Clinical Practice Guideline SUMMARY

Management of  

Substance Use Disorders (SUD)

August, 2009

VA/DoD Evidence Based Practice
VA/DoD CLINICAL PRACTICE GUIDELINE FOR MANAGEMENT OF 

SUBSTANCE USE DISORDERS 

Department of Veterans Affairs 

Department of Defense 

GUIDELINE SUMMARY 

 

QUALIFYING STATEMENTS 

The Department of Veterans Affairs (VA) and The Department of Defense (DoD) guidelines are based 

on the best information available at the time of publication. They are designed to provide information 

and assist decision-making. They are not intended to define a standard of care and should not be 

construed as one. Neither should they be interpreted as prescribing an exclusive course of 

management. 

Variations in practice will inevitably and appropriately occur when providers take into account the 

needs of individual patients, available resources, and limitations unique to an institution or type of 

practice. Every healthcare professional making use of these guidelines is responsible for evaluating 

the appropriateness of applying them in the setting of any particular clinical situation. 

Version 2.0 – 2009 

 
Prepared by: 

The Management of SUD Working Group 

With support from: 

The Office of Quality and Performance, VA, Washington, DC 

& 

Quality Management Directorate, United States Army MEDCOM 
Guideline Summary VA/DoD Clinical Practice Guideline 

For Management of Substance Use Disorder

Table of Contents 

Page

Introduction 1

Guideline Update Working Group    4

Definitions    5

Algorithms and Annotations    6

Module A: Screening and Initial Assessment for Substance Use 11

Module B: Management of SUD in Specialty SUD Care 19

Module C: Management of SUD in (Primary) General Healthcare 28

Module P: Addiction‐Focused Pharmacotherapy 38

Module S: Stabilization and Withdrawal Management 51

Appendices (only C and F included in Summary) 60

Appendix A: Guideline Development Process

Appendix B: Screening and Assessment Tools

Appendix C: Addiction‐Focused Psychosocial Interventions

Appendix D: Department of Defense Instruction (DoDI 1010.6)

Appendix E: Sedative‐Hypnotic Equivalent Oral Doses

Appendix F: Acronym List

Appendix G: Participant List

Appendix H: References

The full version of this guideline is available for download at: 

www.healthquality.va.gov 

Table of Contents 
Guideline Summary VA/DoD Clinical Practice Guideline 

For Management of Substance Use Disorder

INTRODUCTION 

The Clinical Practice Guideline for the Management of Substance Use Disorders (SUD) was 

developed under the auspices of the Veterans Health Administration (VHA) and the Department of 

Defense (DoD) pursuant to directives from the Department of Veterans Affairs (VA). VHA and DoD 

define clinical practice guidelines as: 

“Recommendations for the performance or exclusion of specific procedures or services 

derived through a rigorous methodological approach that includes: 

• Determination of appropriate criteria such as effectiveness, efficacy, population 

benefit, or patient satisfaction; and 

• Literature review to determine the strength of the evidence in relation to these 

criteria.” 

The intent of the guidelines is to: 

• Reduce current unwarranted practice variation and provide facilities with a structured 

framework to help improve patient outcomes 

• Provide evidence-based recommendations to assist providers and their patients in the 

decision-making process 

• Identify outcome measures to support the development of practice-based evidence that can 

ultimately be used to improve clinical guidelines. 

Background 

Substance use disorders (SUD) constitute a major public health problem with a substantial impact on 

health, societal costs, and personal consequences. 

• SUD in the VA population: In 2007 fiscal year, over 375,000 VA patients had a substance 

use disorder diagnosis and nearly 500,000 additional patients had a nicotine dependence 

diagnosis in the absence of other substance use disorders. (Dalton A, Saweikis M, McKellar 

JD: Health Services for VA Substance Use Disorder Patients: Comparison of Utilization 

Fiscal Years 2005, 2004, 2003 and 2002. Palo Alto, CA, Program Evaluation and Resource 

Center, 2004.)

• SUD in the DoD population: The substantial negative consequences of alcohol use on the 

work performance, health, and social relationships of military personnel have been a 

continuing concern assessed in DoD surveys. In 2005, 8.1 percent of military personnel 

anonymously responding to a survey reported one or more serious consequences associated 

with alcohol use during the year, a decline from 9.6 percent in 2002. Using AUDIT criteria, 

2.9 percent of respondents were estimated to be highly likely to be dependent on alcohol in 

2005. (Bray RM, Hourani LL, Olmsted KLR, et al. 2005 Department of Defense Survey of 

Health Related Behaviors Among Active Duty Military Personnel. Research Triangle Park, 

NC: Research Triangle International, December, 2006. Available at: 

http://www.ha.osd.mil/special_reports/2005_Health_Behaviors_Survey_1-07.pdf )

Target population 

This guideline applies to adult patients with substance use conditions treated in any VA/DoD 

clinical setting, including patients who have both substance use and other health conditions; and 

patients with any level of severity ranging from hazardous and problematic use to substance use 

disorders. 

Introduction - Page 1
Guideline Summary VA/DoD Clinical Practice Guideline 

For Management of Substance Use Disorder

Audiences 

The guideline is relevant to all healthcare professionals providing or directing treatment services to 

patients with substance use conditions in any VA/DoD healthcare setting, including specialty SUD 

care, and both general and mental healthcare settings. 

Goals of the Guideline 

• To identify patients with substance use conditions, including at-risk use, substance use 

problems and substance use disorders 

• To promote early engagement and retention of patients with substance use conditions who can 

benefit from treatment 

• To improve outcomes for patients with substance use conditions (cessation or reduction of 

substance use, reduction in occurrence and severity of relapse, improved psychological and 

social functioning and quality of life, improved co-occurring medical and health conditions, 

and reduction in mortality). 

Content of the Guideline 

The guideline consists of five modules that address inter-related aspects of care for patients with 

SUDs. 

Module A: Screening and Initial Assessment for Substance Use includes screening, brief 

intervention, and specialty referral considerations. 

Module B: Management of SUD in Specialty SUD Care focuses on patients in need of further 

assessment or motivational enhancement or who are seeking remission.

Module C: Management of SUD in General Healthcare (including primary care) emphasizes 

earlier intervention for less severe SUD, or chronic disease management for patients 

unwilling or unable to engage in treatment in specialty SUD care or not yet ready to 

abstain. 

Module P: Addiction-Focused Pharmacotherapy addresses use of medication approved by the 

Food and Drug Administration for the treatment of alcohol and opioid dependence. 

Module S: Stabilization and Withdrawal Management addresses withdrawal management 

including pharmacological management of withdrawal symptoms. 

Each module consists of an algorithm that describes the step-by-step process of the clinical decisionmaking and intervention that should occur in the specified group of patients. General and specific 

recommendations for each step in the algorithm are included in the annotations following the 

algorithm. The links to these recommendations are embedded in the relevant specific steps in the 

algorithm. 

Each annotation includes a brief discussion of the research supporting the recommendations and the 

rationale behind the grading of the evidence and the determination of the strength of the 

recommendations. 

Tobacco use should be addressed in all patients and is a major cause of morbidity and mortality among 

patients with non-nicotine SUDs. For management of nicotine dependence, refer to the Clinical 

Practice Guideline: Treating Tobacco Use & Dependence: 2008 Update from the U.S. Department of 

Health and Human Services available at: 

http://www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pdf and the VA/DoD Clinical 

Practice Guideline for Management of Tobacco Use. 

Introduction - Page 2
Guideline Summary VA/DoD Clinical Practice Guideline 

For Management of Substance Use Disorder

For management of patients presenting with SUDs and depression, refer to the VA/DoD Clinical 

Practice Guideline for the Management of Major Depressive Disorder (MDD). For management of 

prescribed opioids for chronic pain, refer to the VA/DoD Clinical Practice Guideline for the 

Management of Chronic Opioid Therapy. Additional recommendations for patients with co-occurring 

conditions may be found in the VA/DoD Clinical Practice Guideline for the Management of Post 

Traumatic Stress (ASD and PTSD). 

