11) Guia de La Asociacion Americana de Psiquiatria PDF

TREATING
SUBSTANCE USE DISORDERS

A Quick Reference Guide
Based on Practice Guideline for the Treatment of Patients With Substance Use Disorders:
Alcohol, Cocaine, Opioids, originally published in November 1995. A revision of this
practice guideline was begun in 2002 and is expected to be completed in fall 2003.
1
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for APA Practice Guidelines,
visit www.psych.org/cme.
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TREATING SUBSTANCE USE DISORDERS • 3
Introduction
“Treating Substance Use Disorders: A Quick Reference Guide” is a sum-
mary and synopsis of the American Psychiatric Association’s Practice
Guideline for the Treatment of Patients With Substance Use Disorders,
which was originally published in The American Journal of Psychiatry in
November 1995 and is available through American Psychiatric
Publishing, Inc. (A revision of this Practice Guideline was begun in 2002
and is expected to be completed in fall 2003.) The Quick Reference
Guide is not designed to stand on its own and should be used in con-
junction with the full text of the Practice Guideline. Graphical algorithms
illustrating the treatment of substance use disorders are included.
Statement of Intent
The Practice Guidelines and the Quick Reference Guides are not intend-
ed to be construed or to serve as a standard of medical care. Standards
of medical care are determined on the basis of all clinical data available
for an individual case and are subject to change as scientific knowledge
and technology advance and practice patterns evolve. These parameters
of practice should be considered guidelines only. Adherence to them will
not ensure a successful outcome in every case, nor should they be con-
strued as including all proper methods of care or excluding other accept-
able methods of care aimed at the same results. The ultimate judgment
regarding a particular clinical procedure or treatment plan must be made
by the psychiatrist in light of the clinical data presented by the patient
and the diagnostic and treatment options available.
The development of the APA Practice Guidelines and Quick Reference
Guides has not been financially supported by any commercial organiza-
tion.
4 • TREATING SUBSTANCE USE DISORDERS
OUTLINE
B. Psychiatric
A. Goals of Substance
Management
Use Treatment ..............5
1. Establish and maintain
a therapeutic
alliance ....................7
2. Monitor clinical
C. Assessment ...................5 status .......................7
3. Manage intoxication
and withdrawal .........8
4. Develop and facilitate
D. Overall Treatment adherence to a
treatment plan ...........8
Issues 5. Use relapse prevention
1. Formulation and strategies ..................9
Implementation of a 6. Provide education ......9
Treatment Plan............10 7. Diagnose and treat
2. Treatment Settings .......11 comorbid psychiatric
3. Pharmacological disorders ..................9
Treatments..................13
4. Psychosocial
Treatments..................14
E. Substance-Specific
Recommendations
1. Alcohol Use
Disorders ................16
2. Cocaine Use
Disorders ................21
3. Opioid Use
Disorders ................23
A. Goals of Substance Use Treatment
Reduce use of substance or achieve complete abstinence.

• Abstinence is the ideal outcome.
• Many patients are unable or unwilling to achieve abstinence.
• Controlled use is unattainable for many patients.
Reduce frequency and severity of relapse.
Improve psychological and social functioning.

• Repair disrupted relationships.
• Reduce impulsivity.
• Develop social and vocational skills.
• Obtain and maintain employment.
C. Assessment
The psychiatrist should obtain information from the patient, available

family members and peers, current and past treaters, employers, and
others as appropriate. Assessment should include the following:
Detailed history of the patient’s past and present substance use,

including
• effects on cognitive, psychological, behavioral, and physiological
functioning and
• pattern of substance use: where, with whom, how much, and by
what route of administration.
General medical and psychiatric history and examination (including

a complete physical and mental status examination) to
• determine comorbid medical and psychiatric disorders and
• assess for signs and symptoms of current intoxication or
withdrawal.
C. Assessment (continued)
History of prior substance use treatments (e.g., settings, context,

modalities, duration, and adherence) and outcomes (e.g., subsequent
substance use and social and occupational functioning achieved)
Family history of substance use or psychiatric disorder
Social history (including school or vocational adjustment, peer

relationships, financial and legal problems)
Qualitative or quantitative screening of blood, breath, or urine for

substances and laboratory tests for abnormalities that may
accompany acute or chronic substance use
Screening and assessment for infectious and other diseases (e.g.,

