PCSS SUD 101 Core Curriculum

Understanding addiction is essential to successfully addressing it. In this overview of substance use disorders we discuss the spectrum of use, neurobiological responses to substances, theories that explain the disorders, public health impact and epidemiology, comorbidity, harm reduction and integrated care for this chronic condition.

Language can be used intentionally or unintentionally to perpetuate stigma. The language used towards people who use drugs or alcohol and people with addiction includes many stigmatizing terms which have been shown to increase negative attitudes among the public and clinicians. Examples include words like “abuse,” “abuser,” “addict,” and “dirty.” There are also more subtle ways that language can be used to frame issues related to addiction or substance use which can enhance stigma. Nationally there has been growing awareness around the importance of language and the need to use medically appropriate, person first terminology. Changing our language is a crucial component of reducing stigma to improve the lives and health of people who use drugs or alcohol and people with addiction. This module will discuss the importance of language when discussing substance use and review ways to improve language to improve care.

Risky substance use and substance use disorders may often go unrecognized in primary care settings, either due to insufficient screening or provider discomfort with how to manage a positive screening. There are several brief, simple, validated screening tools that can provide information to indicate risky substance use or the possible presence of a substance use disorder. This information can inform providers as to whether a simple brief intervention or a referral to treatment is warranted. This module will: introduce screening tools related to drug and alcohol use; review more detailed substance use, medical, and psychiatric assessment considerations; demonstrate effective strategies for brief interventions; and discuss considerations for treatment referrals.

Alcohol use disorder (AUD) is commonly encountered in clinical settings, and FDA approved medications are available. This module reviews and compares pharmacological treatments for individuals with AUD, including acamprosate, disulfiram, and naltrexone (oral and long-acting intramuscular formulations), as well as non-approved (off-label) options including topiramate and gabapentin. Diagnosis of AUD and definitions of binge drinking and “at risk” drinking levels (per US Dietary Guidelines) are discussed. Effects of alcohol use on the brain, including neurotransmitter effects and withdrawal symptoms, are also reviewed. The module concludes with discussion of a case vignette in which medication options for AUD are considered.

Opioid use disorder (OUD) has highly effective FDA approved medications for its treatment. This module reviews and compares pharmacological treatment options for individuals with OUD, including methadone, buprenorphine (SL and injectable formulations), and naltrexone (oral and long-acting intramuscular formulations). Current evidence for each medication is reviewed in detail and studies comparing each are discussed. The purpose and goal of medications for OUD is reviewed and different treatment models are presented. The module includes a discussion of a case vignette in which medication options for OUD are considered.

This module discusses the importance of integrating opioid use disorder (OUD) pharmacotherapy into general medical settings, describes models in primary care, emergency rooms, and hospitals where medications for OUD treatment are successfully included as standard care, and reviews keys to OUD pharmacotherapy implementation in clinical practice. Participants are encouraged to adapt this information for use in their own clinical practices.

Tobacco use disorder is still a major cause of preventable death. Populations with low income, lower education and/or behavioral health comorbidity (mental illness or SUD) use tobacco at higher rates. Even brief interventions can be effective and should be provided routinely in health care settings. Counseling and medications are both considered first-line treatments and outcomes are better if they are provided together. Assessment of the time to first cigarette use in the morning is a good indicator of level of addiction to tobacco. Tobacco withdrawal causes clinically significant symptoms of agitation, anxiety, restlessness, and impaired concentration that can undermine success in quitting. Medications are effective in reducing these withdrawal symptoms and at least doubling the smoker’s chance of success in quitting. These medications include nicotine replacement, bupropion and varenicline. These are generally well tolerated and safer than the ongoing use of tobacco. Varenicline or combination NRT can be considered first line treatments since they are associated with greater success in quitting than other treatments. Use of medications is also associated with reductions in tobacco use that can lead to future quit attempts. This educational activity will review updates in evidence-based treatments for tobacco use disorder.

Utilization of evidence-based counseling to effectively manage primary care patients with Opioid Use Disorders (OUD) provides the best chance of improving motivation for change, treatment engagement and ultimate remission. Standard Medical Management (SMM) is one such option that can be used that is efficient, focused, and relatively easily integrated into primary care practice. The goal of this module is to prepare participants to deliver the assessment and treatment components of the initial and subsequent 15-minute SMM sessions. Participants will also review brief motivational strategies to manage resistance and/or lack of progress, as well as common issues when treating OUD.

