Substance Use Disorder in Primary Care: Which Drugs Are Used and How to Intervene

Philip J. Gyura, MS, FNP-BC
Volume 56 - Issue 3 - March 2016

ABSTRACT: Substance use is a growing problem in the primary care setting. Screening and assessing patients for substance use is the first step in addressing this problem. Screening tools and other interventions can assist in evaluating which substances are being used in a given geographic area, can identify patients at risk, and can direct the care of these patients when help is wanted. Each substance of abuse has its own guidelines, counseling techniques, and pharmacologic treatments. The goal of substance use disorder intervention is to build a relationship with patients, to identify the substance being used, and to employ patient-centered methods to help patients achieve better health and, potentially, sobriety.

KEYWORDS: Substance use disorder, alcohol, marijuana, opiates, benzodiazepines, cocaine, amphetamines, motivational interviewing, primary care

More than half of all Americans 12 years and older drink alcohol, which translates to an estimated 136.9 million current drinkers, according to the Substance Abuse and Mental Health Services Administration.1,2 Among this population, 16.5 million (6.3%) report heavy drinking. The number of Americans 12 and older who have used illicit drugs in the past month is 24.6 million (9.4%), with 21.6 million (8.2%) of them meeting the criteria for substance use disorder.1,2

In the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the American Psychiatric Association combined the criteria for substance abuse and substance dependence, and replaced the terms abuse and dependence in diagnostic terminology with the term use disorder.3 The disorders are listed from mild to severe depending on the criteria met.

Screening and interventions for alcohol use are standard in most practices,4 but health care providers must also keep up to date with trends in substance use in their geographic area. This article is an overview of the substances that are commonly used in the United States and the methods that health care providers can use in primary care to help patients achieve their optimal health.

Alcohol

In the United States, approximately 136.9 million people 12 years or older self-reported consuming alcohol in 2013.1,2 Of those, 60.1 million (22.9%) reported binge drinking, and 16.5 million (6.3%) reported heavy drinking.1,2 In the DSM-5, alcohol abuse and alcohol dependence have been combined into alcohol use disorder (AUD), labeled as mild to severe.3,5

Screening for AUD in primary care is recommended by the US Preventive Services Task Force,6 and there are multiple acceptable tools.7 Similar to treating other chronic illnesses, health care providers must assess a patient’s alcohol use to determine whether they can provide the necessary level of care or if the patient must be referred for a higher level of care, such as inpatient treatment or emergency department (ED) care.6 If the patient is stable enough to be treated in an outpatient office, the clinician can use a 2-prong method of behavioral counseling interventions and pharmacologic management.

Behavioral counseling interventions can be done in a 15-minute office visit, without requiring the entire visit. Evidence suggests that patients with AUD have best results when they have multiple short counseling interventions up to 10 minutes each rather than a single long session.7 The outpatient medical management of AUD has had barriers in the past due to clinicians’ lack of familiarity with the therapeutic options.6 Research has shown that there are many options, with the best option depending on the patient’s drinking pattern.

The oldest option, disulfiram, has been shown to work in motivated individuals who can be monitored every day for adherence.8 Topiramate also can be used as an off-label option, but this option requires further study.8

Acamprosate and oral naltrexone are considered the strongest options for reducing alcohol consumption or maintaining sobriety.6 In a comparative study,9 acamprosate was found to be more useful in promoting abstinence, while oral naltrexone was found to help reduce heavy drinking. Both medications have been shown to work better if initiated after the patient has undergone detoxification—the safe, controlled stopping of a substance of dependence.10 When choosing how to detoxify a patient safely, a clinician must take into consideration the patient’s preferences, the severity of AUD, and the clinician’s own comfort with detoxifying the patient.10 Detoxification can be done in the outpatient setting using benzodiazepines on a set dosing schedule, or it can be done in a hospital inpatient setting.11 To be safely achieved, however, outpatient detox requires extra education and setup by the provider.12

Marijuana

In 2013, marijuana was the most commonly used illicit drug in the United States, reportedly used by 80.6% of illicit drug users that year.1 Daily or near daily users of marijuana increased from 5.1 million persons in 2005 to 2007 to 8.1 million persons in 2013.2