HIV, tuberculosis, hepatitis, bacterial endocarditis) that are often
found in substance-dependent persons and are particularly prevalent
with the use of substances by injection
B. Psychiatric Management
During the ongoing process of choosing among and implementing

various treatments, psychiatric management is crucial to monitoring the
patient’s clinical status and coordinating treatment components.
1. Establish and maintain a therapeutic alliance.
• The primary goal is to have the patient learn, practice, and

internalize changes in attitudes and behavior conducive to relapse
prevention.
• A stronger alliance predicts less substance use and better
psychological functioning during follow-up.
2. Monitor clinical status.
Look for the following:

• Potential emergence of self-destructive, suicidal, or homicidal
thoughts or behaviors
• Treatment-emergent side effects
• Evidence of relapse
- Breath, blood, saliva, and urine testing for abused drugs is often
initially conducted frequently and on a random basis.
- An elevation of state markers, such as mean corpuscular volume
(MCV) or gamma-glutamyl transpeptidase (GGT), may indicate a
return to drinking.
• Evidence of complications of chronic substance use (e.g., dementia
with chronic heavy use of alcohol)
3. Manage intoxication and withdrawal.
• Provide acutely intoxicated patients with reassurance and

containment in a safe and monitored environment.
• Ascertain which substances have been used, route of
administration, dose, time since last dose, and whether level of
intoxication is waxing or waning.
• Hasten removal of substances from the body—e.g., by gastric
lavage (if the substance has been recently ingested), or by
increasing rate of excretion (e.g., by hydration).
• Reverse drug effects by administering antagonists (e.g., naloxone
for heroin overdose) that can displace agonists from neuronal and
other receptors.
• Watch for withdrawal syndromes in physically dependent
individuals who discontinue or reduce their substance use after
heavy or prolonged use.
• Treat with medications to ameliorate withdrawal symptoms (e.g.,
clonidine for opioid withdrawal).
• Replace the abused drug with a drug in the same or a similar class
with a longer duration of action and taper the longer-acting drug.
• Consider psychosocial treatments, along with other strategies, for
intoxication and withdrawal.
4. Develop and facilitate adherence to a treatment plan.
• Monitor attitudes about participating in treatment and complying

with specific recommendations.
• Address barriers to treatment participation.
5. Use relapse prevention strategies.
• Help the patient anticipate and avoid drug-related cues (e.g.,

instruct the patient to avoid drug-using peers).
• Train the patient to self-monitor states associated with increased
craving.
• Use contingency contracting (e.g., set up positive and negative
reinforcements in advance).
• Teach desensitization and relaxation techniques to reduce the
power of drug-related stimuli.
• Help patients develop alternative, nonchemical coping responses.
• Provide social skills training.
6. Provide education.
Educate the patient, family, and significant others about substance

use disorders and treatment.
7. Diagnose and treat comorbid psychiatric disorders.
Diagnose and treat comorbid psychiatric disorders that

• affect the course and outcome of the substance use disorder,
• may complicate the substance use treatment,
• may reemerge with cessation of substance use, and
• may require the addition of specific treatments (e.g., an
antidepressant medication).
D. Overall Treatment Issues
1. Formulation and Implementation of a Treatment Plan
Develop a treatment plan.

