Expert addresses top clinical challenges in substance use disorder treatment

NEW ORLEANS — In a session here, Thomas R. Kosten, MD, of Baylor College of Medicine and MD Anderson Cancer Center, Houston, discussed top clinical challenges in substance use disorders and provided solutions to them.

Past Psych Congress attendees were surveyed on questions they had about clinical treatment of substance use disorders. Kosten addressed the most common questions during his presentation.

Question: Is it diagnostically important to differentiate substance use disorders attributable to an attempt to ‘self-treat’ from other forms of substance use disorders?

Answer: “Simple answer: yes,” Kosten said. “First, you have to be familiar with DSM-5. If people meet only two of the DSM-5 criteria, they’re thought to have some harmful use but really don’t meet criteria for anything you’d want to treat. On the other hand, when you reach five criteria, then you really are talking to someone who has a substance use disorder and might benefit from a treatment for it.”

Kosten told clinicians to be aware that there are currently no FDA-approved pharmacotherapies for cannabis use disorder and none “that have shown great promise so far.”

Q : How do you decide when to use an opioid antagonistic therapy (like naltrexone), when to use opioid partial agonist therapy (like buprenorphine) and when to use opioid agonist therapy (like methadone) for patients with opioid addiction?

A : “The first thing to be aware of is there are very different mechanisms for these three different drugs,” Kosten said.

Methadone is a full -opioid receptor agonist that involves cross-tolerance.

“[Cross-tolerance] means if you come in and are a typical substance opioid user and we give you 25 mg of methadone, 25 mg once a day will be sufficient to prevent you from getting withdrawal symptoms ... [and] from feeling uncomfortable; you get to sleep again,” Kosten said.

The typical methadone dose starts at 80 mg and increases to 150 mg.

“What does that tell you? We are making you more dependent than you were to begin with,” Kosten said. “That’s how it works. You just can’t buy enough of the short-acting opiate to get a high, only the high level of dependence that methadone has produced.”

Naltrexone is completely opposite, according to Kosten. It blocks the -opioid receptor and euphoria. Naltrexone is difficult to begin but easy to stop, with no withdrawal symptoms.

Buprenorphine is a partial opioid agonist with lower overdose potential and abuse liability. It blocks euphoria at a high dose. For treatment retention and decreased heroin abuse, buprenorphine is comparable to methadone, according to Kosten.

Ultimately, Kosten recommended collaborating with the patient and his or her family on lifestyle and treatment goals. However, he strongly endorsed buprenorphine.

Q : Which nonpharmacologic treatment approaches to alcohol use disorder are most appropriate , including integrating harm reduction practices and the efficacy of continued Alcoholics Anonymous meetings?

A : “They're good for you,” Kosten said. “The motivational enhancement probably has the best application, and the CDC has an app that you can use, particularly for opioid use, with motivational enhancement.”

Other non-pharmacological treatments include contingency management, cognitive-behavioral therapy and family engagement self-help.

Much work needs to be done in this area, according to Kosten. – by Amanda Oldt

Reference:

Kosten TR. Solving clinical challenges in substance use disorders. Presented at: U.S. Psychiatric and Mental Health Congress; Sept. 16-19, 2017; New Orleans.

Disclosure: Kosten reports financial ties with Alkermes, Novartis and Purdue.