Disclaimer: The answers below are general comments. They do not represent official policies of the American Academy of Addiction Psychiatry, nor are they recommendations for the clinical care of specific patients.
Addictions are not simply disorders of drug use, they are disorders of thought processes as it relates to drug use. Persons with SUDs often experience cognitive distortions, resulting in an increased valuation of substance/drug use compared to non-drug related experiences. So, substance use disorders, unless in recovery, can undermine a person's ability to attend to their children's safety and wellbeing. For for a person with a substance use disorder to safely have children in the home with them, they should be abstinent from substances/drugs and in a state of recovery defined by not meeting any of the DSM-5 diagnostic criteria for substance use disorders (with the exception of cravings, as ongoing craving does not preclude recovery states).
First, education should be provided for those working in all aspects of the justice/legal sections, such as probation, about how medications for treating opioid use disorders (MOUD) and other addictions are distinct from a person using substances related to a substance use disorder, and that MOUD is an evidence-based and medically sound approach to treating individuals with OUDs. Second, probation officers should get releases of information in case there are questions or issues of concern that require input of the probationer's prescriber.
Courtrooms by their very nature can be intimidating and trigger traumatic reactions, as individuals may have memories of being in court where various traumatic things happened. For example, courtrooms may represent a place where custody of children was removed or a place where the individual was detained and placed in handcuffs and shackles and where the individual felt humiliated. At the same time, court personnel may have trauma reactions recalling an individual yelling, threatening or being out of control. Some of these situations are unavoidable. At the same time, SAMHSA reminds us of the four R’s in being trauma informed: First, courtroom personnel should REALIZE that trauma is widespread among persons in court, including staff and defendants/respondents, and that there are paths to healing. They should also RECOGNIZE signs that an individual may be exhibiting a trauma, and with that recognition, court personnel can RESPOND to those signs and RESIST re-traumatizing individuals.
Pharmacology of Medications for Opioid use Disorder (MOUD)
Opinions in the medical community differ on this question, particularly as it pertains to certain populations. Generally, for treatment-seeking individuals, buprenorphine is thought to have minimal cognitive impairment compared to methadone. For certain groups, such as physicians or pilots, the concern about cognitive impairment is higher based upon the safety-sensitive nature of their professions, so some clinicians recommend naltrexone for individuals in safety-sensitive occupations.
Dosing of medications is individualized and there is no pre-determined therapeutic dose for either one. The goal for medication is to suppress opioid withdrawal, block effects of illicit opioids, reduce craving for opioid, and allow the individual to engage in psychosocial treatment and recovery-oriented activities. In other words, these medications allow the individual to go about their daily life without the chronic cycle of intoxication and withdrawal. Some imaging studies have found that saturation of the opioid receptors in the brain occurs at certain doses of medications, though this does not necessarily translate to the individual’s experience of withdrawal symptoms or cravings. A typical dose for buprenorphine is between 8mg to 16 mg, per day although some individuals require higher doses. For methadone, patients usually require doses of 60 mgs per day or higher. Adequate dosing greatly diminishes illicit opioid and other drug use.
Buprenorphine is an opioid, so the opioid-naïve person taking buprenorphine may experience a mild "buzz." Buprenorphine is a partial opioid agonist, so its effects will be less pronounced than full opioid agonists like oxycodone or heroin. However, for patients with OUD, buprenorphine is unlikely to result in a "high" sensation.
During pregnancy, women prescribed any medication should consult with their obstetrician. Almost always, pregnant women are advised to continue to take their MOUD during pregnancy. Research has shown that buprenorphine and methadone are both safe in pregnancy and associated with improved pregnancy outcomes including lower risk of relapse and better APGAR scores. Naltrexone is not recommended for pregnant women, and women with OUD, when pregnant, usually transition to buprenorphine or methadone. Pregnant women with OUD should not attempt to stop "cold turkey" because the relapse to opioid risk is very high, and the physiologic stress associated with opioid withdrawal can impair fetal development.
Starting buprenorphine (induction) for patients taking fentanyl or fentanyl-laced products is more complicated than induction in patients using short acting opioids such as oxycodone or heroin, due to the physiologic unpredictability of fentanyl. While the induction can be initiated around 12 hours after the last opioid dose was used, it is recommended to wait at least 36 or 48 hours before induction when fentanyl use is suspected to prevent precipitated opioid withdrawal.
