Substance Use Disorders 101 for Primary
Care Providers
Ariel Singer, MPH – Northwest Addiction Technology
Transfer Center/OHSU
Anderson Rice, LPC, CADC I – Kaiser Permanente
Addiction Medicine

“I don’t have an ‘off’ switch…one is too many and a thousand is not enough.”
“Incomprehensible demoralization”
“It’s a disease that tells you you don’t have a disease.”
“I really did not get how I could be an addict when I had been successful in all other areas of my life – it didn’t make sense. However, no matter how hard I tried, I couldn’t moderate. I just couldn’t control it.”
“My addiction took everything from me.”
“My substance use was relief from the pain, but it quit working.”

ASAM: Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.
http://www.asam.org/for-the-public/definition-of-addiction
Gabor Maté: Any repeated behavior, substance related or not, in which a person feels compelled to persist, regardless of its negative impact on his or her life and the lives of others.

• The 4 C’s
– Loss of C ontrol
– C ompulsive use
– C ontinued use despite harms
– C raving
Savage SR, et al. J Pain Symptom Manage. 2003;26:655-667.

Diagnosis on a Continuum of Severity
• Taking substance in larger amounts for longer than intended
• Wanting to cut down or stop using, but not managing to
• Spending a lot of time getting, using, or recovering from use
• Cravings and urges to use the substance
• Not managing to do what you should at work, home or school
• Continuing to use, even when it causes problems in relationships
• Giving up important social, occupational or recreational activities
• Using again and again, even when it puts the you in danger
• Continuing to use, when you have a physical or psychological problem that could have been caused or made worse by use
• Needing more of the substance to get desired effect (tolerance)*
• Development of withdrawal symptoms; relieved by taking more of the substance.*
Mild (2-3) Moderate (4-5) Severe (6+)
*Not counted in SUD diagnosis if symptoms of tolerance or withdrawal occur during appropriate medical treatment with prescribed medications.

Physical
Dependence
Tolerance
Physiologic adaptations to chronic opioid therapy
Addiction
Maladaptive behavior associated with opioid misuse
Savage SR, et al. J Pain Symptom Manage. 2003 Jul;26(1):655-67.

Past Year Perceived Need for and Effort Made to
Receive Specialty Treatment among Persons
Aged 12 or Older
SAMHSA. Results from the 2013 National Survey on Drug Use and Health:
Summary of National Findings

Koob, CSAM Addiction Medicine Review Course, 2014

Alcohol Dependence was last among 30 medical conditions in proportion of care received as evidence would recommend
McGlynn E. et al. NEJM, 2003

• Genetic, personal-choice, and environmental factors
• Behavioral change is an important part of treatment
• Relapse and medication adherence issues
• Comply with treatment and medications = better outcomes
• No reliable cure
• Older, employed with stable families = better outcomes
• Reasonably predictable course
McLellan A T, et al. Drug dependence, a chronic medical illness:
Implications for treatment, insurance, and outcomes evaluation. JAMA. 2000;284(13):1689–1695

The Ups and Downs of Chronic Disease
Asthma, Diabetes, HTN, HIV, etc.
Substance Use Disorder
Time
O’Connor, JAMA 1998
Lucas, JAIDS 2005

• People with SUDs have had a history of being ignored
• War on drugs = war on drug addicts
• Acute episodic response has been the historical treatment paradigm
• AA was a response to the lack of treatment options and sustains stigma and marginalization through its anonymity

We are moving from saying, “this is a personal failure...”
To saying, “there is a light at the end of this tunnel…”

The Hook
• The pharmacologic explanation of addiction
• Addiction attributable to intrinsic property of the substance
The Cage
• Family history of SUD
• Co-occurring MH Disorders
• ACES
• Social Determinants of Health
The Empty Glass
• Unquenchable need for relief
• Often substituted

www.brucekaleander.com
, Addiction: The View from Rat Park, ,Professor Emeritus, Simon Fraser University

Gabor Mate’

• Addictive behaviors are a way of controlling an experience through external remedies
• No external remedy improves a condition without internal or external consequences
• Differentiate between the disease model vs a normal response to pain
“We must acknowledge what is right about addiction, not what is wrong…”
Gabor Maté
Remedies provide…
1.
A sense of control
2.
A sense of fulfillment
3.
Relief from real pain
4.
A way to increase the threshold for tolerance

• Seen as a way towards love and vitality
• Replaces genuine intimacy, compassion or honest endeavors to thrive
• Paramount to other ways to self remedy
• Compulsiveness
• Impairment
• Persistence

(Maté)
• Marginalization
• Racism
• Poverty
• Lack of access
• Adverse history
• Socio-economic inequality
• Distress of daily living
• Loss
• Physical pain
• Emotional pain

SUD Treatment: Check the Cage, Minimize the Hooks and Fill the Glass
• Behavioral Treatments: CBT, DBT, ACT, Seeking Safety,
Contingency Management, etc
• Medication Assisted Treatment (MAT) for Opioid and
Alcohol Use Disorders
• Recovery-Oriented Systems of Care
And when treatment is not an option…
• Harm Reduction – a palliative approach

Substance Use Disorder Medications
Underutilized because of Stigma
Alcohol Use Disorder
1.Naltrexone
2.Acamprosate
3.Disulfiram
Opioid Use Disorder
1.Methadone
2.Buprenorphine
3.Naltrexone
Barriers to MAT
• Lack of understanding of the medications
• Organizational philosophy/staff beliefs about use of medications;
• Cost of medications
• Lack of appropriate staffing in treatment centers

• Meeting our patients where they are at
• Medication Assisted
Treatment is not harm reduction
• Respect
• Honoring personal autonomy
• Reduction in drug related harm
• Comfort Care

