SUD 101 Core Curriculum (2023)

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, 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.

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.

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.

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.

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.

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).

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.