Development Process 

The development process of this guideline follows a systematic approach described in “Guideline-forGuidelines,” an internal working document of VA/DoD Evidence-Based Practice Working Group. 

The literature was critically analyzed and evidence was graded using a standardized format. The 

evidence rating system for this document is based on the system used by the U.S. Preventive Services 

Task Force (see Appendix A to the full guideline – Development Process). 

If evidence exists, the discussion of the recommendations includes an evidence table that indentifies 

the studies that have been considered, the quality of the evidence, and the rating of the strength of the 

recommendation [SR]. The strength of recommendation, based on the level of the evidence and 

graded using the USPSTF rating system (see Table: Evidence Rating System), is presented in brackets 

following each guideline recommendation. Recommendations that are based on consensus of the 

Working Group include a discussion of expert opinion on the given topic. No [SR] is presented for 

these recommendations. A complete bibliography of the references found in this guideline can be 

found in Appendix H.

Strength of Recommendation and Evidence Rating System 

SR* 

A A strong recommendation that the clinicians provide the intervention to eligible 

patients. 

Good evidence was found that the intervention improves important health outcomes 

and concludes that benefits substantially outweigh harm. 

B A recommendation that clinicians provide (the service) to eligible patients. 

At least fair evidence was found that the intervention improves health outcomes and 

concludes that benefits outweigh harm. 

C No recommendation for or against the routine provision of the intervention is made. 

At least fair evidence was found that the intervention can improve health outcomes, 

but concludes that the balance of benefits and harms is too close to justify a general 

recommendation. 

D Recommendation is made against routinely providing the intervention. 

At least fair evidence was found that the intervention is ineffective or that harms 

outweigh benefits. 

I The conclusion is that the evidence is insufficient to recommend for or against 

routinely providing the intervention. 

Evidence that the intervention is effective is lacking, or poor quality, or conflicting, 

and the balance of benefits and harms cannot be determined. 

* SR= Strength of Recommendation 

Introduction - Page 3
Guideline Summary VA/DoD Clinical Practice Guideline 

For Management of Substance Use Disorder

Lack of Evidence – Consensus of Experts 

Where existing literature was ambiguous or conflicting, or where scientific data were lacking on an 

issue, recommendations were based on the clinical experience of the Working Group. These 

recommendations are indicated in the evidence tables as based on “Working Group Consensus.” 

This Guideline is the product of many months of diligent effort and consensus-building among 

knowledgeable individuals from the VA, DoD, and academia, and a guideline facilitator from the 

private sector. An experienced moderator facilitated the multidisciplinary Working Group. The draft 

document was discussed in one face-to-face group meeting. The content and validity of each section 

was thoroughly reviewed in a series of conference calls. The final document is the product of those 

discussions by all members of the Working Group. 

The list of participants is included in Appendix G to the full guideline. 

Implementation 

The guideline and algorithms are designed to be adapted to individual facility needs and resources. 

The algorithms will serve as a guide that providers can use to determine best interventions and timing 

of care for their patients to optimize quality of care and clinical outcomes. This should not prevent 

providers from using their own clinical expertise in the care of an individual patient. Guideline 

recommendations are intended to support clinical decision-making but should never replace sound 

clinical judgment. 

Although this guideline represents the state of the art practice at the time of its publication, medical 

practice is evolving and this evolution will require continuous updating of published information. New 

technology and more research will improve patient care in the future. The clinical practice guideline 

can assist in identifying priority areas for research and optimal allocation of resources. Future studies 

examining the results of clinical practice guidelines such as these may lead to the development of new 

practice-based evidence. 

Outcomes 

1. Reduction of consumption 

2. Improvement in quality of life (social and occupational functioning) 

3. Improvement of symptoms 

4. Improvement of retention (keeping patients engaged in the program) 

5. Improvement in co-occurring conditions 

6. Reduction of mortality. 

Introduction - Page 4
Guideline Summary VA/DoD Clinical Practice Guideline 

For Management of Substance Use Disorder

Introduction - Page 5

Guideline Update Working Group * 

VA DoD 

Katherine Bradley, MD, MPH Darrel Dodson, LTC, MD 

Karen Drexler, MD Diane Flynn, COL, MD 

Francine Goodman, PharmD Nicole Frazer, Maj, PhD 

Adam Gordon, MD, MPH, FACP, 

FASAM William Haning, CPT, MD 

Daniel Kivlahan, PhD James McCrary, Lt CoL, DO 

Joseph Liberto, MD Edward McDaniel, LTC, MD 

James McKay, PhD Paul Morrissey, LTC, MD 

Andrew Saxon, MD Jay Stone, Lt Col, PhD 

Office of Quality and Performance, VHA 

Carla Cassidy, RN, MSN, NP 

Quality Management Division 

US Army Medical Command 

Ernest Degenhardt, RN, MSN, ANP-FNP 

Joanne Ksionzky RN, CNOR, RNFA 

Mary Ramos, PhD, RN 

FACILITATOR

Oded Susskind, MPH 

RESEARCH TEAM – ECRI 

Vivian H. Coats, MPH 

Eileen G. Erinoff 

Karen Schoelles, MD 

David Snyder, PhD 

HEALTHCARE QUALITY INFORMATICS, INC. 

Martha D’Erasmo, MPH 

Rosalie Fishman, RN, MSN, CPHQ 

Joanne Marko, MS, SLP 

* Bolded names are Co-Chairs of the guideline. 

 Additional contributor contact information is available in Appendix G to the full guideline. 
Guideline Summary VA/DoD Clinical Practice Guideline 

For Management of Substance Use Disorder

DEFINITIONS 

CONDITIONS AND DISORDERS OF UNHEALTHY ALCOHOL USE 

The spectrum of alcohol use extends from abstinence and low-risk use (the most common patterns of 

alcohol use) to risky use, problem drinking, harmful use and alcohol abuse, and the less common but 

more severe alcoholism and alcohol dependence. (Saitz, 2005) 

UNHEALTHY ALCOHOL USE 

Risky users: For women and persons > 65 years of age, > 7 standard drinks per week or > 3 drinks per 

occasion; for men ≤ 65 years of age, > 14 standard drinks per week or >4 drinks per occasion; there are 

no alcohol-related consequences, but the risk of future physical, psychological, or social harm 

increases with increasing levels of consumption; risks associated with exceeding the amounts per 

occasion that constitute “binge” drinking in the short term include injury and trauma; risks associated 

with exceeding weekly amounts in the long term include cirrhosis, cancer, and other chronic illnesses; 

“risky use” is sometimes used to refer to the spectrum of unhealthy use but usually excludes 

dependence; one third of patients in this category are at risk for dependence. 

Problem drinking: Use of alcohol accompanied by alcohol-related consequences but not meeting 

DSM-IV criteria; sometimes used to refer to the spectrum of unhealthy use but usually excludes 

dependence. 

DIAGNOSED SUBSTANCE USE DISORDERS (DSM IV, American Psychiatric Association, 1994) 

DSM-IV-TR Criteria for Substance Abuse: 

“A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as 

manifested by one (or more) of the following, occurring at any time in the same 12-month period: 

• Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, 

or home 

• Recurrent substance use in situations in which it is physically hazardous 

• Recurrent substance-related legal problems 

• Continued substance use despite having persistent or recurrent social or interpersonal 

problems caused or exacerbated by the effects of the substance.” 

