Developing Education and Treatment Protocols for Substance Use Disorders That Are Socially Responsible, Accountable, and Integrated: Recovery Engagement—Recognize and Treat
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Educating medical professionals regarding opioid use disorders and the process of developing an increased knowledge base to improve decision-making regarding patients continues to be an important topic in the area of treating substance use disorders (SUD). Increased knowledge and improved processes for dealing with a patient in crisis struggling with an SUD will assist medical professionals dealing with this population toward making better and, in some cases, lifesaving decisions. There appears to be a persistent gap between the medical professionals and addiction professionals regarding the importance of sharing knowledge and experiences in the effective treatment of SUD that could significantly improve the outlook and prognosis and treatment outcomes. This chapter will discuss the scope of the problem, recognition of common SUD symptoms, basic information regarding the diagnosis and treatment of SUD, basic information about diagnosis and addiction severity, understanding motivation for the patient struggling with an SUD, and promising approaches or best practices for the treatment of SUD with this population.
Scope of the Problem
Volkow et al.1 (2014) estimated that over 2 million people in the United States suffer from substance use disorders related to prescription opioid pain relievers. The Institute of Addiction Medicine (2008) reported that Americans, who represent less than 5% of the world’s population, are by far the largest group of opioid users; 80% of the world’s supply of opioids (99% of the hydrocodone available globally) are used by people in the United States, and nearly 31% started with the nonmedical use of prescription drugs. Despite this knowledge regarding the effect on the general population, only recently has there been training and information provided to medical professionals about how to recognize symptoms of an SUD. Even then, there seems to be minimal resources dedicated to providing education to medical professionals regarding addiction severity, the role of treatment, and finally misunderstanding about the purpose and goals of treatment and recovery.
Recognition of SUD Symptoms and Patient Motivation
Recognition of an SUD necessitates that any medical professional faced with a patient in medical crisis must first have some level of awareness that any patient in front of them could be struggling with an active SUD while experiencing other medical conditions that require immediate attention. Patients struggling w'ith an SUD in “active” use often will have a history of other mental health or medical conditions that are, according to them, urgent and in need of immediate attention. A patient struggling with an SUD will often NOT be motivated to see their SUD as a problem, but rather be motivated to find a solution to their discomfort that will include continued use. Addiction will manifest itself in a variety of forms and substance preferences, but the culture surrounding their addictive thoughts and behaviors will have some universality.
For example, let’s take a patient with active SUD whose drugs of choice are prescribed medications such as an opioid or benzodiazepine. In spite of observable symptoms—restlessness, disturbed sleeping patterns, confused thinking, or exaggerated physical aches and pains—this patient will maintain that their prescribed medications are necessary and helpful. There will be no overt or noticeable motivation by the patient to consider ceasing any or all substance use. It is also doubtful that ceasing use will be their first thought or choice. It is realistic to expect that many will become defensive about a previous diagnosis that precipitated the necessity of prescription(s) and will attempt to explain and defend the importance of maintaining these prescriptions. It is common, regardless of the substance of preference, for these types of observable behaviors to be present when a patient is dealing with any acute or chronic medical condition and an SUD. Now, let’s explore specific symptoms and their impact on motivation.
There are various explanations of why some patients escalate into an SUD. Some will point to a biological cause, such as having a family history of drug or alcohol abuse. Others will suggest abusing drugs can lead to affiliation with using peers, which, in turn, exposes the individual to progressive use. For example, Hawkins et al.2 (1992) studied youth risk and protective factors and found that those individuals who rapidly escalated into an SUD tend to have higher risk factors and lower levels of protective factors. Gender, race, and geographic location have also been found to play a role. One critical factor to consider is age—the earlier people are exposed to substance use the more likely they are to experience a change in brain state. There are several qualitative studies that suggest that patients who end up addicted and struggling with an SUD described their initial exposure to a mood-altering substance at extraordinarily young ages, which likely exposed a developing brain to the increased risks associated with SUD.
A practical conceptual framework of progression is best described as a patient’s increased use of any mood-altering substances over the course of time. A practical definition of progression is a patient’s need to self-regulate through the use of mood-altering chemicals to alleviate any perceived discomfort, perceived pain, or emotions that appear disruptive despite the increased risk.
The precise relationship between self-regulation and substance use disorders is still not fully explained through research. Several researchers have investigated the role that self-regulatory temperament (e.g., relatively stable individual differences in self-regulatory ability) may play in promoting vulnerability to or resilience relevant to other contextual risk factors for substance use,3-5 but there is not a conclusive answer as to the reasons why people use substances to self-regulate. However, we can look at examples of responses in a variety of external stressors—for example medical problems—that over time start to appear irrational, exaggerated, or self-justified.
When people have progressed into a state of active addiction, they have progressed into a chronic, often relapsing, but treatable brain disease. One characteristic of addiction is cravings. Essentially, cravings tell a patient’s brain that continued use is critical to survival. Cravings are what drive the addicted patient to continue to use and progress to increased amounts, despite the damage that it creates in their life and in the lives of those around them. Patients struggling with an SUD will often attempt to minimize their levels of progression and the damage this progression has caused.