step-down treatment option after completing residential treatment and are usually available 6 to 8 hours a day during the work week. These services are considered to be approximately as intensive but less restrictive than residential programs and are appropriate for patients living in an environment that supports recovery but who need structure to avoid relapse. Pg. 4-18

Outpatient services

This type of treatment provides group and individual therapy, and medications when needed. Offered during the day or evening hours. Individuals who would benefit from this type of treatment are those who:

  • Have a mild to moderate substance use disorder
  • Have completed more intensive treatment programs
  • Have co-occurring mental health conditions

Medication-Assisted Treatment (MAT)

The FDA has approved five medications to treat alcohol and opioid use disorders. To date, there are no approved medications to treat marijuana, cocaine, or amphetamine use disorders.

As with all medications, the medications approved to treat alcohol and opioid use disorders have side-affects. Specifically, methadone and buprenorphine have the likelihood to be misused, and have potential for overdose. Overdose potential is greater with methadone than with buprenorphine. Because of these potential side-affects, only professionally trained health care individuals should choose the necessity of medication, how it is provided considering other services, and how medication should be withdrawn or stopped.

Medication Assisted Treatment (MAT) refers to the combination of behavioral interventions and medication to treat SUD’s. MAT has proven to be greatly effective in treating alcohol and opioid use disorders. Studies have shown reductions in illicit drug use and overdose deaths, improved treatment maintenance, and HIV transmission reduction using MAT.

The benefits from using some medications are withdrawal management, reduction of craving, lessened withdrawal symptoms, and maintenance of recovery. When using these medications, a patient can live contentedly without alcohol or illicit opioids which allows brain circuits to be steadily restored to balance after long-term substance use.

Prescribed in this fashion, medications for substance use disorders are in some ways like insulin for patients with diabetes. Insulin reduces symptoms by normalizing glucose metabolism, but it is part of a broader disease control strategy that also employs diet change, education on healthy living, and self-monitoring. Whether treating diabetes or a substance use disorder, medications are best employed as part of a broader treatment plan involving behavioral health therapies and RSS, as well as regular monitoring. Pg. 4-21

Multiple barriers prevent implementation of MAT however. Barriers such as public, medical providers, and individual attitudes and beliefs about MAT, lack of organization to provide medications, lack of training and development for staff, legislation, policies, and regulations which prevent implementation.

MAT for Opioid Use Disorders

Medication-assisted treatment for opioid use disorders has proven effective in patients who continued treatment for 3 or more years. Relapse rates have been shown to be higher in patients who receive MAT for less than 3 years, and no improved outcome when received for less than 90 days.

Currently, there are three medications which have been approved to treat opioid use disorders: methadone, buprenorphine, and naltrexone.

Methadone

Methadone is used to treat withdrawal symptoms from heroin and other opioids. It is an opioid agonist, which means that it is A chemical substance that binds to and activates certain receptors on cells, causing a biological response. Pg. 4-22, Key Terms side bar

Methadone has been studied through research for over 40 years, and has been shown to be an effective treatment option. It can also be used as an alternative to treat patients with chronic or severe pain. While any licensed physician may prescribe methadone for pain treatment, it may only be prescribed for use in the treatment of addiction through a licensed methadone treatment program.

Studies show that using methadone over a long-term period for treatment of opioid use disorders shows greater results than using it for a short-term period while managing withdrawals. It also shows greater results for individuals, including pregnant women and their infants, who have opioid use disorders. Studies have shown reduced deaths, criminal behavior which comes with opioid drug seeking, and HIV risk behaviors. Pg. 4-22

While some critics view maintenance treatments as “substituting one substance for another”, research has shown otherwise. When compared to behavioral treatments only, MAT has shown increased treatment results.

The initial dosing schedule carried out in a Opioid Treatment Program (OTP), under observation, is a period of orientation, followed by a dose of 20 to 30 mg. Thereafter, dosage is gradually increased to 80 mg or more per day until craving and misuse are greatly reduced. After this initial period of stabilization, if the individual shows positive results, they may be given a supply to take home and administer on their own.

Buprenorphine

Buprenorphine is available as a tablet or film which dissolves on or under the tongue. An implantable formula became available in May of 2016 as well. It has shown to be effective in reducing illegal opioid use.

While buprenorphine is a partial opioid agonist, meaning there is a limit to how much joy, pain relief, or breathing problems it can produce, it still may cause an overdose if an individual uses it with tranquilizers and/or alcohol.

Limitations for the prescribing of buprenorphine prevent some physicians from prescribing it. If a physician wishes to prescribe buprenorphine, they must meet statutory requirements for a waiver in agreement with the Controlled Substances Act. After this waiver is granted, a physician may only treat up to 30 individuals. Following the first year, they may make a request to treat up to 100. Because of lack of physician availability, a final rule was published on July 8, 2016 which allowed eligible practitioners to make a request to be allowed to treat up to 275 patients. However, this patient limit does not apply to OTPs that prescribe buprenorphine.

