Substance use disorder

Individuals with substance use disorder usually have a chemical dependency (also called ‘drug dependence’) on their substance of choice. When someone has a chemical dependency, their body will go into withdrawal when they are not using the substance – their body has developed a physiological need for that substance. Withdrawal is an unpleasant physical state with a lot of negative side effects. The side effects of withdrawal can include fatigue, irritability, nausea, sweating, insomnia, headaches, and other uncomfortable physical and psychological effects. 

Individuals that suffer from substance use disorder can have both a physical dependence on a substance and a psychological dependence on a substance. When someone has a psychological dependence on a substance, they have ‘emotional-motivational’ withdrawal symptoms. They may feel uncomfortable or uneasy, have a lowered capability to feel pleasure, anxiety, or may experience other psychological effects.

Addictions Specialist

An addictions specialist has the education, experience, knowledge, and skills to provide the specific care, prevention, screening, and treatment people tackling addiction and substance abuse need, as well as the psychiatric conditions associated with substance use and addiction.

Medication Assisted Treatment (MAT) for substance use disorders

MAT is helpful in treating substance use disorders. Your doctor or psychiatrist may suggest the use of medications in combination with counseling and behavioral therapies to help you sustain recovery. What type of MAT is right for you will vary based on the type of substance used, how often you can reliably get to treatment, other medications you currently take, and possibly other factors your doctor will identify. 

Opioid Use Disorders

Buprenorphine and methadone: Buprenorphine and methadone are FDA approved methods of treating opioid use disorder. Both have been shown to promote abstinence, improve adherence to treatment, and reduce deaths in people with opioid use disorder. They both act on the opiate receptors in the brain, similar to the way that opioid drugs do. Buprenorphine is a "partial agonist" and methadone is a "full agonist." Because of that difference, buprenorphine is less likely to cause overdose and has a much lower risk of respiratory complications. Other benefits of buprenorphine are that is does not carry the same risk of QTc prolongation as methadone and it has fewer drug-drug interactions. Buprenorphine must be prescribed by a qualified healthcare provide who has received a special prescribing waiver; it can be picked up at a pharmacy. Methadone is dispensed from specialized programs, and, initially, people must come get the dose every day in the clinic. Both buprenorphine and methadone are considered first-line treatments for opioid use disorder.

Suboxone is also sometimes used to treat opioid addiction, a combination medication containing buprenorphine and naloxone. Suboxone works by binding to the same receptors in the brain as other opiates, and thereby blunting the effects of intoxication. It prevents cravings and can allow people to safely transition off narcotic drug use.

Alcohol Use Disorders

First-line treatments for alcohol use disorder include naltrexone (described below) and acamprosate. These medications are FDA approved to treat alcohol use disorder. They help reduce cravings and promote sobriety. Acamprosate is a tablet that is taken three times a day once someone has stopped drinking. Acamprosate cannot be taken by people with severe kidney disease. 

Second-line treatments for alcohol use disorder include disulfiram and gabapentin. Disulfiram is FDA approved to treat alcohol use disorder. Alcohol is eliminated from the body after first being broken down into other chemicals (acetaldehyde and then acetate). Disulfiram acts by blocking the conversion of acetaldehyde into acetate, thus increasing the blood concentration of acetaldehyde and causing an uncomfortable physical reaction (sweating, flushing, nausea) after drinking alcohol. In this way, disulfiram acts as a deterrent to drinking. It should not be used in people with coronary artery disease or psychosis. It works best when taken in a supervised setting such as an inpatient unit or residential rehabilitation program. Gabapentin is sometimes used off-label to treat alcohol use disorder. It has been shown to reduce cravings at higher doses and can help with alcohol detoxification. 

Alcohol or Opioid Use Disorder

Naltrexone is FDA approved for both alcohol use disorder and opioid use disorders; it is sometimes used off-label for other compulsive behaviors. Naltrexone is considered a first-line treatment for alcohol use disorder. Naltrexone works by blocking specific naturally occurring opiate receptors in the brain that are responsible for the reward circuit of the brain. In that way, it reduces the cravings and pleasure associated with alcohol or opioid use. Naltrexone is generally well tolerated, though can sometimes cause nausea. It is available in tablet form or monthly intramuscular injection. It cannot be taken within 7-10 days of opioid use because it can trigger opioid withdrawal. A long-acting injectable form of naltrexone, known as Vivatrol, is also sometimes prescribed.