Substance use or addictive disorders

Rationale

Substance use disorders include addiction to substances such as stimulants (e.g., cocaine, amphetamines), depressants (e.g., opioids, benzodiazepines) and other substances (e.g., nicotine, alcohol). Addictive disorders include process (behavioural) addictions such as gambling. The neurobiological basis of addiction is similar for substance use disorders and addictive disorders. Both disorders can cause direct or indirect harm to patients and families. Harm can occur during intoxication and withdrawal and may adversely affect the individual’s social functioning. There is frequently overlap between addictions, and comorbidities are the rule rather than the exception. Physicians should be aware of the risk of addiction and adhere to best practices when prescribing potentially habit-forming medications.

Causal conditions

(list not exhaustive)

1. Adverse childhood or traumatic experiences
2. Epigenetic factors
3. Comorbid illnesses (e.g., mental illness, chronic disease, trauma, including acute and chronic pain)
4. Psychosocial stressors (e.g., unemployment, social isolation, and systemic racism and other social determinants)

Key Objectives

Given a patient with substance use or addictive disorders, the candidate will identify the issue, potential consequences, and the need for immediate intervention and ongoing support. Given a patient with chronic pain or other condition who is at risk for substance use and/or addictive disorder, the candidate will prescribe medications with due care. Because these issues can be emotional, physicians should strive to approach them in an unbiased and nonjudgmental way, with respect for patient wishes and values.

Enabling Objectives

Given a patient with chronic pain or other condition who is at risk for substance use and/or addictive disorder, the candidate will

1. list and interpret clinical findings, including the potential for habituation, and indicate the most appropriate medication for the diagnosis;
2. construct a management plan, including
   1. prescribing according to evidence-based guidelines (e.g., dosage, prescription interval, monitoring of drug use) to minimize addiction;
   2. initiating alternative therapy or taper/stop therapy where there is evidence of ineffectiveness or habituation (e.g., physiotherapy, psychotherapy).

Given a patient with a substance use disorder, the candidate will

1. list and interpret critical findings, including those derived from
   1. an appropriate history, including a collateral history, relevant to the presenting problem and previous, possibly addictive behaviour and patient insight into the condition, to determine the duration and severity of any substance overuse or addiction;
   2. an appropriate physical examination aimed at determining potential withdrawal symptoms and comorbidities, if necessary;
2. list and interpret critical investigations, including laboratory or diagnostic imaging (e.g., drug screening, liver function studies); and recognition of when explicit consent (e.g., drug testing) may be required;
3. in collaboration with the patient, construct an initial management plan, including
   1. explaining behavioural modification options and appropriate pharmacological intervention (e.g., nicotine or opioid replacement therapy);
   2. determining whether the patient or their family members require specialized psychological or other support services (e.g., addiction treatment) delivered at the individual, family, and/or community level;
   3. anticipating medium- and long-term complications (e.g., psychosocial effect, safety);
   4. advocating for harm reduction strategies (e.g., safe injection sites, naloxone administration education).

Given a patient with a behavioural addictive disorder, the candidate will

1. list and interpret critical clinical findings including, those derived from
   1. an appropriate history, including a collateral history, relevant to the presenting problem and previous, possibly addictive behaviour and patient insight into the condition, to determine the duration and severity;
   2. an appropriate physical examination aimed at determining potential symptoms and comorbidities (e.g., lack of sleep, social neglect, physical deconditioning, depression), if necessary;
2. in collaboration with the patient, construct an initial management plan, including
   1. explaining behavioural modification options and appropriate pharmacological intervention (e.g., SSRIs, SNRIs);
   2. determining whether the patient or their family members require specialized psychological or other support services delivered at the individual, family, or community level (e.g., addiction treatment);
   3. anticipating medium- and long-term complications (e.g., psychosocial effect, safety).