• Apply principles of psychiatric management (see section B, p. 7) to
coordinate the use of multiple clinicians and modalities used in
individual, group, family, and self-help settings.
• Develop and implement a strategy to achieve abstinence or reduce
the use of illicit substances or nonillicit substances that exacerbate
the substance use disorder.
• Use specific pharmacological and psychosocial treatments in the
context of an organized treatment program that combines a
number of different treatment modalities, since it is uncommon for a
single treatment to be effective when used in isolation.
• Plan to enhance ongoing adherence to the treatment program,
prevent relapse, and improve functioning.
- Decrease access to abusable substances.
- Optimize specific pharmacological treatments.
- Develop a psychotherapeutic strategy to support a substance-free
lifestyle.
- Provide disincentives for substance use (e.g., through the use of
monitoring or pharmacological strategies).
- Develop cognitive and behavioral strategies to support a
substance-free lifestyle.
- Consider referral to self-help groups.
- Consider specific rehabilitative interventions to improve
functioning if impairment interferes with treatment adherence.
Choose treatments that take into consideration the patient’s clinical

status and preferences.
Tailor the duration of treatment to individual needs.

Duration may vary from a few months to many years.
Intensify monitoring for substance use during periods

of high risk of relapse.
High-risk periods include
• early stages of treatment,
• times of transition to less intensive levels of care,
• the first year following cessation of active treatment, and
• periods of intensified life stress and lifestyle changes.
2. Treatment Settings
Treat in the least restrictive setting that is likely to be safe and

effective.
Choose site of care based on the patient’s

• ability to cooperate with and benefit from the treatment offered,
• capacity for self-care,
• ability to refrain from illicit use of substances,
• ability to avoid high-risk behaviors,
• need for particular treatments that may be available only in certain
settings,
• history of response in particular settings, and
• preference for a particular treatment setting.
Move from one level of care to another on the basis of the above
factors and an assessment of the patient’s ability to benefit from a
different level of care.
Table 1 (p. 12) suggests appropriate treatment settings for different
patient-related factors.
TABLE 1. Treatment Settings

Hospitalization
Consider for patients who
• have a drug overdose that cannot be safely treated in an outpatient or emergency
room setting (e.g., cardiac instability or toxicity, decreasing levels of consciousness),
• are at risk for severe or medically complicated withdrawal syndromes (e.g., past
history of delirium tremens),
• have comorbid general medical conditions (e.g., severe cardiac disease) that make
ambulatory detoxification unsafe,
• have a documented history of not engaging in or benefiting from treatment in a less
intensive setting (e.g., residential or outpatient),
• have a level of psychiatric comorbidity that would markedly impair their ability to
participate in treatment or whose comorbid disorder would by itself require hospital-
level care (e.g., depression with suicidal thoughts, acute psychosis),
• manifest substance use or other behaviors that constitute an acute danger to
themselves or others,
• have not responded to less intensive treatments and whose substance use disorder
poses an ongoing threat to their physical and mental health or endangers others.
Residential treatment (e.g., 24-hour open-milieu care)
• do not meet the clinical criteria for hospitalization and whose lives and social
interactions have come to focus predominantly on substance use,
• lack sufficient social and vocational skills and drug-free social supports to maintain
abstinence in an outpatient setting,
• demonstrate denial that could respond to interpersonal and group confrontation.
Partial hospitalization
• require intensive care but have a reasonable probability of refraining from illicit use
of substances outside a restricted setting,
• are leaving hospitals or residential settings but who remain at high risk for relapse,
• are thought to lack sufficient motivation to continue in outpatient treatment,
• have severe psychiatric comorbidity,
• have a history of relapse to substance use in the immediate posthospital or
postresidential period,
• are returning to high-risk environments and who have limited psychosocial supports
for remaining drug free,
• are doing poorly in intensive outpatient treatment.
Outpatient
• demonstrate a clinical condition or have environmental circumstances that do not
require a more intensive level of care.
3. Pharmacological Treatments
For selected patients, medications may be used for the following
purposes:
To decrease the reinforcing effects of abused substances

For example, the narcotic antagonist naltrexone blocks the subjective
and physiological effects of subsequently administered opioid drugs.
To discourage the use of substances