DSM-IV-TR Criteria for Substance Dependence: 

“A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as 

manifested by three (or more) of the following seven criteria, occurring at any time in the same 12-

month period: 

1. Tolerance, as defined by either of the following: 

 A need for markedly increased amounts of the substance to achieve intoxication or desired 

effect 

 Markedly diminished effect with continued use of the same amount of the substance. 

2. Withdrawal, as defined by either of the following: 

 The characteristic withdrawal syndrome for the substance (refer to DSM-IV-TR for further 

details) 

 The same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms. 

3. The substance is often taken in larger amounts or over a longer period than was intended. 

Introduction - Page 6
Guideline Summary VA/DoD Clinical Practice Guideline 

For Management of Substance Use Disorder

Introduction - Page 7

4. There is a persistent desire or there are unsuccessful efforts to cut down or control substance use. 

5. A great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple 

doctors or driving long distances to see one), use the substance (e.g., chain smoking), or recover 

from its effects. 

6. Important social, occupational, or recreational activities are given up or reduced because of 

substance use. 

7. The substance use is continued despite knowledge of having a persistent or recurrent physical or 

psychological problem that is likely to have been caused or exacerbated by the substance (e.g., 

current cocaine use despite recognition of cocaine-induced depression or continued drinking 

despite recognition that an ulcer was made worse by alcohol consumption). 

Dependence exists on a continuum of severity: remission requires a period of at least 30 days 

without meeting full diagnostic criteria and is specified as Early (first 12 months) or Sustained

(beyond 12 months) and Partial (some continued criteria met) versus Full (no criteria met). 

SETTINGS OF CARE 

General healthcare settings can be broadly defined as outpatient clinic settings including primary 

care, psychiatry, or other specialty clinics (e.g., HIV, hepatology clinics, medical, pre-operative) and 

may include emergency departments and surgical care clinics. 

Specialty SUD Care focuses on patients in need of further assessment or motivational enhancement or 

who endorse rehabilitation goals. 
Guideline Summary VA/DoD Clinical Practice Guideline 

For Management of Substance Use Disorder

AGORITHMS AND ANNOTATIONS 

 Page 

MODULE A: SCREENING AND INITIAL ASSESSMENT FOR SUBSTANCE USE ......................................................12

A. All Patients Seen in VA or DoD General Medical and Mental Healthcare Settings................................12

B. Screen Annually for Unhealthy Alcohol Use Using a Validated Tool ....................................................12

C. Does the Person Screen Positive or Drink Despite Contraindications?.................................................13

D. Assess Current Alcohol Consumption .................................................................................................13

E. Does the Person Drink Above Recommended Limits or Despite Contraindications? ............................13

F. Provide Brief Intervention .................................................................................................................14

G. Is Referral for Alcohol Use Disorder Also Indicated or Requested? / Offer Referral, if Appropriate......15

H. Does Patient Agree to the Referral or is the Referral Mandated?........................................................15

I. Continue to Provide Brief Interventions and Follow‐up During Future Visits.......................................16

J. Provide Positive Feedback Regarding Changes ...................................................................................16

K. Advise to Stay Below Recommended Limits.......................................................................................16

L. Screen Annually for Unhealthy Alcohol Use........................................................................................17

MODULE B: MANAGEMENT  OF SUBSTANCE USE DISORDERS IN SUD CARE....................................................19

A. Patient with Presumptive or Possible Substance Use Disorder (SUD) Referred or Self‐Referred to

Specialty SUD Care.............................................................................................................................19

B. Ensure Behavioral or Physiological Stabilization, if Necessary.............................................................19

C. Obtain a Comprehensive Biopsychosocial Assessment .......................................................................19

D. Determine Diagnosis of SUD; Develop Integrated Summary and Initial Treatment Plan ......................21

E. Initiate Addiction‐Focused Pharmacotherapy (If Indicated) ................................................................22

F. Initiate Addiction‐Focused Psychosocial Interventions .......................................................................22

G. Address Psychosocial Functioning and Recovery Environment............................................................23

H. Manage General Medical and Psychiatric Co‐occurring Conditions .....................................................24

I. Assess Response to Treatment / Monitor Biological Indicators...........................................................24

J. Reinforce and Follow Up....................................................................................................................25

K. Are Treatment Goals Achieved?.........................................................................................................25

L. Discontinue Specialty SUD Treatment; Develop Aftercare/Recovery Plan...........................................26

M.Reevaluate Treatment Plan Regarding Setting and Strategies.............................................................26

Table of Contents: Page - 8 
Guideline Summary VA/DoD Clinical Practice Guideline 

For Management of Substance Use Disorder

MODULE C: MANAGEMENT OF SUD IN (PRIMARY) GENERAL HEALTHCARE..................................................287

A. Patient with Presumptive or Possible Substance Use Disorder............................................................28

B. Ensure Behavioral or Physiological Stabilization, if Necessary.............................................................28

C. Complete Assessment and Diagnostic Evaluation ...............................................................................29

D. Assess Co‐Occurring Conditions (Psychiatric Illness, Medical Conditions, Legal or Psychosocial

Conditions)........................................................................................................................................29

E. Summarize the Patient's Problem(s), Discuss Treatment Options, and Arrive at Shared Decision

Regarding the Treatment Plan ...........................................................................................................30

F. Referral to Specialty SUD Care ...........................................................................................................31

G. Treatment: Consider Addiction‐Focused Pharmacotherapy ................................................................32

H. Treatment: Medical Management and Monitoring.............................................................................32

I. Treatment: Psychosocial Support for Recovery...................................................................................33

J. Treatment: Management of Medical and Psychiatric Co‐occurring Conditions....................................33

K. Assess Response to Treatment / Monitor Biological Indicators...........................................................34

L. Follow‐Up..........................................................................................................................................34

M.Educate About Substance Use, Associated Problems, and Prevention of Relapse................................35

N. Reevaluate Treatment Plan Regarding Setting and Strategies.............................................................35

MODULE P: ADDICTION‐FOCUSED PHARMACOTHERAPY .............................................................................387

A. Patient with Substance Use Disorder (SUD)........................................................................................38

B. Does the Patient Meet DSM‐IV Criteria for Opioid Dependence?........................................................38

PHARMACOTHERAPY FOR OPIOID DEPENDENCE ....................................................................................38

C. Is Opioid Agonist Treatment (OAT) Medication Appropriate for, and Acceptable to, the Patient? .......38

D. Is Treatment in a Specialized Opioid Agonist Treatment Program (OATP) Setting Appropriate for the

Patient?.............................................................................................................................................40

E. Initiate Opioid Agonist Treatment in an Opioid Agonist Treatment Program (OATP) or Office‐Based

Opioid Treatment (OBOT) with Patient Education and Monitoring .....................................................41

F. Is Naltrexone Therapy Appropriate for and Acceptable to the Patient? ..............................................42

G. Assure Patient is Withdrawn from Opioids and Opioid Free Before Continuing...................................43

H. Initiate Naltrexone for Opioid Dependence with Patient Education and Monitoring ...........................43

PHARMACOTHERAPY FOR ALCOHOL DEPENDENCE .................................................................................44

I. Is the Patient Alcohol Dependent?.....................................................................................................44

J. Initiate Pharmacotherapy for Alcohol Dependence with Patient Education and Monitoring ...............44

Table of Contents: Page - 9 
Guideline Summary VA/DoD Clinical Practice Guideline 

For Management of Substance Use Disorder

Table of Contents: Page - 10 

MODULE S: STABILIZATION and WITHDRAWAL MANAGEMENT.....................................................................49

A. Substance‐Using Patient Who May Require Physiological Stabilization...............................................50

B. Obtain History, Physical Examination, Mental Status Examination (MSE), Medication Including Over‐The

Counter (OTC), and Lab Tests as Indicated..........................................................................................50

