Substance Use and Addiction

CFPC Key Features

1. In all patients, and especially in high-risk groups (e.g., those with mental health issues, chronic disability), opportunistically ask about substance use (tobacco, alcohol, other substances).

2. For a patient using alcohol or substances (including those who use them only occasionally):

   1. Discuss the possible impact of their use on themselves and others (e.g., risk to children, sexual indiscretion)

   2. Discuss harm-reduction strategies in detail (e.g., needle exchange, not drinking and driving, immunizations)

3. For any patient presenting with a functional decline, confusion, or delirium, assess for alcohol/substance use and withdrawal, even when other causes may seem more apparent.

4. Discuss substance use with adolescents and their caregivers when warning signs are present (e.g., school failure, behaviour change).

5. Consider and look for substance use as a possible factor in problems not responding to appropriate intervention (e.g., alcohol use in patients with hypertriglyceridemia, inhalational drug use in asthmatic patients).

6. For a patient with a medical problem being treated with opioids, stimulants, sedatives, or hypnotics:

   1. Episodically reassess their clinical problem to affirm the ongoing need for the medication

   2. Discuss tapering and cessation planning when appropriate

   3. Discuss safety and security of medication (e.g. storing, risk to children, diversion, misuse)

7. For a patient requesting or requiring a new prescription for opioids, stimulants, or tranquillizers:

   1. Assess alcohol and substance use

   2. Explain clearly the benefits and risks, and do not prescribe before the risks of misuse have been assessed and mitigated

8. In patients who use substances or those with a substance use disorder, regularly determine their readiness to change their patterns of use.

See Poisoning, Alcohol Use Disorder, Opioid Use Disorder

General Overview

Diagnosis

• DSM-V: Problematic pattern of using a substance that result in clinically significant impairment/distress, classified by 2+ of the following within a 12-month period (Mild 2-3, Moderate 4-5, Severe 6+):

  • Impaired Control

    1. Had times when you ended up using X more, or longer, than you intended?

    2. More than once wanted or attempted to cut down or stop X but couldn’t?

    3. Spent a lot of time using/getting/recovering from X

    4. Craving: Wanted X so badly you couldn’t think of anything else?

  • Social Impairment

    1. Obligations: Found that X—or being sick from X—often interfered with taking care of your home or family? Or caused job troubles? Or school problems?

    2. Interpersonal: Continued to use X even though it was causing trouble with your family or friends?

    3. Given up or cut back on activities that were important or interesting to you, or gave you pleasure, in order to use X?

  • Risky Use

    1. More than once gotten into situations while or after using X that increased your chances of getting hurt (such as driving, swimming, using machinery, walking in a dangerous area, or having unsafe sex)?

    2. Continued to drink even though it was making you feel depressed or anxious or adding to another health problem? Or after having had a memory blackout?

  • Pharmacological indicators

    1. *Tolerance: Had to use X much more than you once did to get the effect you want? Or found that your usual number/amount had much less effect than before?

    2. *Withdrawal: Found that when the effects of X were wearing off, you had withdrawal symptoms (e.g., alcohol: trouble sleeping, shakiness, restlessness, nausea, sweating, racing heart, seizure? Or sensed things that were not there?)

*Does not apply for diminished effect when used appropriately under medical supervision

• • Types:

    1. Alcohol

    2. Caffeine

    3. Cannabis (marijuana)

    4. Hallucinogens

    5. Inhalants

    6. Opioid (eg. heroin, fentanyl, morphine)

    7. Sedatives, Hypnotics, or Anxiolytics (eg. benzodiazepines, “Quaaludes”)

    8. Stimulants (eg. cocaine, methamphetamine)

    9. Tobacco

General Approach (5 A's)

• Ask (Identify and document at each visit)

  • Routine screening for substance use in all populations, especially those with risk factors:

    • Psychiatric disease, chronic disability, family or personal history of substance use disorder

    • Associated symptoms, eg. Functional decline, confusion, delirium, syncope

    • Associated medical problems, especially if not responding to appropriate intervention (alcohol in hypertriglyceridemia, inhalation drugs in asthmatic)

    • Prescription medication that are commonly misused (opioids, sedatives, hypnotics, or anxiolytics, stimulants)

  • Substance use history should include

    • Amount

    • Frequency

    • Duration of use

    • Last use

    • Signs of tolerance/withdrawal

    • Affect on function

    • Safety of patient and others

    • Consider substance-specific screening tools (eg. AUDIT, CAGE)

• Assess

  • Readiness for change

  • Safety and related risks (eg. children, risk of STI through IV drug use or sex)

  • Causes for substance use

  • Other pertinent medical information (eg. vaccines, medications, past medical and psychiatric history, etc...)

• Advise (brief intervention best provided after asking for permission)

  • Provide clear advice to change

  • Offer feedback on the patient’s personal risk or impairment

  • Explain benefits of change

  • Emphasize that the patient is responsible for changing their use; he or she must decide how

    • Identify the problem, explain why change is important, ask how their life would improve without substance, advocate specific changes

    • Choose a focused goal patient responds to (SMART goal: specific, measurable, achievable, relevant, time-based)

    • If abstinence not desired, provide counselling on harm reduction (e.g., no drinking-and-driving, using clean needles, having drug supply tested before use, never using alone)

    • Reinforcing the patient’s self-efficacy or belief in his or her competence to change behavior

    • Clinician should state their belief that the patient can make a change

• Assist

  • Identify and address barriers

  • Develop care plan (psychosocial and pharmacological therapy)

  • Provide resources/providers (referrals)

• Arrange Follow-up

Prescription medication (opioids, sedatives, hypnotics, or anxiolytics, stimulants)

• Optimize nonopioid pharmacotherapy and nonpharmacologic therapy

• Assess risk of misuse or substance use disorder

• Prior to initiating medication, discuss benefits and risk of adverse effects/complications

• Safety recommendations:

  • Do not share medication

  • Do not receive medications from other sources

  • Store medication in secure location (out of reach of children, adolescents)

  • Ensure regular visits to healthcare provider, and regular urine samples for drug screens as requested

  • Inform your healthcare provider of any changes to health, and if you would like to adjust your prescribed dose

• Avoid concurrent use of sedatives/depressants (eg. Alcohol, benzodiazepines)

• Monitor closely (symptoms, function, therapy goals, adherence, adverse effects and complications, toxicity)

• Monitor closely for aberrant behaviours: substance use disorder, misuse, and diversion

  • If patient receives prescription opioids and suspect opioid use disorder, consider use Prescription Opioid Misuse Index (POMI)

• For patients who do not have a response to treatment, or benefits do not outweigh harm, taper and discontinue medications

  • Consider formal multidisciplinary program if difficulty tapering