On July 22, 2016, the Comprehensive Addiction and Recovery Act (CARA) expanded temporary eligibility to qualifying nurse practitioners and physician assistants to prescribe buprenorphine-based drugs for substance use disorders through October 1, 2021.

Naltrexone

Naltrexone is not able to be abused, and does not produce opioid-like effects. It not only prevents other opioids from having any effects on an individual, but it also anticipates withdrawal syndrome in patients who are dependent on opioids. For this reason, naltrexone may only be administered after the individual has completely detoxed from opioids. Since naltrexone does not produce any withdrawal effects, a patient does not need to be concerned when stopping use. It may be suitable for the following individuals:

  • People who have successfully been treated with buprenorphine or methadone who wish to discontinue use but still be protected from relapse
  • People who prefer not to take an opioid agonist
  • People who have completed detox and/ or rehab
  • People who are being released from incarceration and expect to return to an environment where drugs may be used and wish to avoid relapse
  • Young adults or adolescents with opioid dependence
  • Pg. 4-24

Naltrexone can be prescribed or administered by any nurse practitioner, physician assistant, or physician who has the authority to prescribe medications. It is available in oral/ pill form and an extended-release injectable. The oral/ pill form can be effective for those who have someone to observe them during daily dosing and/ or are very motivated to stay clean. For those individuals who would have trouble with taking a pill every day, the injectable version is also available, and provides craving reduction and prolonged protection from relapse for 30 days.

MAT For Alcohol Use Disorder

While three medications are available for treating alcohol use disorder (disulfiram, naltrexone, and acamprosate), many factors should be taken into consideration before prescribing. Factors such as potential for relapse, motivation for treatment, and severity of co-existing conditions. Pg. 4-24

Because these medications do not carry a risk of addiction or misuse, there are no limitations on health care professionals to prescribe them. However, these three medications do come with potential side effects, which should be taken into consideration before a physician prescribes them.

While research has shown effectiveness in using medications to treat alcohol use disorders, specific responses have proven difficult to forecast. Medication assisted therapy for alcohol use disorders have been shown to be most useful with a combination of brief support and behavioral interventions.

Disulfiram

Disulfiram works by producing effects such as increased heart rate, a drop in blood pressure, sweating, headache, palpitations, warmth and flushing of the skin, nausea and/ or vomiting, and dizziness. Pg. 4-25

The intensity of reaction varies depending upon dosage and the amount of alcohol the individual consumes.

This was the first medication approved by the FDA to treat AUD, and has shown positive results. Disulfiram has been shown to be more effective when use is observed or supervised (i.e. – a significant other or spouse supervising daily dosing) than in individuals who are not observed. Individuals who would benefit most are those who express the desire to be sober and those who are motivated to undergo treatment. Disulfiram is not intended for use to reduce, but not stop, drinking, and should not be used by individuals with advanced liver disease.

Naltrexone

Naltrexone has shown to be effective in treating alcohol use disorders, and research has shown reduction in heavy drinking risk in individuals who have been sober, when beginning treatment, for numerous days. As previously stated in regard to disulfiram, observed or supervised dosing has shown more effective than in individuals who are not observed. In cases where such supervision is not available, the extended-release injectable may be used. Naltrexone should not be used by individuals who have been diagnosed with renal failure, liver failure, or acute hepatitis.

Acamprosate

Acamprosate reduces signs of craving which may lead to relapse, and has shown to be effective when combined with behavioral interventions. Patients who are motivated to stay sober benefit more so than in un-motivated patients. Acamprosate has shown relapse reduction and effectiveness in those wishing to stay sober from alcohol.

Overview of Behavioral Therapies

While behavioral therapies are best suited for individual sessions, they may also be conducted in group and/ or family sessions, in many types of treatment settings. Some of the benefits of behavioral therapies are:

  • Help patients recognize the impact of their behaviors – such as those dealing with stress or interacting in interpersonal relationships – on their substance use and ability to function in a healthy, safe, and productive manner
  • Teach and motivate patients in how to change their behaviors as a way to control their substance use disorders
  • Pg. 4-26

Evidence-based behavioral therapies must be conducted by trained, qualified providers, to be delivered properly. However, a large portion of behavioral intervention conducted in treatment programs has been group counseling. This type of counseling has not been shown to be effective in the reduction of substance use, or related problems, and should only be used largely when combined with other forms of individual therapy, or individual counseling.

Individual counseling helps patients develop real life skills and coping strategies which are delivered in structured sessions, and has been shown to be effective in those with SUDs (Substance Use Disorders).

The following is a brief list of behavioral therapies which have shown to be effective in treating substance use disorders:

  • CBT (Cognitive Behavioral Therapy)
  • Contingency Management
  • Community Reinforcement Approach (CRA)
  • Motivational Enhancement Therapy (MET)
  • The Matrix Model
  • Twelve-Step Facilitation Therapy (TSF)
  • Family Therapies
  • Tobacco Use Cessation Efforts in Substance Use Disorder Treatment Programs
  • 4-26 to 4-31

To view the PDF file of this chapter, please follow this link: https://addiction.surgeongeneral.gov/chapter-4-treatment.pdf

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