Two strategies are as follows:
• Induce unpleasant consequences through a drug-drug interaction
(e.g., disulfiram to discourage alcohol use).
• Couple substance use with an unpleasant, drug-induced condition
(e.g., prescribe succinylcholine, which interferes with respiratory
function, or emetine, to induce vomiting) under carefully controlled
conditions.
To treat intoxication and withdrawal states (see section B.3,

p. 8)
To reduce or eliminate symptoms of withdrawal and decrease craving

This may be accomplished by substituting an agonist for that
particular class of substances (e.g., methadone for opioids).
To treat comorbid psychiatric conditions

Potential problems include the following:
• Overdose may result from potentiation of drug effects (e.g., when
antidepressants and alcohol are combined).
• Lack of adherence to prescribed treatment is a serious issue.
• Treatments may themselves be abused (e.g., benzodiazepines). It is
important to choose medications with low abuse potential (e.g.,
selective serotonin reuptake inhibitors [SSRIs] for depression).
• Drug-drug interactions may occur between several prescribed
medications or between prescribed medications and abused
substances.
4. Psychosocial Treatments
Psychosocial treatments are an essential component of a comprehensive

treatment program.
Cognitive behavior therapies (CBTs)

Goals of CBTs
• Alter cognitive processes that lead to maladaptive behaviors.
• Intervene in chain of events leading to substance use.
• Help reduce acute or chronic drug craving.
• Promote and reinforce the development of effective social skills and
behaviors.
Types of CBTs
• Standard cognitive therapy—modifies maladaptive thinking
patterns to reduce negative feelings and behavior (e.g., substance
use).
• Relapse prevention—employs cognitive behavior techniques to help
patients develop self-control to avoid relapse.
• Motivational enhancement therapy—adopts an empathic approach
to motivate the patient.
Behavior therapies
• Contingency management rewards abstinence (e.g., with vouchers)
or punishes drug taking (e.g., by notification of courts, employers,
or family members).
• It requires frequent, random, supervised urine, saliva, or hair-follicle
monitoring.
Psychodynamic and interpersonal therapies

These therapies may facilitate abstinence when combined with other
treatment modalities (e.g., pharmacotherapies and self-help groups).
Group therapy
• Group therapy can be supportive, therapeutic, and educational.
• This type of therapy increases accountability by providing
opportunities for the group to respond to early warning signs of
relapse.
Family therapy
Dysfunctional families are associated with poor short- and long-term
patient outcome. The goals of family therapy include the following:
• Encourage family support for abstinence.
• Obtain information about the patient’s clinical status.
• Maintain marital relationships.
• Address interpersonal and family interactions that lead to conflict
or that enable substance use behaviors.
• Reinforce behaviors that help prevent relapse and enhance the
prospects for recovery.
Self-help groups
• Participation in self-help groups is an important adjunct to treatment
for some but not all patients.
• Refusal to participate is not synonymous with resistance to
treatment in general.
• Patients who require psychoactive medications (e.g., lithium,
antidepressants) should be directed to groups that are supportive of
such treatment.
E. Substance-Specific Recommendations
1. Alcohol Use Disorders

a. Treatment Setting
Choose setting for patients who do not need detoxification.

Ongoing treatment usually takes place outside the hospital (e.g.,
outpatient treatment, day hospital, or partial hospitalization). Patients
who are unlikely to benefit from less intensive and less restrictive
alternatives may occasionally need hospitalization.

b. Pharmacological Treatment
Naltrexone (ReVia)
At 50 mg/day, naltrexone can lead to reduced drinking and
resolution of alcohol-related problems.
• It may be useful in preventing relapse, particularly when combined
with other therapeutic approaches.
• It may attenuate some of the reinforcing effects of alcohol.
Disulfiram (Antabuse)
Treatment with disulfiram deters subsequent “slips” by causing a
highly aversive reaction after a patient has even a single drink.
• The usual dosage is 250 mg/day (range 125 to 500 mg/day).
• It can be an effective adjunct to a comprehensive treatment
program.
• It should be used only for reliable, motivated patients whose
drinking may be triggered by events. (Patients with impulsive
behavior, psychotic symptoms, or suicidal thoughts are poor
candidates.)
• Because it can cause a variety of potentially serious outcomes,
disulfiram should be avoided in the presence of moderate to severe
hepatic dysfunction, peripheral neuropathy, pregnancy, renal
failure, or cardiac disease.
Specific therapies
Specific therapies may also be used to treat comorbid psychiatric
conditions.
• For many patients, signs and symptoms of depression and anxiety
may not require pharmacotherapy but instead are related to
alcohol intoxication or withdrawal and remit in the first few weeks
of abstinence.
• For alcoholic hallucinosis during or after cessation of prolonged
alcohol use, antipsychotic medication should be considered.
• Korsakoff’s syndrome (alcohol amnestic disorder) should be treated
vigorously with B-complex vitamins (e.g., thiamine, 50 to 100
mg/day i.m. or i.v.).