C. Is the Patient in Any Immediate Medical or Psychiatric Crisis or Intoxicated? .....................................50

D. Provide Appropriate Care to Stabilize Prior to Management of Withdrawal; Follow Policies For DoD

Active Duty Members: Keep Commanding Officer Informed...............................................................51

E. Assess Level of Physiological Dependence and Indications for Stabilization Including Risk of Withdrawal

..........................................................................................................................................................51

F. Is the Patient in Need of Withdrawal Management? ..........................................................................52

G. Does Patient Require Inpatient Medically Supervised Withdrawal?....................................................54

H. Admit to Inpatient Withdrawal Management or Initiate Ambulatory Withdrawal Management.........54

I. Was Withdrawal Management Successful? ........................................................................................57

J. Is Care Management Indicated?.........................................................................................................58

APPENDICES .................................................................................................................................................59

Appendix C: Addiction‐Focused Psychosocial Interventions ....................................................................60

Appendix F: Acronym List.......................................................................................................................63
Guideline Summary VA/DoD Clinical Practice Guideline 

For Management of Substance Use Disorder

Module A: Page - 11 
Guideline Summary VA/DoD Clinical Practice Guideline 

For Management of Substance Use Disorder

Module A: Page - 12 

MODULE A: SCREENING AND INITIAL ASSESSMENT FOR SUBSTANCE USE 

A. All Pa or DoD General Medical and Mental Healthcare Settings 

nts seen in general medical and general mental health settings are the target population for 

alcohol screening. 

BACKGR

 and counseling is ranked third of the top five prevention priorities 

practices recommended by the U.S. Preventive Services Task Force 

demonstrating the efficacy of primary care interventions for drug abuse and dependence. Instead, 

nics), is recommended so 

m, 2007; USPSTF, 2008). 

B. Screen Annually 

BACKGR

en called risky or hazardous drinking) to those with 

severe alcohol dependence. Most screen-positive patients will not be in treatment for alcohol use 

e initial approach to Unhealthy Alcohol Use will include brief alcohol counseling 

hould be screened for Unhealthy Alcohol Use 

2.

3.

C) 

ort any drinking. (see Annotation C) 

l, may be used in addition to an 

appropriate screening method to increase patient’s awareness to unhealthy use or abuse of alcohol. 

See Appendix B for examples of the Screening Instruments

tients Seen in VA

All patie

OUND 

Screening for Unhealthy Alcohol Use 

Unhealthy Alcohol Use screening

for US adults among preventive 

(USPSTF). 

Screening for Other Drug Use 

Population-based screening for drug use disorder is not recommended. This reflects the lower 

prevalence of drug use disorder and the lack of high-quality randomized controlled trials (RCT) 

selective case finding in high-risk populations (e.g., Hepatitis C or HIV cli

that substance use disorders can be addressed (National Quality Foru

for Unhealthy Alcohol Use Using a Validated Tool 

OUND 

Screening should identify patients along the entire continuum of Unhealthy Alcohol Use including

those who drink above recommended limits (oft

disorders and th

(often termed “brief interventions”) or referral. 

RECOMMENDATIONS 

1. Patients in general and mental healthcare settings s

annually. [A] 

Use a validated screening questionnaire for past-year Unhealthy Alcohol Use. [A] 

Select one of two brief methods of screening: [A] 

a. The Alcohol Use Disorders Identification Test Consumption Questions (AUDITor 

b. Ask whether patient drank any alcohol in the past year and administer the SingleItem Alcohol Screening Questionnaire (SASQ) to assess the frequency of heavy 

drinking in patients who rep

4. The CAGE questionnaire alone is not a recommended screen for past-year Unhealthy Alcohol Use 

(e.g., risky or hazardous drinking). [D] 

5. The CAGE questionnaire, used as a self -assessment too
Guideline Summary VA/DoD Clinical Practice Guideline 

For Management of Substance Use Disorder

C. Does the Person Screen Positive or Drink Despite Contraindications? 

BACKGROUND 

Screening is intended to identify patients with Unhealthy Alcohol Use but also patients who are 

drinking despite contraindications to alcohol use even if they screen negative for Unhealthy Alcohol 

Use. 

RECOMMENDATIONS 

1. Consider a screen positive for Unhealthy Alcohol Use if: [B] 

a. AUDIT-C score (range from 0 to 12) is > 4 points for men or > 3 points for women 

b. Patients report drinking 4 or more (women) or 5 or more (men) drinks in a day in the 

past year on the single-item screening question. 

2. Identify contraindications for any alcohol use [C]. Contraindications to alcohol use include: 

a. Pregnancy or trying to conceive 

b. Liver disease including hepatitis C 

c. Other medical conditions potentially exacerbated or complicated by drinking (e.g., 

pancreatitis, congestive heart failure) 

d. Use of medications with clinically important interactions with alcohol or intoxication 

(e.g., warfarin) 

e. An alcohol use disorder. 

D. Assess Current Alcohol Consumption 

BACKGROUND 

If a patient does not have contraindications to any drinking, experts recommend that alcohol 

consumption be evaluated as the first step in a brief intervention. Most, if not all, clinical trials of brief 

alcohol counseling have assessed patients’ drinking after screening and only included those who 

reported drinking above recommended limits on reassessment. 

Epidemiologic studies have shown that drinking above weekly or daily limits is associated with 

development of alcohol-related problems. 

RECOMMENDATIONS 

1. Determine the number of drinks consumed by patient in a typical week and the maximum number 

of drinks on an occasion in the past month. 

E. Does the Person Drink Above Recommended Limits OR Despite Contraindications? 

BACKGROUND 

Patients who drink above the recommended limits or those who have clinical conditions that 

contraindicate alcohol use are candidates for a brief intervention. 

RECOMMENDATIONS 

1. Determine whether patient drinks above recommended limits. [A] 

Module A: Page - 13 
Guideline Summary VA/DoD Clinical Practice Guideline 

For Management of Substance Use Disorder

a. The recommended limits are: 

- FOR MEN— no more than 14 standard-sized drinks a week and no more than 4 

standard-sized drinks on any day 

- FOR WOMEN— no more than 7 standard-sized drinks a week and no more 

than 3 standard-sized drinks on any day 

Standard-sized drinks are: 12 oz beer, 5 oz wine, or 1.5 oz hard liquor. 

2. Contraindications for any alcohol use include: 

a. Pregnancy or trying to conceive 

b. Liver disease including hepatitis C 

c. Other medical conditions potentially exacerbated or complicated by drinking (e.g., 

pancreatitis, congestive heart failure) 

d. Use of medications with clinically important interactions with alcohol or intoxication 

(e.g., warfarin) 

e. An alcohol use disorder. 

Table A- 1: Recommended Drinking Limits 

Men No more than 14 drinks a week; and 

No more than 4 drinks on any occasion 

Women No more than 7 drinks a week; and 

No more than 3 drinks on any occasion 

Standard-sized drinks are: 12 oz beer, 5 oz wine, or 1.5 oz hard liquor 

F. Provide Brief Intervention 

BACKGROUND 

A brief intervention typically lasts from several minutes up to an entire visit and is a patient-centered, 

empathetic brief counseling intervention that can be offered by a clinician who is not a specialist 

addictions provider or counselor. 

A brief intervention for Unhealthy Alcohol Use is a single session or multiple sessions that include 

motivational discussion focused on increasing insight and awareness regarding alcohol use and 

motivation toward behavioral change. Brief interventions can be tailored for variance in population or 

setting and can be used as a stand-alone treatment for those at-risk as well as a vehicle for engaging 

those in need of more extensive levels of care. 