Marijuana is available in forms that can be smoked, vaporized, or ingested. Its main active ingredient is tetrahydrocannabinol (THC), which produces the psychoactive effects of mild euphoria, reduced anxiety, improved mood, and stimulation of appetite.13 Adverse cognitive effects of marijuana include impaired memory, impaired motor coordination, altered judgment, and, in high doses, paranoia and psychosis.14 Research findings have called into question the short- and long-term effects of marijuana use, with strong correlation with increased response time, prolongation of word viewing time, basic oculomotor deficit, impaired residual verbal memory, and impaired executive functioning, with an additional association between cannabis and psychotic disorders.15 Newer research shows evidence of respiratory and cardiac harm with cannabis use.13

Due to the high prevalence of marijuana use, health care providers should screen all patients for it. If the patient uses marijuana more than twice a week, the provider should determine severity, including amount, frequency, withdrawal, tolerance, and attempts to reduce use, using the severity of addiction criteria.13 Cannabis use must be assessed in the same way as alcohol use is assessed. Just as not all forms of alcohol are equal, not all forms of cannabis are equal in potency, route, frequency, and concentration. The provider must consider this information during the assessment.16

No pharmaceutical options are available for the treatment of cannabis use, although a number of options have been studied. The antidepressants bupropion and buspirone and the norepinephrine reuptake inhibitor atomoxetine showed little or no affect on dependency; further research into the use of THC supplements as treatment options must be conducted before they can be used.14

Health care providers can offer a patient brief counseling and use a harm-reduction model to help reduce any adverse affects that marijuana use might be causing.16 If the patient’s condition is not responding properly or if the risks to the patient are deemed too high, referral to a higher level of care is appropriate.13

Opiates

Opiate use disorder is a chronic, relapsing condition with a high mortality rate. Using the DSM-5, it is identified using 11 criteria.17 An estimated 750,000 to 1 million Americans are dependent on heroin.17 In 2013, 4.5 million Americans engaged in nonmedical use of prescription opiates, and approximately 1.9 million met the criteria for an opiate-use disorder in the previous year.1

Pharmacologic substitution therapy with the partial µ-opioid receptor agonist buprenorphine combined with the potent µ-opioid antagonist naloxone in a 4:1 ratio has proven to be the most effective option for this population, especially when given in combination with psychosocial interventions.18 When taken sublingually, the naloxone exerts no effect, and the action of buprenorphine predominates.19

Buprenorphine-naloxone is an effective maintenance therapy for opioid use disorder and can be dispensed legally from a primary care office.19 It also has been shown to be cost-effective.20 Buprenorphine-naloxone treatment programs have been shown to be successful in the setting of a nonspecialized primary care office with limited resources.21

Benzodiazepines

Benzodiazepines (BZDs) have been prescribed for generations for conditions involving anxiety and insomnia. Their duration of use for treating moderate to severe anxiety should be between 2 and 4 weeks, and their use for patients with insomnia should be reserved for only those with severe symptoms not responding to more conventional therapies.22

BZD treatment can be very beneficial initially, but with time the patient builds a tolerance to the medication and has to take higher doses and experiences withdrawal symptoms when attempting to reduce or stop use.23 Withdrawal symptoms related to BZD use include rebound anxiety, depression, nausea, perceptual changes, and even seizures and psychosis in rare instances. These symptoms can arise from a few hours to 3 weeks after taking the medication.23 The withdrawal of BZDs should be done slowly to get the patient to the lowest possible dose.10 This can be done either by using the patient’s own medication or switching to a long-acting BZD such as diazepam. The withdrawal should take place over 8 to 12 weeks for most patients, but some patients might require 6 months.24 Cognitive behavioral therapy also was found to be helpful in reducing BZD use over 3 months.23

Cocaine

Cocaine can be used as a powder for intranasal or injection use or smoked as a free-base form (crack cocaine). Cocaine dependence is a major public health problem because of the associated medical risks and psychosocial complications, including the spread of infections such as HIV, hepatitis, tuberculosis, as well as crime, violence, and neonatal drug exposure.25 In 2013, approximately 1.5 million people aged 12 and older reported current use of cocaine in any form.1

Many pharmacotherapies, including stimulants,26 antidepressants,25 antipsychotics,27 and anticonvulsants28 have been tried in the treatment of cocaine use, with all showing little or no evidence of maintaining substance abstinence or retention in a treatment program. Research is ongoing on a stimulant vaccine that uses antibodies to block the drug from crossing the blood-brain barrier.29

