Opioid addiction is a neurobehavioral syndrome characterized by the repeated, compulsive seeking or use of an opioid despite adverse social, psychological, and/or physical consequences.
Addiction is often (but not always) accompanied by physical dependence, a withdrawal syndrome, and tolerance. Physical dependence is defined as a physiological state of adaptation to a substance, the absence of which produces symptoms and signs of withdrawal. Withdrawal syndrome consists of a predictable group of signs and symptoms resulting from abrupt removal of, or a rapid decrease in the regular dosage of, a psychoactive substance. The syndrome is often characterized by over-activity of the physiological functions that were suppressed by the drug and/or depression of the functions that were stimulated by the drug. Tolerance is a state in which a drug produces a diminishing biological or behavioral response; in other words, higher doses are needed to produce the same effect that the user experienced initially.
It is possible to be physically dependent on a drug without being addicted to it, and conversely, it is possible to be addicted without being physically dependent (Nelson et al. 1982). An example of physical dependence on opioids without addiction is a patient with cancer who becomes tolerant of and physically dependent on opioids prescribed to control pain. Such a patient may experience withdrawal symptoms with discontinuation of the usual dose but will not experience social, psychological, or physical harm from using the drug and would not seek out the drug if it were no longer needed for analgesia (Jacox et al. 1994).
Pharmacotherapy alone is rarely sufficient treatment for drug addiction (McLellan et al. 1993). Treatment outcomes demonstrate a dose response effect based on the level or amount of psychosocial treatment services that are provided. Therefore, physicians have an additional level of responsibility to patients with opioid addiction problems; this responsibility goes beyond prescribing and/or administering buprenorphine. For most patients, drug abuse counseling—individual or group—and participation in self-help programs (e.g., Alcoholics Anonymous [AA]; Narcotics Anonymous [NA]; Methadone Anonymous, a 12-Step group that supports recovery concurrent with OAT; Self Management and Recovery Training [SMART] Recovery; or Moderation Management) are considered necessary. Self-help groups may be beneficial for some patients and should be considered as one adjunctive form of psychosocial treatment. It should be kept in mind, however, that the acceptance of patients who are maintained on medication for opioid treatment is often challenged by many 12-Step groups. Furthermore, many patients have better treatment outcomes with formal therapy in either individual or group settings.
The ability to provide counseling and education within the context of office-based practice may vary considerably, depending on the type and structure of the practice. Psychiatrists, for example, may include components of cognitive-behavioral therapy or motivational enhancement therapy during psychotherapy sessions. Some medical clinics may offer patient education, which generally is provided by allied health professionals (e.g., nurses, nurse practitioners, physician assistants). A drug abuse treatment program typically includes counseling and prevention education as an integral part of the clinic program. In a stand-alone general or family practice, the opportunities for education/counseling may be more limited. As part of their training in opioid addiction treatment, physicians should obtain, at a minimum, some knowledge of the basic principles of brief intervention in case of relapse. (See appendix E.) Physicians may want to consider providing to office staff some training in brief treatment interventions and motivational interviewing; this information could also enhance the effectiveness of treatment for other medical problems. A list of trainers may be found at http://www.motivationalinterview.org.
Many physicians already have the capability to assess and link substance abuse patients to ancillary services for substance abuse. Physicians considering making buprenorphine available to their patients should ensure that they are capable of providing psychosocial services, either in their own practices or through referrals to reputable behavioral health practitioners in their communities. In fact, the Drug Addiction Treatment Act of 2000 (DATA 2000) stipulates that, when physicians submit notification to the Substance Abuse and Mental Health Services Administration (SAMHSA) to obtain the required waiver to practice opioid addiction therapy outside the OTP setting, they must attest to their capacity to refer such patients for appropriate counseling and other nonpharmacological therapies.
It is incumbent on practitioners of buprenorphine treatment to be aware of the options and services that are available in their communities and to be able to make appropriate referrals. Physicians should be able to determine the intensity of services needed by individual patients and when those needs exceed what the practitioner can offer. Contingency plans should be established for patients who do not follow through with referrals to psychosocial treatments. Physicians should work with qualified behavioral health practitioners to determine the intensity of services needed beyond the medical services.
Factors contributing to the development of opioid addiction include the reinforcing properties and availability of opioids, family and peer influences, sociocultural environment, personality, and existing psychiatric disorders. Genetic heritage appears to influence susceptibility to alcohol addiction and, possibly, addiction to tobacco and other drugs as well (Goldstein 1994).
This information on treating Opioid Dependence and Addiction is from the Substance Abuse and Mental Health Services Administration’s manual.
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