RECOMMENDATIONS 

1. Provide a brief intervention (counseling) for Unhealthy Alcohol Use, which includes the following 

components: [A] 

a. Express concern that the patient is drinking at unhealthy levels known to increase 

his/her risk of alcohol-related health problems 

b. Provide feedback linking alcohol use and health, including: 

- Personalized feedback (i.e., explaining how alcohol use can interact with 

patient’s medical concerns [e.g., hypertension, depression/anxiety, insomnia, 

injury, congestive heart failure (CHF), diabetes mellitus (DM), breast cancer 

risk, interactions with medications]) OR 

- General feedback on health risks associated with drinking. 

Module A: Page - 14 
Guideline Summary VA/DoD Clinical Practice Guideline 

For Management of Substance Use Disorder

c. Advise : 

- To abstain (if there are contraindications to drinking) OR 

- To drink below recommended limits (specified for patient age and gender). 

d. Support the patient in choosing a drinking goal, if he/she is ready to make a change 

e. Offer referral to specialty addictions treatment if appropriate. 

G. Is Referral for Alcohol Use Disorder Also Indicated or Requested? / Offer Referral, if Appropriate 

BACKGROUND 

Scores of controlled studies over several decades consistently show that a variety of forms of alcohol 

dependence treatment including behavioral interventions and pharmacotherapies significantly reduce 

alcohol consumption among alcohol-dependent patients. 

Specialty addictions programs or mental health providers integrated in primary care settings who have 

addictions expertise can be helpful for assessment, motivational interviewing and treatment. Patients 

who are open to assessment or who are ready for assistance should be referred to a specialty addictions 

provider or program, or mental health provider integrated in primary care. 

RECOMMENDATIONS 

1. Offer referral to specialty SUD care for addiction treatment if the patient: 

a. May benefit from additional evaluation of his/her drinking or substance use and 

related problems or from motivational interviewing 

b. Has tried and been unable to change drinking or substance use on his/her own or 

does not respond to brief intervention 

c. Has been diagnosed for alcohol or other substance dependence 

d. Has previously been treated for an alcohol or other substance use disorders 

e. Has an AUDIT-C score > 8. 

2. DoD active duty members involved in an incident in which substance use is suspected to be a 

contributing factor are required to be referred to specialty SUD care for evaluation. Command 

should be contacted to discuss administrative and clinical options if the member refuses to be 

evaluated (see Appendix D to the full guideline). 

H. Does Patient Agree to the Referral or is the Referral Mandated? 

BACKGROUND 

Many patients may initially decline voluntary referral, but provider encouragement and support may 

improve patient willingness to complete the referral. 

RECOMMENDATIONS 

1. Agree on a set of specific goals with the patient. 

a. Review with the patient results of previous efforts of self-change and formal 

treatment experience, including reasons for treatment dropout 

b. Ask patient about willingness to accept referral 

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c. Consider bringing an addiction specialist into a general medical or mental health 

visit to assist with referral decision. 

2. Patients at high risk for alcohol use disorder but who are not ready for specialty addictions 

treatment should be engaged in monitoring of alcohol-related medical problems in the medical 

setting. 

3. DoD active duty members involved in an incident in which substance use is suspected to be a 

contributing factor are required to be referred to specialty SUD care for evaluation. Command 

should be contacted to discuss administrative and clinical options if the member refuses to be 

evaluated. (See Appendix D to the full guideline) 

I. Continue to Provide Brief Interventions and Follow-up During Future Visits 

BACKGROUND 

Patients should be frequently re-evaluated to follow progress, assessed for changes in alcohol-related 

biomarkers if possible, and supported to problem-solve if barriers to improvement are encountered. 

Periodically, the patient’s interest in specialty treatment and mutual support groups should be reevaluated. Patient-centered approaches such as motivational interviewing may be helpful. 

The interval of follow-up for a particular patient will depend on individual circumstances including 

(but not limited to) the severity of their Unhealthy Alcohol Use, the existence of co-occurring 

conditions, readiness to change, and personal circumstances (difficulty making appointments due to 

employment or other responsibilities). 

RECOMMENDATIONS 

1. Address alcohol at the next medical visit scheduled to address other issues, or schedule a separate 

appointment to specifically address drinking if the patient agrees. [B] 

2. Repeat brief intervention at the follow-up visit if the patient has not responded to a previous brief 

intervention. [B] 

J. Provide Positive Feedback Regarding Changes 

BACKGROUND 

Expert opinion supports optimistic, empathetic interventions that note the importance of the changes 

patients have made to their health and encouragement for continued abstinence or drinking below 

recommended limits. 

RECOMMENDATIONS 

1. Provide positive feedback to patients for decreases in drinking. 

2. Relate changes in drinking to any changes in presenting health conditions. 

K. Advise to Stay Below Recommended Limits 

BACKGROUND 

Patients who screen positive near the screening threshold of the AUDIT-C (scores of 3-5) can report 

drinking within recommended limits, but many are under-reporting actual drinking. Therefore, based 

on Working Group consensus, patients who initially screen positive for Unhealthy Alcohol Use but 

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For Management of Substance Use Disorder

Module A: Page - 17 

report drinking below recommended limits should nevertheless be explicitly advised about 

recommended limits and encouraged to continue drinking below those limits. 

RECOMMENDATIONS 

1. Advise patients who screen positive for Unhealthy Alcohol Use but who report drinking below 

recommended limits to continue to drink below recommended limits. 

L. Screen Annually for Unhealthy Alcohol Use 

BACKGROUND 

No trials have compared different intervals of screening. This recommendation for annual screening is 

based on Working Group consensus consistent with routine annual preventive screening for other 

disorders in VA/DoD primary care settings and the past-year assessment window of the AUDIT-C. 

RECOMMENDATIONS 

1. Repeat alcohol screening annually. 
Guideline Summary VA/DoD Clinical Practice Guideline 

For Management of Substance Use Disorder

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MODULE B: MANAGEMENT OF SUBSTANCE USE DISORDERS 

 IN SUD SPECIALTY CARE 

A. Patient with Presumptive or Possible Substance Use Disorder (SUD) Referred or Self-Referred to 

Specialty SUD Care 

BACKGROUND 

Patients may be referred to this module based on the following indications for treatment: hazardous 

substance use, substance abuse, substance dependence, risk of relapse, suspected or possible SUD, or 

mandated referral within the DoD. Patients seeking to achieve remission may be appropriately 

managed using this module. Other patients may be ambivalent about rehabilitation goals and may 

benefit from more comprehensive assessment and discussion of treatment options. Finally, patients 

may be referred to a specialist for more extensive evaluation of risks related to substance use. 

B. Ensure Behavioral or Physiological Stabilization, if Necessary 

BACKGROUND 

Most patients referred to specialty SUD care are not acutely intoxicated or in need of immediate 

physiological stabilization prior to initiating assessment and treatment planning. Others may have 

been stable at the time of referral, but require stabilization when they present for specialty SUD care 

evaluation or treatment and should be managed using Module S: Stabilization and Withdrawal 

Management.

RECOMMENDATIONS 

1. Assure patient safety and readiness to cooperate with further assessment by referring the patient to 

an emergency department or appropriate setting for stabilization as needed. 

C. Obtain a Comprehensive Biopsychosocial Assessment 

BACKGROUND 

Comprehensive and multidimensional assessment procedures are needed to evaluate an individual’s 

strengths, needs, abilities, and preferences, and to determine priorities so that an initial treatment plan 

can be developed. In less severe cases, the assessment should at least involve screening of these 

elements, through the use of a multidimensional screening instrument. 