Chronic cocaine use cycles between binge and abstinence, contributing to the addictive nature of the substance, with 10% to 15% of users becoming dependent.30 The adverse effects related to cocaine use are vast, ranging from cardiac complications to nervous system toxicity. Health care providers must screen, intervene, and refer patients who use cocaine to optimize recovery and avoid potential medical complications.30

Amphetamines

Amphetamines come in numerous forms, from the street drug methamphetamine (otherwise known as “crystal,” “crank,” “speed,” or “meth”), its crystalline form (“glass” or “Tina”), or prescription medications for attention-deficit/hyperactivity disorder, narcolepsy, and weight control.

Methamphetamine has a long history of use in the United States dating to the 1990s in California; it saw its peak production in 2000, with 10,249 methamphetamine laboratories seized by US law enforcement officials.30 In 2013, more than half a million Americans reported having used methamphetamine in the past month.1

The effects of methamphetamine on the body are similar to those of cocaine but can present in a more exaggerated manner, due to that the half-life of the drug is 10 to 12 hours, compared with the 30- to 60-minute half-life of cocaine; moreover, methamphetamine has possible long-term effects on behavior and brain function with chronic use.31

Withdrawal from amphetamines can create intense cravings and hyperarousal, with possible clinically severe suicidal ideation or attempts.32 For these reasons, research has focused on finding a medication to treat amphetamine withdrawal. Recent research points to the possibility of mirtazapine to reduce withdrawal symptoms, but more research is needed.32 Stimulant treatment involves behavioral and psychosocial approaches that are best achieved in a higher level of care than a primary care office, so referral to addiction specialist services should be made.30

Other Substances of Abuse

Synthetic cannabinoids. Synthetic marijuana is sold routinely in retail locations under the label “potpourri” or “herbal incense,” despite that its sale is illegal in many states. On the street it may be called “K2,” “genie,” or “Yucatan fire,” but most commonly it is referred to as “spice.”33 With the intention of circumventing controlled substance laws, the manufacturers of these products change the chemical compounds routinely and label them, for example, as “unsafe for human consumption.”33

In 2012, 11.3% of high school seniors reported using synthetic marijuana in the past year.1 These products are relatively inexpensive and widely available, with the added benefit being undetectable on drug screening tests.34 The number of reports to poison control centers of spice-related incidents rose from 13 in 2009 to 6959 in 2011.33 Synthetic cannabinoids are more toxic and potent than THC, the concentration of each batch is unpredictable due to a lack of quality control, and there is a high potential for abuse due to mainstream availability.34

Treatment for synthetic marijuana withdrawal is mostly supportive, but patients with toxicity should be referred to an ED.34

Synthetic cathinones. The use of synthetic cathinones, or “bath salts,” has been increasing in the United States, with poison control centers reporting zero reports in 2009 to 5625 in 2011.33

Synthetic cathinones give users a high much like cocaine, methamphetamine, or 3,4-methylenedioxy-methamphetamine (MDMA). The substance also is known on the street as “ivory wave,” “bliss,” “white lightning,” “M-cat” and “meow meow,” and as with synthetic cannabinoids, sales of these products are hidden by labels that deem them unsafe for human consumption while being sold as bath additives.35

The 3 main chemicals in bath salts are 4-methylmethcathinone (mephedrone), 3,4-methylenedioxymethcathinone (methylone), and 3,4- methylenedioxypyrovalerone (MDPV), and they are designed to mimic the effects of the khat plant (Catha edulis), which contains cathinone, a substance that has been popular in East Africa and the Arabian peninsula for centuries due to its amphetamine-like stimulant properties.33

In the United States, toxicology tests are used to detect MDPV in patients who present with toxic symptoms. Bath salt toxicity has been associated with agitation, delirium, acidosis, sustained hyperthermia, and autonomic dysfunction, as well as cardiovascular symptoms, and it should be considered life-threatening with an emergent need for high-level care.35 Patients using these products need extensive education and an assessment for abuse potential with appropriate referrals to treatment.33

MDMA. MDMA, also known as “ecstasy” or “Molly,” is an illicit drug that has both stimulant and hallucinogenic properties. MDMA usually is taken by mouth but also can be snorted or smoked. MDMA produces feelings of increased energy and euphoria, and it distorts the user’s senses and perception of time.36

