for Health Care Providers

Management of Specific Substance Use Disorders

Heroin and other opioids
Behavioral Interventions
In addition to brief primary care provider interventions suggested above, refer for specialty evaluation and treatment, or to substance abuse counselors in community-based organizations, rehabilitation facilities, and methadone maintenance sites. Specific psychosocial interventions for opioid use have not demonstrated consistent efficacy. Opioid agonist therapy is the gold standard for heroin addiction treatment. If the patient is in withdrawal, or at high risk of withdrawal, refer for detoxification or to an emergency department. If unstable (medically or psychiatrically), refer to an emergency department. For local (non-VA) substance abuse resources: 800-662-HELP. Narcotics Anonymous provides group support. Counsel on safe injection practices, including reducing risk of transmission of HIV and other bloodborne pathogens.
Pharmacologic Interventions
Treat comorbid psychiatric conditions. Methadone is a full opioid agonist used for opioid agonist therapy in opioid treatment programs. Methadone maintenance programs typically start with a dose of ≤30 mg and adjust to the lowest effective dose that suppresses withdrawal signs and symptoms. Typical dosage is between 60 mg and 120 mg QD. Adverse effects include constipation, weight gain, drowsiness, excessive sweating, and changes in libido. Can increase QT interval, precipitating torsade de pointes and other arrhythmias. Avoid use in patients with baseline prolonged QTc; use with caution if coadministered with other medications that prolong QT. Methadone levels may be lowered by various ARVs; see Potential ARV Interactions and Common Medications. Buprenorphine is a partial mu-opioid agonist and weak kappa antagonist with 25-50 times the analgesic potency of morphine. It has a pharmacologic "ceiling," and lower risk of overdose and abuse than full opioid agonists. Buprenorphine use is controlled nationally and within the VHA; physicians are able to prescribe buprenorphine only with special training and a specific DEA certificate. See PBM Criteria for Use. It is administered sublingually. At high dosages, it may block the effects of full opioid agonists, leading to withdrawal. Therefore, patients should stop taking short-acting opioids 12-24 hours before starting buprenorphine and reduce their methadone use to a maximum of 30-40 mg/day. In the United States, buprenorphine is coformulated with naloxone. Naloxone is poorly absorbed sublingually; however, if the tablet is crushed and injected parenterally, the naloxone precipitates opiate withdrawal. Buprenorphine has been approved for use in office-based opioid dependence treatment. Buprenorphine is induced over the first 3 days of treatment, with an initial daily dosage of 4-8 mg, increased by 4-8 mg QD until relief from withdrawal symptoms is achieved. The maximum recommended dosage is 32 mg QD. Side effects include disturbed sleep, drowsiness, sweating, headaches, nausea, constipation, and reduced libido. Mild increases in ALT have been reported. Buprenorphine may interact with PIs and with EFV; see Potential ARV Interactions. In acute pain episodes, buprenorphine can be used Q8H for analgesic effects. Naltrexone: opioid antagonist. Precipitates opiate withdrawal; appropriate only for patients with >7 days of abstinence. Not recommended because compliance is poor; consider as component of substance abuse program for highly motivated patients.
Methamphetamine
Behavioral Interventions
If unstable (medically or psychiatrically), refer to an emergency department or hospitalize. Behavioral interventions are the mainstay of treatment; no pharmacologic agents have proven efficacy. Refer to outpatient or inpatient behavioral counseling: motivational interviewing and cognitive-based therapy (eg, Matrix Model). Refer to harm reduction programs. Consider referral to contingency management programs that provide vouchers of escalating value for successive urine samples documenting abstinence. For local (non-VA) substance abuse resources: 800-662-HELP. Narcotics Anonymous provides methamphetamine-specific groups. Crystal Meth Anonymous. Ask about ART adherence at each visit, as methamphetamine users frequently go on binges that lead to interruptions in ART adherence. Methamphetamine use is associated with unsafe sexual behaviors. Explore risk behaviors, screen for STDs, and counsel on safer sex options; see Prevention for Positives. Provide written or illustrated instructions that can be processed visually, as methamphetamine users often have impaired auditory memory.
Pharmacologic Interventions
Treat comorbid psychiatric conditions. Dextroamphetamine "replacement therapy" has not shown greater efficacy than placebo. Ongoing studies suggest that bupropion may be useful as an adjunct to behavioral therapies. RTV inhibits amphetamine metabolism and can lead to a 2- to 3-fold increase in amphetamine levels. Patients should be educated about this interaction.
Cocaine
Behavioral Interventions
Refer to cognitive-behavioral therapy tailored to substance abusers. For local substance abuse resources: 800-662-HELP. Narcotics Anonymous also provides cocaine-specific groups.
Pharmacologic Interventions
Treat comorbid psychiatric conditions. Consider the pharmacologic adjunct naltrexone at 50 mg QD for 12 weeks in combination with participation in relapse prevention programs.
Club drugs (see below)
Behavioral Interventions
Refer to cognitive-behavioral therapy tailored to substance abusers. For local substance abuse resources: 800-662-HELP. Narcotics Anonymous also provides group support for club drug users.
Pharmacologic Interventions
Treat comorbid psychiatric conditions. RTV increases MDMA levels 5- to 10-fold and can increase the risk of fatal heatstroke and dehydration. RTV also increases GHB levels, leading to increased risk of seizures, respiratory depression, and loss of consciousness.

From Substance Use
Primary Care of Veterans with HIV
Office of Clinical Public Health Programs
Veterans Health Administration, 2009