c. Psychosocial Treatment
Potentially helpful psychosocial treatments include the following:

• Cognitive behavior therapies aimed at improving self-control and
social skills.
• Behavior therapies.
• Psychodynamic/interpersonal therapies.
• Brief interventions (i.e., abbreviated assessments of drinking
severity and related problems and provision of motivational
feedback and advice).
• Marital and family therapy.
• Group therapies.
• Aftercare during the period following an intense treatment
intervention (e.g., hospital or residential care). Aftercare, which
may include partial hospitalization, outpatient care, or involvement
in self-help approaches, may help maintain abstinence.
• Self-help groups, such as Alcoholics Anonymous.

d. Management of Alcohol Intoxication and Withdrawal
Assess symptoms of intoxication and withdrawal.

• Withdrawal symptoms generally begin within 4 to 12 hours after
cessation or reduction of alcohol use, peak in intensity during the
second day of abstinence, and generally resolve within 4 to 5
days.
• Laboratory tests should be used to determine whether the presence
of other substances is contributing to the clinical presentation.
• Gastrointestinal distress, anxiety, irritability, elevated blood
pressure, tachycardia, and autonomic hyperactivity are symptoms
of mild to moderate withdrawal.
• Fewer than 5% of patients develop severe withdrawal. Symptoms
include delirium, hallucinations, grand mal seizures, respiratory
alkalosis, and fever.
Determine whether risk factors for withdrawal are present.

Moderate risk of withdrawal is associated with the presence of any
of the following:
• Prior history of delirium tremens
• Documented history of very heavy alcohol use and high tolerance
• Concurrent abuse of other drugs
• Severe comorbid general medical condition or psychiatric disorder
• Repeated failures at outpatient detoxification
Treat intoxication and withdrawal.

• For acute intoxication, monitor and maintain in a safe environment.
• For mild to moderate withdrawal, provide generalized support,
reassurance, and frequent monitoring. For approximately two-thirds
of patients with mild to moderate withdrawal symptoms, this
treatment is sufficient and can occur in outpatient settings that
provide for frequent clinical assessment and any needed clinical
treatments.
• Treat moderate to severe withdrawal as follows:
- Arrange for an appropriate setting (residential or hospital
admission may be needed, with hospitalization required in the
presence of delirium tremens).
- Reduce CNS irritability with benzodiazepines (see Figure 1,
p. 20).
- Beta-blockers or clonidine may be used in combination with
benzodiazepines to decrease symptoms of withdrawal.
- Restore physiological homeostasis (e.g., thiamine and fluids).
- After patient is clinically stable, taper benzodiazepines and other
medications.
- Observe for reemergence of withdrawal symptoms.
- Observe for emergence of signs and symptoms suggestive of a
comorbid psychiatric disorder.
- Use an antipsychotic agent (as adjunct) for delirium, delusions, or
hallucinations.
Treat or prevent common neurological sequelae of chronic alcohol use

by routinely giving thiamine if moderate to severe alcohol use is
present.
FIGURE 1. Benzodiazepine Treatment of