RECOMMENDATIONS 

1. Obtain a comprehensive biopsychosocial assessment that includes all of the following: * 

a. History of recent substance use and related problems, including precipitating factors, current 

symptoms and pertinent present risks: 

• Family history: 

- Family alcohol and drug use history, including past treatment episodes 

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- Family social history, including profiles of parents (or guardians or other 

caretakers), home atmosphere, economic status, religious affiliation, 

cultural influences, leisure activities, monitoring and supervision, and 

relocations 

- Family medical and psychiatric history 

• Developmental history, including pregnancy and delivery, developmental milestones 

and temperament 

• Comprehensive substance use history, including onset and pattern of progression, 

past sequelae and past treatment episodes (include all substances, e.g., alcohol, illicit 

drugs, tobacco, caffeine, over-the-counter medications, prescription medications, 

inhalants) 

• Nearly all daily nicotine users are nicotine dependent. Identification and treatment 

of co-morbid nicotine dependence may improve recovery rates of other SUDs. For 

patients using nicotine, offer and recommend tobacco use cessation treatment. Use 

the Clinical Practice Guideline: Treating Tobacco Use & Dependence: 2008 Update 

from the U.S. Department of Health and Human Services at: 

http://www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pdf and the 

VA/DoD Clinical Practice Guideline for Management of Tobacco Use

• Recent pattern of substance use based on self-report and urine drug screening 

• Personal/social history (including housing issues, religious/spiritual affiliation, 

cultural influences) 

• School history 

• Military history 

• Marital history 

• Peer relationships and friendships 

• Leisure activities 

• Sexual activity 

• Physical or sexual abuse 

• Legal/non-judicial punishment history, including past behaviors and their relation to 

substance use, arrests, adjudications and details of current status 

• Psychiatric history, including symptoms and their relation to substance use, current 

and past diagnoses, treatments and providers 

• Medical history, including pertinent medical problems and treatment, surgeries, head 

injuries, present medications and allergies 

• Review of systems, including present and past medical and psychological symptoms. 

b. Laboratory tests for infectious diseases (HIV, Hepatitis C, sexually transmitted disease) and 

consequences of substance use (e.g., liver function tests) 

c. Mental status examination 

d. Survey of assets, vulnerabilities and supports 

e. Patient’s perspective on current problems, treatment goals and preferences. 

2. Use empathic and non-judgmental (versus confrontational) therapist style, being sensitive to 

gender, cultural and ethnic differences. 

*Adapted from ASAM Patient Placement Criteria, 2nd Edition-Revised (ASAM PPC-2R, 2001) 

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D. Determine Diagnosis of SUD; Develop Integrated Summary and Initial Treatment Plan 

BACKGROUND 

The comprehensive intake assessment report should integrate assessment information from various 

sources, as a basis for formulating the diagnosis and treatment recommendations, followed by 

involvement of the patient in prioritizing problems and negotiating the initial treatment plan. The 

patient’s motivational level and personal goals should be assessed and considered in selecting 

treatment goals and options. 

RECOMMENDATIONS 

1. Provide a narrative to consolidate and interpret the information obtained during the assessment 

process. 

2. Include a diagnostic formulation. 

3. Include past treatment response and patient’s perspective on current problems. 

4. Review the patient’s motivational level, treatment preferences and goals, and consider these 

factors, along with an interdisciplinary perspective and available programming, in recommending 

specific treatment options. [B] 

5. Present and discuss the treatment options with the patient and significant others. 

6. Determine whether the treatment plan can be implemented in general healthcare (including 

primary care) based on availability of a willing provider, severity and chronicity of the SUD, 

active involvement with recovery supports in the community, prior treatment response, and patient 

preference and likelihood of adherence. 

7. If treatment in specialty SUD care is appropriate, determine the appropriate initial intensity and 

level of specialty SUD care, based on ASAM patient placement criteria. [B] 

8. If treatment in specialty SUD care is recommended, determine if it is an acceptable mode of 

treatment to the patient. 

9. Involve the patient in prioritizing problems to be addressed in the initial treatment plan, and in 

selecting specific treatment goals, regardless of the level of care selected. (See Table B-1) 

10. If the patient does not agree to the treatment plan, provide motivational intervention and offer to 

renegotiate the treatment plan. 

For DoD Active Duty Members 

11. A treatment team shall convene with the patient and command to review the treatment plan and 

goals. 

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Table B- 1. Treatment Goal and Expected Outcomes 

Treatment Goal Expected Outcomes 

Patient seeking to achieve 

remission 

Complete and sustained remission of all SUDs 

Resolution of, or significant improvement in, all coexisting 

biopsychosocial problems and health-related quality of life 

Patient seeking help but 

not committed to 

abstinence 

Short- to intermediate-term resolution or partial improvement of SUDs 

for a specified period of time 

Resolution or improvement of at least some coexisting problems and 

health-related quality of life 

Patient not willing to 

engage in treatment and 

not yet ready to abstain 

Engagement in general health treatment process, which may continue 

for long periods of time or indefinitely 

Continuity of care 

Continuous enhancement of motivation to change 

Availability of crisis intervention 

Improvement in SUDs, even if temporary or partial 

Improvement in coexisting medical, psychiatric, and social conditions 

Improvement in quality of life 

Reduction in the need for high-intensity healthcare services 

Maintenance of progress 

Reduction in the rate of illness progression 

E. Initiate Addiction-Focused Pharmacotherapy (If Indicated) 

BACKGROUND 

Addiction-focused pharmacotherapy should be considered, available and offered if indicated, for all 

patients with opioid dependence and/or alcohol dependence. Addiction-focused pharmacotherapy 

should be provided in addition to indicated pharmacotherapy for co-occurring psychiatric conditions. 

In addition, it should be directly coordinated with specialty psychosocial treatment and adjunctive 

services for psychosocial problems as well as with the patient’s primary care and/or general mental 

health providers. 

RECOMMENDATIONS 

1. Discuss addiction-focused pharmacotherapy options with all patients with opioid and/or alcohol 

dependence. 

2. Initiate addiction-focused pharmacotherapy if indicated and monitor adherence and treatment 

response. 

(See Module P for specific recommendations and evidence.) 

F. Initiate Addiction-Focused Psychosocial Interventions 

BACKGROUND 

The goals of evidence-based psychosocial treatment for SUD are to engage the patient to establish 

early problem resolution or remission, improve psychosocial functioning and prevent relapse to 

substance use. A number of effective psychosocial interventions have been developed and evaluated, 

and there is no clear evidence that any one of these approaches is the treatment of choice or can be 

accurately matched to specific patient characteristics. There is considerable evidence from 

psychotherapy research that general factors such as therapist skill, the strength of the therapeutic 

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For Management of Substance Use Disorder

alliance, and the structure provided by regular treatment contact can have as powerful an effect as the 

specific content or conceptual approach of the interventions. Therefore, attention to these general 

therapeutic factors is at least as important as the specific treatment approach selected. 

RECOMMENDATIONS 

1. Indicate to the patient and significant others that treatment is more effective than no treatment (i.e., 

“Treatment works”). 

2. Consider the patient’s prior treatment experience and respect patient preference for the initial 

psychosocial intervention approach, since no single intervention approach has emerged as the 

treatment of choice. 

3. Regardless of the particular psychosocial intervention chosen, use motivational interviewing style 

during therapeutic encounters with patients and emphasize the common elements of effective 

interventions including: enhancing patient motivation to stop or reduce substance use, improving 

self-efficacy for change, promoting a therapeutic relationship, strengthening coping skills, 

changing reinforcement contingencies for recovery, and enhancing social support for recovery. 

4. Emphasize that the most consistent predictors of successful outcome are retention in formal 

treatment and/or active involvement with community support for recovery. 

5. Use strategies demonstrated to be efficacious to promote active involvement in available mutual 

help programs (e.g., Alcoholics Anonymous, Narcotics Anonymous). 

6. Based on locally available expertise, initiate addiction-focused psychosocial interventions with 

empirical support. Consider the following interventions that have been developed into published 

treatment manuals and evaluated in randomized trials: 

a. Behavioral Couples Counseling 

b. Cognitive Behavioral Coping Skills Training 

c. Community Reinforcement Approach 

d. Contingency Management/Motivational Incentives 

e. Motivational Enhancement Therapy 

f. Twelve-Step Facilitation. 