Inside the Black Box: What Treatment
Looks Like
Before any treatment can occur a full Biopsychosocial assessment must take place.
Data is gathered in 6 dimensions to determine the appropriate level of care:
↓
Dimension 1 – Acute Intoxication and/or Withdrawal Potential
Dimension 2 – Biomedical Conditions and Complications
Dimension 3 – Emotional, Behavioral or Cognitive Conditions and
Complications
Dimension 4 - Readiness to Change
Dimension 5 – Relapse, Continued Use or Continued Problem Potential
Dimension 6 – Recovery Environment
Is there a DSM – 5 diagnosis based on a thorough assessment?
Example: Alcohol Use Disorder – Mild, Moderate, or Severe

Continuum of Care – patients enter treatment at a level appropriate for their needs and step up for more intense treatment or down for less intense treatment.
• Level 1
• Level 2
• Level 3
• Outpatient Treatment
1 treatment encounter/week
• Intensive Outpatient
Treatment
3-5 treatment encounters/week
• Residential/Inpatient
2 weeks to one year

Residential Treatment
may need detox before residential
Focus on:
Stabilization
Acceptance
Skill building
Becoming relational
Relapse prevention planning
Possible housing/job skills

Education
• Alcohol/Drug education
• Relapse Prevention
• Mindfulness/Stress Reduction
• DBT/CBT
• Neuroscience of Addiction
• Diet/Sleep/Daily living activities
• Co-Occurring MH education
Anxiety, Depression, ADD, PTSD, etc.
• Family Education
Therapeutic Process Groups

What was important about residential?
“It gave me a safe and structured place to go through withdrawal.
It gave me the first glimpse of myself sober – the good and the not so good – that I had had in over a decade. I went in to residential thinking my only problem was an addiction to meth. I came out convinced I was an addict.
Writing a list of ten insane behaviors, which had to be whittled down from about ten thousand, convinced me that addiction was a disease, because there is no way any sane person could have done all the things I did and made all the choices I did, night after night, year after year, for my next hit.
Residential treatment also gave me a first taste of what it means to follow direction, trust in my counselors and guides, and to connect to other addicts.
- Kaiser patient/38 yr old male

Outpatient Treatment
• 1-5 treatment encounters per week
• Group education and process
• Individual counseling and treatment planning
• Integration of recovery efforts with daily life
• Consistent support and structure through changes

• Mindfulness
• Cognitive Behavioral Therapy
• Dialectical Behavioral Therapy
• Motivational Enhancement
• Seeking Safety/Mental Health

What was your treatment experience in an outpatient program?
“Well, obviously it provided a safe space for the months it took for my emotions and brain to calm down, and to engage many of the issues and problems that fueled my using in the first place. It taught me what it means to be honest and to value and respect the honesty of others, to let everyone have their own process and honor that. It has been the most thorough schooling in addiction I can imagine; every day in group brings a list of lessons about how this disease works, the different forms it can take with different drugs of choice or different people, the unique challenges addicts face, the skills they can use, and the stages of addiction or recovery. It provided needed structure and a more directly engaged process than twelve-step groups, though I think those groups are absolutely necessary for developing community, finding support, and rebuilding a new way of life.”
- Kaiser Patient/38 yr old male

Integration of community supports:
Many options – all road tested by others

One of the biggest challenges in early recovery is ________ ?
Staying focused. Making it through the emotions.
And the confusion.
Being told again and again, “More will be revealed.”
- Kaiser patient/38 yr old male

• Biopsychosocial Assessment
• Motivational Interviewing
• Advocacy
• Psycho-education
• Care Coordination
• Follow up
• Rx Adherence & Support
• Community resource education
• Tx planning and goal setting
• Multi-systemic settings and multidisciplinary assessments

Screening
Brief
Intervention
Referral to
Treatment
“A public health approach to the delivery of early intervention and treatment services for people with substance use disorders and those at risk of developing these disorders.”
SAMHSA

SBIRT implemented
• Routine and universal screening, regardless of medical complaint
• Validated, standardized screening tools
• Alcohol use seen as a continuum
No SBIRT
• Inconsistent and selective screening
• Non‐systematized narrative questions
• Alcohol use seen as dichotomous
• Evidence-based, patient-centered change talk
• Ineffective, directive style of communication
• Ongoing transition between primary care and treatment
• Discoordinate/unclear referrals and follow up

• F – Feedback
• R – Responsibility
• A – Advise
• M – Menu
• E – Empathy
• S – Self-efficacy

“The results of your questionnaire indicate that your use of alcohol puts you at risk from problems due to drinking.
Of course, any decisions regarding a change are yours to make.
As your doctor, I would like to share some advice with you on modifying your drinking habits – would that be ok?
I want you to know that we have a lot of options to help you, should you decide to make a change.
.
I know that change can be difficult and at the same time, I am confident that if you decide to change you will be able to do so. Would you like to talk about some options that we have for supporting you in this?”

medical
expert
Lots of options
Be genuine

F. What do you already know about how ______ affects your health?
Would it be ok if I share some information with you about ______? How does this affect your thinking?
R. These are always your choices to make and I am very interested to hear your thoughts.
A. From a medical standpoint, it would be better for your health to_______.
M. What are some things you have considered for making this change?
Why might you want to _______?
E. What are the three most important benefits for you to ____? How important is it for you, on a scale of 0-10, to make this change? Why are you at a ___ and not a lower number? If you did decide to ______, how would you do it?
S. Your willingness to talk about this today shows how important this is to you and I am confident that you can make progress towards the goals that you have for your health. What do you think your next step might be?