Moderate to Severe Withdrawal
Give an orally administered benzodiazepine, e.g.,

chlordiazepoxide (50 mg every 2 to 4 hours), diazepam
(10 to 20 mg every 2 to 4 hours), oxazepam (60 mg
every 2 to 4 hours), or lorazepam (1 to 4 mg every 2 to
4 hours), as needed for signs and symptoms of alcohol
withdrawal.
Calculate the total number of milligrams of

benzodiazepine required in the first 24 hours.
Taper over the next 2 to 5 days, monitoring for

reemergence of withdrawal symptoms. (Patients in
severe withdrawal and those with a history of
withdrawal-related symptoms may require up to 10 days
before benzodiazepines are completely withdrawn.)

e. Treatment of Pregnant Women
Alcohol use during pregnancy may have adverse effects on the

pregnant woman’s health, the pregnancy course, fetal and early child
development, and parenting behavior.
The best-established effect of in utero exposure to alcohol is fetal

alcohol syndrome, which is associated with low birth weight,
retarded growth and development, poor coordination, hypotonia,
neonatal irritability, craniofacial abnormalities (including
microcephaly), cardiovascular defects, mild to moderate retardation,
childhood hyperactivity, and impaired school performance.
Goals for the treatment of pregnant women include the following:

• Eliminate the patient’s use of alcohol.
• Treat any comorbid psychiatric or general medical disorders.
• Guide the patient safely through the pregnancy.
• Refer the patient for education in parenting skills.
• Motivate the patient to remain in treatment after delivery to
decrease relapse risk.
2. Cocaine Use Disorders

Intensive (i.e., more than twice a week) outpatient treatment is most

effective. The effectiveness of self-help groups is also greatest with
regular participation.

• Pharmacological treatment is not ordinarily indicated as an initial

treatment.
• Medications should be considered for patients who have more
severe dependence or fail to respond to psychosocial treatment.
• Medications have had limited effectiveness; desipramine and
amantadine have shown the most promising results.

Focus on abstinence.
Consider the following specific types of psychotherapies

and self-help groups:
• Cognitive behavior
• Behavior
• Psychodynamic
• Self-help groups, including 12-step–oriented programs
(e.g., Narcotics Anonymous)

d. Management of Cocaine Intoxication and Withdrawal
Intoxication
• Cocaine intoxication can produce hypertension, tachycardia,
seizures, and paranoid delusions.
• Intoxication is usually self-limited and typically requires only
supportive care.
• Acutely agitated patients may benefit from sedation with
benzodiazepines.
Withdrawal
• Following cessation of cocaine use, anhedonia and craving are
common.
• Currently available pharmacotherapy provides no clear benefit.

e. Treatment of Pregnant Women
Minimize or eliminate cocaine use to prevent increased risk of

prematurity, low birth weight, stillbirth, and sudden infant death
syndrome (SIDS).
3. Opioid Use Disorders

In addition to drug treatment programs, therapeutic communities are

effective.

Methadone or LAAM maintenance treatment

Treatment rationale
• Reduces the morbidity associated with opioid dependence.
• Appropriate when history of opioid dependence is prolonged
(>1 year).
Treatment goals
• Achieve a stable maintenance dose.
• Facilitate engagement in a comprehensive program of
rehabilitation.
(continued)

b. Pharmacological Treatment (continued)
Methadone or LAAM maintenance treatment (continued)

Dosing
• Methadone
- A dosage of 40 to 60 mg/day is usually sufficient to block
withdrawal symptoms.
- Higher dosages (average, 70 to 80 mg/day) are associated with
better outcomes during maintenance treatment and are needed to
block craving for opiates and associated drug use.
- Monitoring of plasma methadone concentrations may be helpful if
higher doses are used, with the aim of maintaining minimum
levels of 150 to 200 ng/mL.
• LAAM
- It is usually prescribed in doses of 20 to 140 mg
(average, 60 mg).
- Dosing can be as infrequent as three times per week.
Naltrexone
• Naltrexone is an opioid antagonist that blocks the effects of usual
street doses of opioids.
• It can be administered orally three times per week (e.g., 100 mg
on Monday and Wednesday, 150 mg on Friday).
• Because it can precipitate severe withdrawal symptoms in opioid-
dependent patients, naltrexone should be administered only to
patients who are withdrawn from opioids under medical
supervision and are opioid free for at least 5 days after use of
short-acting opioids, or 7 days after longer-acting opioids.
• Utility is often limited by poor adherence and low treatment
retention.
Although abstinence can never be achieved in some patients,

important reductions in morbidity and mortality can be achieved
through efforts to reduce the deleterious effects of opioid use.

