Substance Use Disorder (SUD)¶

Ben Johnson

Background¶

SUDs are common, complex, and chronic neuropsychiatric disorders with well-described inherited risk, dysregulated neurophysiology, and multiple effective treatment modalities
Patients with SUD face significant stigma, prior traumatic experiences in healthcare environments
- Using the term “abuse” undermines the disease model of addiction and perpetuates stigma
- Person-centered, specific terminology: “Person with opioid and alcohol use disorders”
Avoid the qualifier “Polysubstance.” Instead, clarify specific diagnoses for each substance category
DSM 5 Criteria (same for most substance categories): Requires 2+ criteria met in past year and the patient’s use must cause clinically significant impairment and/or distress:
- Loss of control: Larger amounts, longer time, ongoing use despite consequences, efforts/desire to reduce use
- Physiologic changes: Tolerance, withdrawal (these 2 alone do not necessarily imply a disorder if they result from prescribed therapy), craving
- Consequences: hazardous use, interpersonal problems, medical problems, failed role obligations, lost activities

First priority in the inpatient medical setting is to identify and stabilize withdrawal states
- Mitigate risks of severe sequelae (seizure, delirium)
- Avoid unintended iatrogenic harm (e.g. opioid abstinence leading to lost tolerance and post-discharge overdose)
- Avoid distress-driven AMA discharge (discrimination resulting from stigma)
Consider Addiction Psychiatry consultation for:
- Management of complex withdrawal states
- Substance use disorders and co-occurring psychiatric diagnoses
- Assistance with risk stratification for discharge with PICC lines for outpatient antibiotics and/or people who continue to use illicit substances while hospitalized
- Differentiation of pain requiring opioid therapy and opioid use disorder
- Harm reduction resources
If in the emergency room and not admitted, consult PAS