Yes. An individual can be on pain medication for surgery while they are on MOUD, but it will depend on many factors, such as which medication they are on both for the pain and for their MOUD (for example, it is recommended that an individual be off of opioids when taking naltrexone). Also, there are many ways to treat pain and medications that do not create any concerns like Tylenol for example. If there is an opioid medication used to treat pain, there should be careful discussion and pre-planning to the extent possible about how to manage the OUD and the pain medications. Also, there are treatments for pain that do not involve medications. For acute pain following surgery, it is important to manage the pain appropriately with proper medical consideration of the OUD and the acute pain issues, including the use of opioids at times, so that the individual does not seek alternative pathways to treating their own pain with drugs of misuse. Also, it is important that the management of pain with opioid medications is for the most appropriate shortest duration and lowest dose to prevent secondary issues.
When a patient prescribed buprenorphine or any medication for addiction/opioid use disorder has a scheduled surgery, communication between the prescriber, the surgeon, and the patient about how best to manage pain related to the surgery is paramount. It will be important to consider the circumstances (i.e., the type of surgery, the anticipated recovery time, etc.) in making these decisions, and the course of action is highly dependent upon the particular circumstances of the case. Some individual’s post-operative pain can be managed well with adjustment of the buprenorphine for several days and adjunctive treatments. In other cases, it may be determined that the buprenorphine should be tapered and temporarily stopped around the time of the surgery.
Treatment of Opioid Use Disorder (OUD)
No. Although some people believe this to be true, the use of buprenorphine, naltrexone and methadone is much different than the use of illicit drugs. Medical professionals have extensive training in the assessment of individuals with OUD and particularly in the pharmacology of buprenorphine, naltrexone and methadone. Medical professionals are familiar with dosing, side effects, and interactions with other drugs, and prescribe the medication specifically for the individual. Furthermore, when buprenorphine, naltrexone or methadone are obtained from a legitimate source, such as a pharmacy or an outpatient treatment program, one is assured of the composition of that medication, unlike the purchase of substances on the street. As many people are aware, illicit pills are produced to look like a particular product but may contain deadly ingredients, such as fentanyl or carfentanyl. Also, individuals receiving treatment with buprenorphine, naltrexone or methadone do not place themselves in risky situations obtaining them, as often happens with the purchase of illicit drugs. There are many other differences, but these are the key differences and collectively represent a healthier lifestyle.
Substance use disorders share many similarities with other chronic diseases. For example, there are genetic predispositions, they follow a relapsing and remitting course, and environmental cues play a role. When a person develops a substance use disorder, changes in the brain occur which provoke the clinical and behavioral manifestations that we frequently encounter. In the same way that a person does not choose to have diabetes or hypertension, a person with a substance use disorder does note choose to have a compulsive, self-damaging pattern of substance use. We must focus our efforts on making proper treatment programs available and encouraging participation in treatment, because simply punishing diseases typically leads to disappointment.
Treatment of Substance Use Disorder (SUD)
They have not failed treatment. Several avenues can be explored in this scenario. One approach entails providing more structure around the treatment with the buprenorphine, such as: 1) more frequent appointments with the prescriber, 2) shorter prescription duration, 3) adjustment of buprenorphine dose, 4) addition of counseling or therapy services, 5) addition or enhancement of toxicology testing, or 6) engagement or enhanced engagement in mutual aid groups or peer support services. Another approach may be to revisit the medication choice for opioid use disorder and consider other medications such as naltrexone or methadone or Sublocade (injectable buprenorphine). Some individuals do better on methadone given the structure that is inherently provided at outpatient treatment programs, such as daily dosing and check-ins with a counselor/clinic staff. Each person is different and, as with any medication, treatment must be individualized.
Substance use disorders, like other medical conditions, may be managed in an outpatient setting, an inpatient setting and settings in between with various levels of medical oversight and monitoring all the way to non-medical support. An assessment of the level of care needed ensures that the treatment offered meets the needs of the individual, rather than putting people in a level of care based on a cookie cutter approach. For example, it would not make clinical sense to require all individuals identified with a substance use disorder to need residential placement, and residential-based treatment should not be a substitute for addressing homelessness if the person does not need that level of support for their addiction.
Medications used to treat opioid use disorder are designed to reduce/eliminate illicit opioid use. While we do not want a patient with opioid use disorder using any other addictive substances, provided no illicit opioid use has occurred, their opioid use disorder remains in remission. If they also have a co-occurring substance use disorder, they will need to be in treatment for that as well. A harm reduction approach to opioid use disorder treatment would be to permit occasional use of other substances provided there is no opioid use. However, other substance use is always discussed and discouraged. If cannabis use is occurring, adjustments could be made in the treatment program, i.e., more frequent visits, closer monitoring or referral to a higher level of care.