Motivational interviewing (MI) has emerged as one of the most critical evidence-based approaches when working with patients to promote behavior change. Originally developed in the context of treating substance use disorders, MI is a collaborative method of communication that pays particular attention to the language of change. MI helps to strengthen intrinsic motivation for change by exploring the patient’s own reasons for change within an atmosphere of acceptance, partnership, evocation and compassion. This educational activity will introduce key MI principles, including the four processes, the spirit of MI, patient-centered communications skills, and the importance of evoking change talk.

Mutual-help organizations (MHOs) such as Alcoholic Anonymous, SMART Recovery, LifeRing and many others, are ubiquitous across the United States and are found in small, medium, and large cities. They can be a valuable addition to treatment plans and extend the reach of the clinician by providing their patients with ongoing paths to recovery via crucial sober social support that has been found to confer valuable relapse prevention skills. This presentation provides education about the origin, types, scope, and theoretical orientation of a variety of MHOs, including new evidence for their clinical and public health utility, as well as evidence on why they are so helpful. Examples of proven clinical strategies to enhance involvement with MHOs during and following treatment will be provided including for those patients taking medications.

Opioids are commonly prescribed for chronic pain, but are also associated with a risk for serious harms including overdose and opioid use disorder. This module reviews risk factors for opioid misuse, opioid use disorder, and overdose in patients with chronic pain, explains methods for screening and assessing for problematic opioid use, reviews methods for mitigating risks associated with prescribed opioids, and details non-opioid treatment approaches for pain. The module is based on principles in the Center for Disease Control and Prevention’s guideline on opioids for chronic pain and reviews recent evidence on benefits and harms of opioids.

Lab testing in the assessment of substance use disorders may involve many different substrates, though urine drug testing (UDT) dominates clinical practice. This module is meant to provide a short guide to effective use of lab testing in treatment of the patient with a substance use disorder, which to a surprising degree is often misused or misunderstood. The module describes the clinical role of lab testing to guide treatment and not to be punitive. To properly use and interpret UDT, it reviews common false positive and false negatives that might occur in the immunologic-based first step in UDT. To understand confirmatory gas chromatography/mass spectrometry, it goes on to describe the metabolism of common opioids and benzodiazepines, because the detected confirmed moiety often is just a downstream metabolite of several possible parent compounds to which the patient was exposed. The module concludes with a discussion of the difference between UDT for clinical purposes versus forensic ones.

At the conclusion of this activity participants should be able to describe the historical evolution and current state of the policies regulating office based prescribing of medications for opioid use disorder, and distinguish these from the federal regulations applicable to opioid treatment programs (OTPs). Participants will also be able to which identify which prescribing clinicians are eligible for the DATA-2000 waiver, the applicable waiver limits including the relevant practice settings impacting waiver limits, and the specific medications for opioid use disorder and clinic settings where the DATA-2000 does not apply. Participants will also be able to explain applicable privacy regulations and the regulations governing managing medications for opioid use disorder via telehealth.

Medical complications are common among patients with opioid use disorder. Signs and symptoms of acute or chronic infectious diseases often prompt patients to seek medical care. The time of presentation for complications related to injection drug use present an opportunity to screen and employ early intervention strategies for other complications, engage individuals in addiction treatment and implement harm reduction. This module reviews features of skin and soft tissue infections among people who inject drugs, reviews risk factors for Hepatitis C (HCV) and HIV, describes prevention interventions for HCV and HIV, and discusses treatment approaches for HCV and HIV in patients with opioid use disorder.

Co-occurring psychiatric conditions are frequently seen in patients with substance use disorders. Clinicians should be alert to the signs and symptoms of common psychiatric disorders and should understand how to distinguish independent psychiatric disorders from substance-induced disorders. Depressive disorders and anxiety disorders, including post-traumatic stress disorder, are the most common co-occurring conditions, though ADHD is often encountered across the range of substance use disorders. Substance use disorder patients with co-occurring psychiatric disorders will respond to most standard psychological and pharmacological treatments for these psychiatric conditions, though clinicians should avoid the use of scheduled medications and must always focus on sobriety as a primary treatment goal. Treatment that integrates addiction and psychiatric care is the most effective.