7. Addiction-focused psychosocial interventions should be coordinated with evidence-based 

intervention(s) for other biopsychosocial problems to address identified concurrent problems. 

8. Intervention should be provided in the least restrictive setting necessary for safety and 

effectiveness. 

(See Appendix C for description of evidence-based psychosocial interventions.)

G. Address Psychosocial Functioning and Recovery Environment 

BACKGROUND 

Many patients have co-existing psychosocial problems that affect their likelihood of establishing and 

maintaining good clinical outcome and improved functional status. 

Some of these problems are consequences of SUD that persist even after early recovery is established. 

Others occur independently of SUD, but can complicate access to care or present relapse risk. These 

problems include access to a supportive recovery environment (housing and social support for 

sobriety), difficulties with family and social relationships, unemployment/underemployment, and/or 

unresolved legal issues. 

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RECOMMENDATIONS 

1. Prioritize and address other coexisting biopsychosocial problems with services targeted to these 

problem areas, rather than increasing intensity of addiction-focused psychosocial treatment alone. 

[B] 

2. Address transitional housing needs to facilitate access to treatment and promote a supportive 

recovery environment. 

3. Provide social/vocational/legal services in the most accessible setting to promote engagement and 

coordination of care. 

4. Address deferred problems as part of treatment plan updates and monitor emerging needs. 

5. Coordinate care with other social service providers or case managers. 

H. Manage General Medical and Psychiatric Co-occurring Conditions 

BACKGROUND 

In addition to the standard addiction-focused services, programs should address psychiatric and general 

medical conditions that exist in association with the SUD. Treatment services directed toward these 

additional problems, when they exist, are associated with improvement. Problems typically show little 

spontaneous improvement if services are not provided. 

RECOMMENDATIONS 

1. Prioritize and address other medical and psychiatric co-occurring conditions. 

2. Recommend and offer cessation treatment to patients with nicotine dependence. 

3. Treat concurrent psychiatric disorders consistent with VA/DoD clinical practice guidelines (e.g., 

Major Depressive Disorder, Bipolar Disorder, Post Traumatic Stress, Psychoses) including 

concurrent pharmacotherapy. 

4. Provide or arrange treatment via referral for medical conditions (e.g. management of diabetes, 

chronic heart failure, management of unexplained medical symptoms). (See other VA/DoD 

Clinical Practice Guidelines at: www.healthquality.va.gov) 

5. Provide multiple services in the most accessible setting to promote engagement and coordination 

of care. 

6. Monitor and address deferred problems and emerging needs through ongoing treatment plan 

updates. 

7. Coordinate care with other providers. 

I. Assess Response to Treatment / Monitor Biological Indicators 

BACKGROUND 

At each periodic reassessment, the patient may have achieved the goals set for specialty SUD care, be 

successfully completing interim steps toward each goal, not improving, or may have dropped out of 

treatment altogether. Periodic monitoring of progress toward treatment goals helps to coordinate care 

and to motivate the patient and treatment team members to accomplish interim steps. Periodic 

reassessments also provide opportunities to address emerging problems and to change treatment 

strategies when the initial plan is not fully successful. 

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RECOMMENDATIONS 

1. Reassess response to treatment periodically and systematically, using standardized and valid selfreport instrument(s) and laboratory tests. Indicators of treatment response include ongoing 

substance use, craving, side effects of medication, emerging symptoms, etc. (see example for a 

treatment response monitor; Appendix B-9: Brief Addiction Monitor). 

J. Reinforce and Follow Up 

BACKGROUND 

For many patients, substance use disorders are chronic conditions that warrant extended efforts at 

relapse prevention and encouragement by providers for progress. 

RECOMMENDATIONS 

1. For patients who accomplish their initial goals in early recovery, the treatment team should 

collaborate with the patient to develop a continuing care plan (e.g., aftercare plan) which may 

include: 

a. Transition to an appropriate alternative specialty care setting (see Annotation L - 

Aftercare), such as PTSD specialty treatment, etc. 

b. Return to primary care. 

2. For patients who are progressing toward goals, providers should: 

a. Provide positive feedback and encouragement to remain engaged in specialty SUD 

care 

b. Involve patients in identifying the next interim steps toward achieving the goals. 

K. Are Treatment Goals Achieved? 

BACKGROUND 

In general, longer lengths of time in treatment correlate with better outcomes for more severely 

dependent patients. However when no further addiction-focused specialty treatment visits are 

scheduled, care should be transitioned to their primary medical or behavioral healthcare provider for 

relapse monitoring and ongoing management of co-occurring general medical and/or psychiatric 

conditions. 

RECOMMENDATIONS 

1. Use the patient’s progress in attaining recovery goals to individualize treatment continuation and 

avoid adopting uniform treatment plans with standardized duration and intensity. 

2. Consider patient report of craving and other subjective indications of relapse risk. 

3. For patients who achieve sustained remission or problem resolution, provide appropriate 

continuity of care and follow-up with providers in the general medical or mental healthcare setting 

(see Module C). 

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Module B: Page - 26 

L. Discontinue Specialty SUD Treatment; Develop Aftercare/Recovery Plan 

BACKGROUND 

An aftercare or recovery plan is a mutual effort between the patient and treatment team to identify and 

promote those aspects of continuing care for SUDs that are associated with success in recovery. At the 

point that the patient has achieved the initial stabilization goals of intensive treatment, he/she receives 

a written plan for continuing care to maintain recovery. 

RECOMMENDATIONS 

1. Provide continuing care following intensive outpatient or residential rehabilitation (individual, 

group or telephone follow-up). 

2. Consider objective monitoring of substance use and medical consequences. [A] 

3. Encourage active involvement in community support for recovery (e.g., Alcoholics Anonymous, 

Cocaine Anonymous). [A] 

4. As part of the discharge instructions from the intensive phase, provide the patient a written plan to 

facilitate compliance with aftercare which may include “the basic things I need to do to meet my 

treatment goals,” such as: 

a. Information on treatment appointments and prescribed medications 

b. Recognizing relapse warning signs and triggers and appropriate coping responses 

c. Maintaining contact with recovery support network and identifying mutual help meetings 

to attend. 

5. For DoD Active Duty: Rehabilitation and Referral Services for Alcohol and Drug Abusers, 

requires an individualized aftercare plan designed to identify the continued support of the patient 

with monthly monitoring (minimally) during the first year after inpatient treatment. 

M. Reevaluate Treatment Plan Regarding Setting and Strategies 

BACKGROUND 

Relapse can be used as a signal to reevaluate the treatment plan rather than evidence that the patient 

cannot succeed or that the patient was not sufficiently motivated. 

RECOMMENDATIONS 

1. For patients who are not improving, providers should consider either: 

a. Adding or substituting another medication or psychosocial intervention, or 

b. Changing treatment intensity by: 

• Increasing the intensity of care, or 

• Increasing the dose of the medication, or 

• Decreasing the intensity to a minimum level of care that is agreeable to 

the patient such as monitoring in general healthcare (see Module C). 

2. If patients drop out of treatment, the treatment team should make efforts to contact the patient and 

re-engage him/her in treatment. 
Guideline Summary VA/DoD Clinical Practice Guideline 

For Management of Substance Use Disorder

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Guideline Summary VA/DoD Clinical Practice Guideline 

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MODULE C: MANAGEMENT OF SUD IN (PRIMARY) GENERAL HEALTHCARE 

A. Patient with Presumptive or Possible Substance Use Disorder 

BACKGROUND 

Clinicians in general medical and in mental healthcare settings are likely to encounter patients with 

presumptive or possible substance use who are either referred, self-referred, or otherwise seek help 

related to substance use. Substance use can include Unhealthy Alcohol Use, misuse of prescription 

medications, and illegal substance use (e.g., heroin, cocaine). Substance use conditions are prevalent 

among outpatient clinic populations. 

