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Substance Use Disorder (SUD)

Barrington Hwang, Kristopher Kast


  • SUDs are common, complex, and chronic neuropsychiatric disorders with well-described inherited risk, dysregulated neurophysiology, and multiple effective treatment modalities

  • Pts w/SUD face significant stigma, prior traumatic experiences in healthcare environments

    • Using the term “abuse” undermines the disease model of addiction

    • Person-centered, specific terminology: “person with opioid and alcohol use disorders”

  • Avoid the qualifier “Polysubstance.” Instead, clarify specific diagnoses for each substance category

  • DSM 5 Criteria (same for most substance categories): Requires 2+ criteria met in past year; use must cause clinically significant impairment and/or distress:

    • Loss of control – larger amounts, longer time, ongoing use despite consequences, efforts/desire to reduce use

    • Physiologic changes -- tolerance, withdrawal (these 2 alone do not necessarily imply a disorder if they result from prescribed therapy), craving

    • Consequences – hazardous use, interpersonal problems, medical problems, failed role obligations, lost activities

General Management:

  • First priority in the inpatient medical setting is to identify and stabilize withdrawal states

    • Mitigate risks of severe sequelae (seizure, delirium)

    • Avoid unintended iatrogenic harm (ex: opioid abstinence leading to lost tolerance and post-discharge overdose)

    • Avoid distress-driven AMA discharge

  • 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

  • If in the emergency room and not admitted, consult PAS

Last update: 2022-06-26 15:47:54