This educational activity reviews other substance use disorders that often co-occur with opioid use disorder (OUD), including benzodiazepines and other tranquilizers, cocaine and stimulants, and cannabis. The presentation will also discuss principles of diagnosis and evaluation of treatment for each of these by themselves, and in the context of OUD.

With the recent increase in use of vaping devices among youth, nicotine use disorder remains prevalent in adolescents and young adults. While rates of use of illicit stimulants including cocaine, ecstasy/MDMA and methamphetamine have decreased in adolescents in recent years, misuse of prescription stimulants remains common in this age group. This module reviews recent trends in nicotine and stimulant use in adolescents in young adults. It also presents a summary of the neurobiology of nicotine, discusses the different health effects and risks of harm of nicotine and stimulants (including illicit stimulants, prescription stimulants and caffeine) and offers an overview of prevention, harm reduction and treatment strategies for youth.

Brain development during adolescence makes youth particularly vulnerable to both initiating substance use and developing substance use disorders (SUD). Alcohol and cannabis use are both common and the impacts of these substances on the developing brain leads to a predictable set of consequences. Primary and secondary prevention and treatment can all improve outcomes. This module discusses Screening, Brief Intervention, and Referral to Treatment (SBIRT) to identify and address substance use, and the medical management of SUD treatment in primary care.

Substance Use disorders in Older Adults is a growing problem not only in the United States but throughout the developed world. The Baby Boomer generation, born between 1946 and 1964 is turning 58-76 years old this year. This group is presenting with more Substance Use Disorders and need for substance use treatment now. The use of an artificial cut off age of 65 years of age as the definition of elderly or old is somewhat arbitrary and this will be discussed. The module will look at the prevalence, screening and treatment of tobacco, alcohol, opioids, non-medical use of prescription drugs and illicit opioids as well as stimulants and cocaine, marijuana and non-opioid sedative hypnotic agents. A case vignette will drive the CME portion and elucidate the tenants of the module.

Opioid use disorder (OUD) among women and people who become pregnant is increasing in prevalence in clinical settings. The standard of care is to provide buprenorphine or methadone as a part of a complete treatment approach during pregnancy and beyond the postpartum period. This module reviews the historical and current context of opioid use among women and birthing people during pregnancy. It compares pharmacological treatment options for women and people who become pregnant with an OUD and also discusses the issues with detoxification or medically assisted withdrawal from opioids during pregnancy. Issues related to the treatment of OUD during pregnancy and in the postpartum period for the birthing person, fetus and child will also be discussed (e.g., induction, dosing, pain management, neonatal withdrawal and how to reduce its severity).

There is an over-representation of individuals with substance use disorders in the criminal justice system. This can be true for individuals with opioid use disorders in need of MAT. Healthcare practitioners treating justice-involved patients may have limited information about how the criminal justice system is constructed and how best to help their patients who are at risk for disruption in care and treatment due to arrest, court oversight and incarceration. This information can be helpful given challenges when MAT becomes difficult to access due to the constraints of the justice system. Although the justice system is becoming more aware of the importance of MAT, it is important also for healthcare providers to have awareness of the justice system to best help support their patients. This educational activity provides an overview and basic information about the criminal justice system from arrest to incarceration to re-entry.

Overdose is the leading cause of accidental injury death in the United States surpassing motor vehicle crashes, claiming more than 100,000 American lives annually. Fentanyl, a synthetic opioid, that is sold as heroin and counterfeit prescription opioids is driving the recent surges in overdose deaths in most communities. Overdose prevention, that includes equipping people who use drugs and their social networks with naloxone rescue kits is an established strategy to address opioid overdose.

Successfully implementing substance use disorder best practices continues to be a challenge across healthcare settings, often due to limited understanding of barriers and facilitators and a lack of systematic planning. This module introduces, defines, and discusses key implementation science models and strategies that can support the successful integration of substance use disorder treatment best practices into diverse community health and addiction settings. Real-world examples from implementation practice for integrating medications for opioid use disorder are used to demonstrate how this information can be used in daily practice.