Substance Use Disorder (SUD)¶
Barrington Hwang, Kristopher Kast
Background¶
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SUDs are common, complex, and chronic neuropsychiatric disorders with well-described inherited risk, dysregulated neurophysiology, and multiple effective treatment modalities
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Pts w/SUD face significant stigma, prior traumatic experiences in healthcare environments
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Using the term “abuse” undermines the disease model of addiction
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Person-centered, specific terminology: “person with opioid and alcohol use disorders”
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Avoid the qualifier “Polysubstance.” Instead, clarify specific diagnoses for each substance category
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DSM 5 Criteria (same for most substance categories): Requires 2+ criteria met in past year; use must cause clinically significant impairment and/or distress:
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Loss of control – larger amounts, longer time, ongoing use despite consequences, efforts/desire to reduce use
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Physiologic changes -- tolerance, withdrawal (these 2 alone do not necessarily imply a disorder if they result from prescribed therapy), craving
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Consequences – hazardous use, interpersonal problems, medical problems, failed role obligations, lost activities
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General Management:¶
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First priority in the inpatient medical setting is to identify and stabilize withdrawal states
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Mitigate risks of severe sequelae (seizure, delirium)
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Avoid unintended iatrogenic harm (ex: opioid abstinence leading to lost tolerance and post-discharge overdose)
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Avoid distress-driven AMA discharge
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Consider Addiction Psychiatry consultation for management of complex withdrawal states, substance use disorders and co-occurring psychiatric diagnoses, assistance with risk stratification for hospital misuse and/or hospital discharge with PICC lines for outpatient antibiotics, and differentiation of pain requiring opioid therapy and opioid use disorder
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If in the emergency room and not admitted, consult PAS