_________________________________________________________________________ Opioid Use Disorder
ACUPUNCTURE Auricular acupuncture is the most common acupuncture approach for substance abuse, including opioid abuse and dependence, in the United States and the United Kingdom. This technique consists of bilateral insertion of acupuncture needles in the outer ears [178]. There is controversy sur- rounding the presumed mechanism of action of acupuncture. Western scientists attempt to explain its action on the body’s electromagnetic system, with the acupuncture needle creating a difference in electrical potential that stimulates extracel- lular ion flow. Chinese practitioners, who have been using acupuncture for several thousand years to treat a wide range of maladies, attribute its effects to unblocking or removing an excess of qi , or life energy, along key channels referred to as meridians [179]. Results from well-designed studies indicate that auricular acu- puncture treatment is not sufficient in efficacy as a stand-alone treatment for opioid dependence. The placebo response rate is substantial, and the body of evidence does not demonstrate the type of qualitative and quantitative rigor needed to vali- date acupuncture efficacy in the treatment of opioid-addicted patients. Common adverse events from acupuncture include needle pain, fatigue, and bleeding; fainting and syncope are uncommon. Feelings of relaxation are reported by as many as 86% of patients [178]. There is some evidence that differences in efficacy may be influenced by racial physiologic differences among persons of European and Asian descent [178]. A 2016 review of 199 studies found that contradictory results, intergroup differences, and acupuncture placebo effects made it difficult to evaluate the effectiveness of acupuncture for drug addiction treatment [180]. The authors of another review looked at clinical trials of 100-Hz electroacupuncture for detoxification treatment. They found a potential for the treatment to allay opioid-associated depression and anxiety but no effect for opioid craving [181]. INTERVENTIONS FOR NON-ENGLISH-PROFICIENT PATIENTS For those who are not proficient in English, it is important that information regarding the risks associated with the use of opioids and available resources be provided in their native language, if possible. When there is an obvious disconnect in the communication process between the practitioner and patient due to the patient’s lack of proficiency in the English language, an interpreter is required. Interpreters can be a valu- able resource to help bridge the communication and cultural gap between patients and practitioners. Interpreters are more than passive agents who translate and transmit information back and forth from party to party. When they are enlisted and treated as part of the interdisciplinary clinical team, they serve as cultural brokers, who ultimately enhance the clinical encounter. In any case in which information regarding treat- ment options and medication/treatment measures are being provided, the use of an interpreter should be considered. Print materials are also available in many languages, and these should be offered whenever necessary.
MANAGEMENT OF COMORBID PSYCHOPATHOLOGY
Psychiatric comorbidity often accompanies opioid dependence and plays an important role in treatment outcome. Multiple national population surveys have found that roughly 50% of those who experience mental illness during their lives will also experience a substance use disorder and vice versa [182; 183]. More than 60% of adolescents in community-based substance abuse treatment programs also meet diagnostic criteria for another mental illness [184]. An estimated 43% of individuals in treatment for nonmedical use of prescription opioids have a diagnosis or symptoms of a mental health disorder, particularly depression and anxiety [185]. Major depression prevalence among opioid-dependent patients is estimated to be 20% to 30% lifetime and 10% to 20% at enrollment in treatment. Depression is also associated with the use of prescription opioids for chronic pain and worse treatment outcomes. Approximately 50% of patients with chronic pain have a comorbid psychiatric condition, and 35% of patients with chronic back and neck pain have a comorbid depression or anxiety disorder [33; 152; 186; 187]. The preva- lence of depression is lower in out-of-treatment patients than in those seeking treatment and is associated with increased retention in methadone treatment. Thus, depression has a mixed effect on prognosis. It appears to be a motivating factor in treatment-seeking while at the same time interfering with treatment effectiveness [33; 152; 186; 187]. In addition, opioid- dependent patients with Axis I psychiatric comorbidity often require significantly higher methadone doses [56]. Psychiatric comorbidity is especially pronounced with seri- ous mental illness, which is defined by the Substance Abuse and Mental Health Services Administration as individuals 18 years of age or older having, at any time during the past year, a diagnosable mental, behavior, or emotional disorder that causes serious functional impairment that substantially interferes with or limits one or more major life activities [188]. Approximately one in four individuals with a serious mental illness (e.g., major depression, schizophrenia, bipolar disorder) have a comorbid substance use disorder [189]. A main issue in managing comorbid conditions is the differen- tiation of independent versus substance-induced disorders, as therapeutic plans differ for the two conditions [186]. Substance abuse can result in changes in mood, appetite, sleep patterns, beliefs, and perceptual experiences, all of which may present as psychiatric disorders but resolve with stabilization of drug use. Treatment should not focus solely on the non-substance-use psychiatric diagnosis, as symptom reduction will not translate into reduced drug use. Active substance use can also alter the presentation of personality and diagnosis of a personality disorder [190].
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MDRI2026
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