Psychosocial treatments, when combined with opioid antagonist or

opiate agonist treatments, can improve treatment adherence and
prevent relapse. The following treatments may be helpful:
• Cognitive behavior therapies
• Behavior therapies
• Psychodynamic psychotherapies
• Group and family therapies
• Self-help groups

d. Management of Opioid Intoxication
Recognize and treat acute intoxication.

Patients with opioid use disorders frequently relapse and present with
intoxication.
Level of Intoxication Indicators Treatment
Mild to moderate Drowsiness, pupillary Specific treatment is
constriction, slurred usually not required
speech
Severe overdose Respiratory depression, Requires treatment in
(may be fatal) stupor, coma inpatient or emergency
department setting
May require ventilatory
assistance
Use naloxone to
reverse

d. Management of Opioid Intoxication (continued)
Reverse respiratory depression by administering naloxone.

• The usual dose is 0.4 mg (1 mL) i.v.
• A positive response (with increases in respiratory rate and volume,
increased systolic blood pressure, and pupillary dilation) should
occur within 2 minutes.
• If there is no response, the same or a higher dose (e.g., 0.8 mg) of
naloxone can be given twice more at 5-minute intervals.
• Failure to respond to naloxone suggests a concurrent, or
completely different, etiology of the problem (e.g., barbiturate
overdose, head injury).

e. Management of Opioid Withdrawal
The goals of withdrawal management are to ameliorate acute symptoms

and facilitate entry into a long-term treatment program.
Methadone substitution with gradual tapering

• The daily stabilization dose should be based on the response of
objective signs of withdrawal to a methadone dose of 10 mg every
2 to 4 hours as needed.
• During the first 24 hours, 10 to 40 mg of methadone will stabilize
most patients and control withdrawal symptoms.
• Once the stabilization dosage is determined, methadone can be
slowly tapered (e.g., by 5 mg/day).
• When the methadone dosage drops below 20 to 30 mg/day,
many patients begin to complain of renewed (but milder)
withdrawal symptoms. These may be ameliorated by the addition
of clonidine (see the following).
Abrupt discontinuation of opioids, with the use of clonidine to

suppress withdrawal symptoms
• Clonidine suppresses nausea, vomiting, diarrhea, cramps, and
sweating but does little to reduce muscle aches, insomnia, and
drug craving.
• Be aware that some patients are extremely sensitive to clonidine
and experience profound hypotension, even at low doses.
• On day 1, clonidine-aided detoxification involves either a test-dose
approach or a treatment dosage ranging from 0.1 to 0.6 mg in
three divided doses. Thereafter, dosage is adjusted until withdrawal
symptoms are reduced.
• If blood pressure falls below 90/60 mm Hg, the next dose should
be withheld.
• Tapering can be resumed while the patient is monitored for signs of
withdrawal.
• Advantages over methadone:
- Clonidine does not produce opioid-like tolerance or physical
dependence.
- It avoids the postmethadone rebound in withdrawal symptoms.
- If indicated, an opioid antagonist (e.g., naltrexone) can be used
immediately after the course of withdrawal.
• Disadvantages:
- Side effects include insomnia, sedation, and hypotension.
- Clonidine will not ameliorate some symptoms of opioid
withdrawal, such as insomnia and muscle pain.
- It is contraindicated in patients with moderate to severe
hypotension and cardiac, renal, or metabolic disease.
• Clonidine-assisted detoxification is easiest to carry out in inpatient
settings.
• Outpatient detoxification with clonidine is a reasonable approach
with experienced staff; outpatients should not be given more than a
3-day supply of clonidine for unsupervised use.