The use of MDMA has increased, and with it, related ED visits of people under 21 years old increased 128% between 2005 and 2011; 33% of those visits were attributed to taking ecstasy while consuming alcohol.36 The health effects of MDMA use are varied due to the additives in MDMA pills purchased on the street, including stimulants, methamphetamine, or bath salts; the long-term health effects are yet unclear.37 Thus, patients must be educated about the use of MDMA, the possible adverse effects when taken with alcohol, and the possible presence of additives that can cause even more harm.36

Because MDMA may cause hyperarousal, the related increased sexual activity may require safe-sex education and screening for sexually transmitted infections.38 While taking pure MDMA has an unclear abuse potential with some dependency, research is ongoing into its potential use in the treatment of posttraumatic stress disorder, as well as anxiety in patients with terminal cancer.38

Over-the-counter medications. In 2006, approximately 3.1 million people in the United States between the ages of 12 and 25 used an over-the-counter (OTC) cough or cold medication to get high.1 The most commonly abused product was dextromethorphan, a common ingredient in cough and cold preparations.1 Other commonly abused OTC products are antihistamines, laxatives, and nicotine replacement products.39 Because of the potential for abuse, teenagers and young adults in particular should undergo screening for their use.

Intervention

Substance use disorders in primary care usually are uncovered through the use of standard screening tools, but the patient often is unwilling to change or is unaware that change might be needed. Numerous tools may be used to determine a patient’s readiness for change; a number of motivational tools also are available.

The transtheoretical model (TTM) of behavior change (stages of change) is a tool to assess a patient’s readiness for change that is widely used in the substance-abuse specialty.40 The stages of the TMM are precontemplation (the person has no intention of changing behavior), contemplation (the person has awareness of the problem and has thoughts about taking action), preparation/action (the person intends to take action in the near future, makes overt changes in behavior and shows a commitment to change), and maintenance (relapse prevention and treatment gains).40

Once a patient’s stage has been established, a health care provider can use motivational interviewing (MI) to help the patient either progress to a new stage or help the patient maintain his or her current stage. MI is a patient-centered method of guiding conversation to elicit strength and personal motivation for change, and it is the polar opposite of giving unsolicited advice.41 MI has been proven to produce a significant positive impact on patient outcomes related to the amount of alcohol consumed and marijuana used.42

The use of MI is based on 3 key components: collaboration, evocation, and autonomy. There is equal collaboration between the patient and the provider; the provider is not the expert. The evoked thoughts and change must come from the patient and not be an imposed idea from the provider. Patients must be autonomous in their change, and the strength to change must come from them.41 The general principles of MI include expressing empathy through reflective listening; developing discrepancies by emphasizing patients’ own discrepancies in behavior vs their goals; avoiding arguments and direct confrontation, since it patients are responsible for their own change; rolling with resistance as it arises by involving patients in problem-solving; and supporting self-efficacy and optimism.41 These components of MI are not hard rules but instead are a guide for conversation. They are easily implemented in primary care because they are meant to be brief encounters.

Summary

While primary care providers historically have been unprepared to assist patients with substance use disorders, the relatively high prevalence of substance use among the US population requires knowledge of and preparedness for the detection and treatment of use disorders. Health care providers must educate themselves on the substances that are used prevalently in their areas and their potential for abuse. Providers must also strive to increase their knowledge base and comfort level about in-office treatment and to know when to refer patients to a higher level of care. With thorough screening, appropriate pharmacotherapy, and behavioral counseling, primary care providers can effectively manage their patients’ substance use disorders.

Philip J. Gyura, MS, FNP-BC, AAHIVS, is a student in the Doctor of Nursing Practice program at the Columbia University School of Nursing and is a family nurse practitioner at Harlem United in New York, New York.

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Acknowledgement:

Philip J. Gyura gratefully acknowledges Ashley N. Gyura, MS, CPNP-PC, Casey M. Clark, MS, FNP-BC, Susan Doyle-Lindrud, DNP, ANP, DCC, and Elizabeth K. Hall, DNP, FNP, GNP, at the Columbia University School of Nursing for assistance and guidance in writing this article.

Click here to read about our experiences with implementing an outpatient detox program.