Psychiatric disorders and substance use disorders commonly co-occur. Some common psychiatric disorders that co-occur with substance use disorders include major depressive disorder, generalized anxiety disorder, PTSD, bipolar disorder and personality disorders.
There are several basic risk factors for the development of a substance use disorder. One of these risk factors is a family history of a substance use disorder. Those with a first degree (meaning mother, father, sibling) relative with a substance use disorder are at an elevated risk for developing a substance use disorder themselves and thus should proceed with added caution. Additionally, if one or both parents have an alcohol use disorder, exposure to alcohol during childhood is likely to increase and be normalized, thus creating an environmental risk factor.
Cannabis is not currently approved for or indicated for the treatment of anxiety. However, similar to alcohol, in the short term, use of cannabis may lead to a reduction in symptoms of anxiety. This may cause someone with an anxiety disorder to seek out cannabis or request it from a physician. Chronic use of cannabis may provoke a worsening of anxiety, paranoia, decreased motivation or a substance use disorder.
Benzodiazepines can be effective and safe medications if used appropriately to treat anxiety, especially in the short-term for acute issues. For example, it is common to be prescribed a benzodiazepine after an acute event, such as the loss of a loved one, or to treat anxiety associated with an adjustment to a new circumstance. Benzodiazepines, however, can be habit forming and dangerous when used with opioid-containing MOUD like methadone or buprenorphine. Benzodiazepine use should be monitored carefully, with awareness of who is prescribing the medication, along with the frequency and dosing of the medication. Since some patients may buy illicit benzodiazepines, there should be monitoring for any concerning observations such as over-sedation or frequent requests for prescription renewals beyond what would make sense clinically.
Much like family history is a risk factor for substance use disorders, so is a history of trauma. Resiliency and coping with traumatic events vary from person to person. Some will cope with a trauma by seeking a substance that provides temporary emotional relief. Over time, the emotional relief only comes in the presence of the substance, and this may lead to a substance use disorder.
Ask, ask, ask. Individuals who have experienced trauma or abuse deal with a lot of shame and guilt and are unlikely to volunteer information about their experiences. Healthcare providers should make it a regular part of their clinical interactions to ask about any history of traumatic experiences, demonstrate empathy when working with traumatized or otherwise victimized patients, and recognize that patients might initially deny having experienced trauma or abuse for long periods of time until they have established a strong therapeutic relationship with the clinician.
Treatment should always be individualized, and as such, there is no "right" duration to be in a residential or outpatient rehabilitation/treatment program. In fact, residential rehabilitation or treatment programs are not always indicated and can have the opposite effect when used in patients who are not ready for that level of care, as patients might not benefit from the program and see that experience as evidence of "treatment failure" or "treatment resistance." That might reduce the likelihood that they will seek out such services in the future when they might need them. Research demonstrates for many remaining in the home with family and support system can be more effective in maintaining their sobriety.
AA and NA are not treatment. They are mutual support groups where persons who have had similar experiences can support each other in a unique way. They should not be considered alternatives to medically driven, evidence-based treatment approaches. Rather, they should be utilized as ancillary services that support the actual treatments that patients are receiving. Some individuals find support groups to be extremely beneficial for their care, but others find it not as effective for their own personal needs.
In the past, there was a belief that underlying mental health conditions needed to wait until an individual “achieved sobriety” before their mental illness could be treated. It is now understood that substance use disorders and mental illness must be treated simultaneously to avoid one making the other worse. There are different medications used to treat anxiety and depression. Some of them have no or very low risk when combined with MOUD. However, one particularly concerning combination is the use of benzodiazepines (anti-anxiety medications with their own addiction potential) and opioids. Many overdoses are associated with the combined use of these medications. This does not mean that they can never be prescribed together; in fact, with a careful prescription regimen and monitoring, they can be used safely together in limited ways. Thus, the treatment of co-occurring psychiatric and substance use disorders should be handled by a prescriber familiar with monitoring and support for both conditions.
The frequency of screening for substances should be based on an individualized treatment plan and completed in a way that reflects the nature of the condition for which the person is being monitored. Screening can be broad or it can be narrow. Not all labs automatically test for all substances, and some substances may not have great laboratory testing options. It may be prudent in some cases for court personnel to work with a prescriber of MOUD around testing frequency. Courts and treatment providers can work together, even if they have to use different labs to follow up on an individual’s test results for legal reasons. At the same time there should be appropriate releases of information for sharing of information about clinical lab findings related to the use of substances, which will have different thresholds and parameters from some of the tests used for legal purposes.