e. Management of Opioid Withdrawal (continued)
Clonidine-naltrexone ultrarapid withdrawal

• Clonidine pretreatment avoids naltrexone-precipitated withdrawal.
• It is most useful for opioid-dependent patients who are in transition
to narcotic antagonist treatment.
• It necessitates monitoring of patients for 8 hours on day 1 (because
of the potential severity of naltrexone-induced withdrawal).
• It requires careful monitoring of blood pressure throughout
withdrawal.

f. Treatment of Pregnant Women
Opioid use during pregnancy is associated with an increased risk of

low birth weight, prematurity, neonatal abstinence syndrome,
stillbirth, and sudden infant death syndrome (SIDS).
Goals for the treatment of pregnant women include the following:

• Ensure physiological stabilization and avoidance of opioid
withdrawal.
• Prevent further abuse of illicit drugs or alcohol.
• Improve maternal nutrition.
• Encourage participation in prenatal care and rehabilitation.
• Reduce the risk of obstetrical complications, including low birth
weight and neonatal withdrawal, which can be lethal if untreated.
• Arrange for appropriate postnatal care when necessary.

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TREATING

SUBSTANCE USE DISORDERS

To order individual Practice Guidelines or the

A. Goals of Substance Use Treatment

Reduce use of substance or achieve complete abstinence.

Reduce frequency and severity of relapse.

Improve psychological and social functioning.

The psychiatrist should obtain information from the patient, available

Detailed history of the patient’s past and present substance use,

General medical and psychiatric history and examination (including

History of prior substance use treatments (e.g., settings, context,

Family history of substance use or psychiatric disorder

Social history (including school or vocational adjustment, peer

Qualitative or quantitative screening of blood, breath, or urine for

Screening and assessment for infectious and other diseases (e.g.,

During the ongoing process of choosing among and implementing

1. Establish and maintain a therapeutic alliance.

• The primary goal is to have the patient learn, practice, and

2. Monitor clinical status.

Look for the following:

3. Manage intoxication and withdrawal.

• Provide acutely intoxicated patients with reassurance and

4. Develop and facilitate adherence to a treatment plan.

• Monitor attitudes about participating in treatment and complying

5. Use relapse prevention strategies.

• Help the patient anticipate and avoid drug-related cues (e.g.,

Educate the patient, family, and significant others about substance

7. Diagnose and treat comorbid psychiatric disorders.

Diagnose and treat comorbid psychiatric disorders that

D. Overall Treatment Issues

1. Formulation and Implementation of a Treatment Plan

Develop a treatment plan.

Choose treatments that take into consideration the patient’s clinical

Tailor the duration of treatment to individual needs.

Intensify monitoring for substance use during periods

Treat in the least restrictive setting that is likely to be safe and

Choose site of care based on the patient’s

TABLE 1. Treatment Settings

To decrease the reinforcing effects of abused substances

To discourage the use of substances

To treat intoxication and withdrawal states (see section B.3,

To reduce or eliminate symptoms of withdrawal and decrease craving

To treat comorbid psychiatric conditions

Psychosocial treatments are an essential component of a comprehensive

Cognitive behavior therapies (CBTs)

Psychodynamic and interpersonal therapies

1. Alcohol Use Disorders

Choose setting for patients who do not need detoxification.

1. Alcohol Use Disorders

1. Alcohol Use Disorders

Potentially helpful psychosocial treatments include the following:

1. Alcohol Use Disorders

Assess symptoms of intoxication and withdrawal.

Determine whether risk factors for withdrawal are present.

Treat intoxication and withdrawal.

Treat or prevent common neurological sequelae of chronic alcohol use

FIGURE 1. Benzodiazepine Treatment of

Give an orally administered benzodiazepine, e.g.,

Calculate the total number of milligrams of

Taper over the next 2 to 5 days, monitoring for

1. Alcohol Use Disorders

Alcohol use during pregnancy may have adverse effects on the