Opioid Use Disorder __________________________________________________________________________
ASSESSMENT It is important to assess dependent opioid users for other psychiatric and substance use disorders, especially alcohol and cocaine dependence because they are frequent comorbidities in opioid-dependent patients and can aggravate depressive symptoms [107; 189]. Bipolar illness is rare but has substantial treatment implications. Anxiety disorders frequently co-occur with depression, and traumatic experiences and post-traumatic stress disorder are common and should be thoroughly evalu- ated and treated [152; 189]. Independent disorders are psychi- atric conditions occurring during periods of sustained absti- nence or having an onset before the substance-use disorder. A positive family history can aid in identifying an independent psychiatric disorder. Comprehensive assessment tools can reduce the chance of a missed or incorrect diagnosis. Patients with psychiatric comorbidities often exhibit symptoms that are more persistent, severe, and resistant to treatment compared to patients who have either disorder alone [191; 192; 193; 194]. Assessment is critical to identify concomitant medical and psychiatric conditions that may need immediate attention and require transfer to a higher level of care [107]. The ASAM recommends that clinicians also assess social and environmental factors to identify facilitators and barriers to treatment, specifically to pharmacotherapy [107]. TREATMENT APPROACH Treatment should initially focus on stabilization of the patient’s substance use disorder, with an initial goal of two to four weeks abstinence before addressing comorbidities. Patients who persistently display symptoms of a psychiatric disorder during abstinence should be considered as having an independent dis- order and should receive prompt psychiatric treatment [190]. Although depressive symptoms often improve following treat- ment admission, significant symptoms will persist in some patients [152]. Antidepressant medications can be effective in patients dually diagnosed with opioid dependence and depres- sion when used at adequate doses for at least six weeks [195]. Factors emphasizing prompt antidepressant treatment include greater severity of depression, suicide risk, and co-occurring anxiety disorders [152]. SSRIs are generally safe and well-tolerated, but clinical trials with these agents in methadone patients have been negative [152]. Therefore, SSRIs may be considered first-line treat- ment based on their safety profile, but if the patient does not respond, then TCAs or newer generation agents should be considered. SSRIs in combination with cognitive-behavioral therapy have been found to be highly effective for treating clients with comorbid depression [183]. More stimulating antidepressants, such as venlafaxine and bupropion, may be suitable in patients with prominent low energy or past or cur- rent symptoms consistent with attention deficit hyperactivity disorder (ADHD) [152]. The utility of nonpharmacologic
treatments should be emphasized. Psychosocial therapies are as effective as pharmacotherapy in the treatment of mild-to- moderate depressive and anxiety symptoms. Treatment of personality disorders is nonpharmacologic [190]. If depression persists, psychosocial modalities, such as cognitive therapy, supportive therapy, or contingency management, have some evidence to support their efficacy in opioid-dependent patients [152; 183]. In the treatment of insomnia and anxiety, trazodone and nefazodone are helpful agents, although nefazodone should be used with caution because of reports of liver toxicity. Mir- tazapine, a sedating antidepressant, is a logical alternative. A baseline ECG is recommended prior to a TCA trial in opioid users [152]. Benzodiazepines for anxiety should be avoided due to the liability of abuse and the potential of drug-seeking behav- ior, which is detrimental to treatment. Effective alternatives to benzodiazepines include antidepressants and anticonvulsant mood stabilizers. Sedating atypical antipsychotics may also be useful but should be used with caution due to potential side effects [152]. Medical comorbidities that may impact mental status and treatment response include [152]: • Hypothyroidism • HIV infection • Hepatitis C and B • Chronic lung disease • Hypertension • Diabetes • Cardiovascular disease The presence of comorbid conditions increases severity and complicates recovery. Patients with comorbid disorders demonstrate poorer treatment adherence and higher rates of treatment dropout [193; 196]. A natural outgrowth of increased severity has been greater interest in and use of integrated treatment, compared with separate treatment of combined conditions [183]. Integrated treatment refers to a treatment focus on two or more conditions and the use of multiple treatments (e.g., combination of psychotherapy and pharmacotherapy). It is an approach supported by research that demonstrates the superiority of an integrated approach [197; 198; 199; 200; 201].
TREATING POLYSUBSTANCE ABUSE/ DEPENDENCE
As noted, polysubstance use is the norm rather than the excep- tion among opioid-dependent patients. The optimal approach to treating multiple substance abuse depends on the substances being used, the severity of the abuse, the treatment setting, familiarity of the clinician with treatment of the substance problem, and available resources for treatment. Optimal patient outcomes occur with pharmacologic and psychosocial combination therapy [190].
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MDRI2026
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