Substance Use Disorder Management

Assessment and Screening

• Brief validated screening tools should be used to assess substance use patterns and conduct brief assessments to stratify patients into hazardous use, substance abuse, or substance dependence categories, as recommended by the American Academy of Family Physicians, with a strength of evidence rated as high 1

Treatment Approach

• Combined pharmacotherapy and cognitive behavioral therapy is recommended for substance use disorders, according to the American Medical Association 2
• A combination of counseling, referral to specialty treatment, and appropriate pharmacotherapy should be implemented for substance dependence, as suggested by the American Academy of Family Physicians 1
• Cognitive behavioral therapy combined with current pharmacotherapy is recommended, as per the American Medical Association 2

Monitoring and Follow-up

• Regular urine drug screening and frequent follow-up appointments should be conducted to monitor substance use and assess treatment response, using a motivational interviewing approach rather than a confrontational style, as recommended by the American Academy of Family Physicians 1

Medication Management

• The effectiveness of the current regimen should be evaluated, and adjustments should be made before adding new agents, considering potential interactions and risks, with a strength of evidence rated as moderate 1
• Non-stimulant options like atomoxetine may be safer with lower abuse potential, especially in patients with substance use disorders, according to the American Psychiatric Association 2
• Lorazepam is recommended as a PRN anxiety medication due to its short half-life, which reduces the risk of accumulation and prolonged sedation, with an initial dosage of 0.5-1 mg PO every 4 hours as needed, as recommended by the American Academy of Family Physicians and the National Comprehensive Cancer Network 3, 4
• The maximum daily dose of lorazepam should generally not exceed 4 mg for PRN use 4
• Buspirone (BuSpar) is an alternative option for anxiety management, with an initial dose of 5 mg twice daily, which may take 2-4 weeks to become effective 3
• Benzodiazepines should be avoided in patients with a history of substance use disorders, severe respiratory disease, sleep apnea, or concurrent use of opioids 3
• Bupropion should be used with caution or avoided in patients with seizure disorders, history of seizures, eating disorders (anorexia nervosa or bulimia), or uncontrolled hypertension 5, 6
• For long-term anxiety control, consider adding an SSRI (if Wellbutrin is being used for depression) or buspirone (if the patient has chronic anxiety), as recommended by the American College of Physicians 3, 7, 8
• Aripiprazole or other atypical antipsychotics may be considered for more treatment-resistant cases 7
• Cognitive behavioral therapy, mindfulness practices, and stress management techniques are recommended as adjuncts to medication for anxiety management 3
• Bupropion is associated with lower rates of sexual dysfunction compared to selective serotonin reuptake inhibitors (SSRIs) and may be beneficial for patients with depression who also have sexual dysfunction, weight gain concerns, need for smoking cessation, or low energy or fatigue as prominent symptoms, but may not be ideal for patients with anxiety as a predominant symptom or seizure risk factors 3, 9, 10, 6
• Patients should be monitored closely for side effects and reassessed in 4-6 weeks after augmentation therapy, particularly for potential drug interactions with SSRIs that inhibit CYP2D6 and the emergence of serotonin syndrome if combining with serotonergic agents, as recommended by the American College of Physicians 7