General healthcare settings can be broadly defined as outpatient clinic settings including primary care, 

psychiatry, or other specialty clinics (e.g., HIV, hepatology clinics, medical sub-specialty, preoperative) and may include emergency departments and surgical care clinics. 

All patients in general or in mental healthcare settings should be screened for Unhealthy Alcohol 

Use. Population-based screening for other drug use disorder is not recommended. This reflects the 

lower prevalence of drug use disorder and the lack of high-quality randomized controlled trials 

demonstrating the efficacy of primary care interventions for drug abuse and dependence. Instead, 

selective case finding in high-risk populations (e.g., Hepatitis C or HIV clinics), is recommend d. e

Patients who are  diagnosed with SUD  or who are  seeking  help with problem  drinking  or  drug 

use, should be offered  treatment and/or a referral to specialty addiction treatment, and monitored 

for unstable medical or psychiatric conditions. Patients should be referred for acute stabilization or 

withdrawal management if needed. 

Management of SUD in the general or mental healthcare settings is likely to be a more acceptable and 

effective alternative for the patient when one of the following applies: 

a. The patient refuses referral to specialty SUD care but continues to seek some services, 

especially medical and/or psychiatric services 

b. The patient has serious co-morbidity that precludes participation in available specialty 

SUD care 

c. The patient has been engaged repeatedly in specialty SUD treatment with minimal 

progress toward abstinence or sustained improvement. 

B. Ensure Behavioral or Physiological Stabilization, if Necessary 

BACKGROUND 

Patients who are intoxicated, undergoing withdrawal, or at risk for imminent severe harm associated 

with their substance use may be considered medically unstable or at risk for harm of self or others. 

These patients may be delirious or otherwise not able to engage collaboratively with a provider 

regarding their assessment and treatment. Screening, assessment, or treatment of substance use 

disorders should occur in patients who are medically stable. 

For example, patients with severe physical dependence on alcohol may undergo alcohol withdrawal 

syndrome and may incur hallucinations, seizures, delirium, and delirium tremens. Treatment of 

withdrawal symptoms, as well as intoxication with alcohol or opioids, may require specialty treatments 

in an inpatient acute care or addiction specialty setting. Patients with cocaine intoxication may require 

close cardiac monitoring. 

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RECOMMENDATIONS 

1. Assure patient safety and readiness to cooperate with further assessment by referring the patient to 

an emergency department or appropriate acute care setting for stabilization as needed. 

(See Module S – Stabilization and Withdrawal Management) 

C. Complete Assessment and Diagnostic Evaluation 

BACKGROUND 

Comprehensive and multidimensional assessment procedures are needed to evaluate an individual’s 

strengths, weaknesses, needs, and preferences and to determine priorities so that an initial treatment 

plan can be developed. In less severe cases, the assessment should at least involve screening of these 

elements through the use of a multidimensional screening instrument. 

A complete evaluation that includes history, physical, and laboratory assessments is important to 

properly diagnose patients with SUD. Many patients may be involved with more than one substance 

and poly-substance use may not be readily apparent. 

For diagnostic criteria of substance abuse and dependence, see Introduction: Definitions (page 5). 

RECOMMENDATIONS 

1. Patients with suspected, presumed, or identified substance use disorder (SUD) should receive a 

comprehensive assessment to include: 

a. Medical history, including pertinent medical problems and treatment, surgeries, head 

injuries, present medications and allergies and family history of substance use 

b. Physical examination including mental status examination (MSE) 

c. Laboratory evaluation as indicated. 

2. Comprehensive substance use history, including onset and pattern of progression, past sequelae 

and past treatment episodes (include all substances, e.g., alcohol, illicit drugs, tobacco, caffeine, 

over-the-counter medications, prescription medications, inhalants). 

3. Use empathic and non-judgmental (versus confrontational) therapist style, being sensitive to 

gender, cultural and ethnic differences. 

4. DoD active duty members involved in an incident in which substance use is suspected to be a 

contributing factor are required to be referred to specialty SUD care for evaluation. Command 

should be contacted to discuss administrative and clinical options if the member refuses to be 

evaluated. (See Appendix D to the full guideline.) 

D. Assess Co-Occurring Conditions (Psychiatric Illness, Medical Conditions, Legal or Psychosocial 

Conditions) 

BACKGROUND 

Co-occurring disorders (CODs) are common with SUD and must be identified and addressed as a part 

of comprehensive care. CODs, also termed co-morbid disorders, are defined as sub-clinical or 

diagnosed medical and/or behavioral health conditions that occur with and influence the SUD 

condition. CODs threaten the health of patients and may complicate the treatment of SUD. 

SUD is highly correlated with posttraumatic stress disorder and other psychological disorders that may 

occur after stressful and traumatic events, such as those associated with war. 

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For Management of Substance Use Disorder

RECOMMENDATIONS 

1. Identify and document any co-occurring disorders (COD) in patients with substance use disorders. 

a. Psychiatric history, including symptoms and their relation to substance use, current 

and past diagnoses, treatments and providers 

b. Infectious diseases (HIV, Hepatitis C, sexually transmitted disease) 

c. Nearly all daily nicotine users are nicotine dependent. Identification and treatment 

of co-morbid nicotine dependence may improve recovery rates of other SUDs. For 

patients using nicotine offer and recommend tobacco use cessation treatment. Use 

the Clinical Practice Guideline: Treating Tobacco Use & Dependence: 2008 Update 

from the U.S. Department of Health and Human Services at: 

http://www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pdf and the 

VA/DoD Clinical Practice Guideline for Management of Tobacco Use

d. Medical COD that may be related to or affected by substance use (e.g., diabetes, 

cardiovascular disease, digestive disorders, skin infections, respiratory disorders). 

2. Individuals with SUD should be assessed for any significant, unmet psychosocial needs or 

situational stressors. These include but are not limited to: 

a. Inadequate or no housing 

b. Financial difficulties, especially if unable to meet basic needs 

c. Problematic family relationships or situations (including caregiver burden or 

domestic violence) 

d. Poor social support 

e. Religious and spiritual problems 

f. Occupational problems 

g. Difficulties with activities of daily living or instrumental activities of daily living 

h. Any other acute or chronic situational stressors. 

E. Summarize the Patient's Problem(s), Discuss Treatment Options, and Arrive at Shared Decision 

Regarding the Treatment Plan 

BACKGROUND 

Informed decision-making involves explaining the medical condition, outlining treatment options, and 

guiding the patient to a decision about their own care. Even when patients refuse referral or are unable 

to participate in specialized addiction treatment, many are accepting of general medical or psychiatric 

care. 

RECOMMENDATIONS 

1. Recognize that feedback about laboratory assessments may improve patients’ motivation to 

change and may serve as a baseline to monitor SUD treatment progress. 

2. Review the assessment, including diagnosis, past treatment response and the patient’s perspective 

on current problems; co-occurring disorders related to SUD; the patient’s motivational level, 

treatment preferences and short- and long-term goals. 

3. Present and discuss with the patient appropriate treatment options in a way that motivates ongoing 

cooperation with the provider and supports subsequent decisions about referral or brief 

intervention. 

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4. Present and discuss the treatment options with the patient and significant others. 

5. Determine which treatments could be offered in general healthcare (including primary care), based 

on availability of a provider, severity and chronicity of the SUD, active involvement with recovery 

supports in the community, prior treatment response, and patient’s preference and likelihood of 

adherence. 

6. Involve the patient in prioritizing problems to be addressed in the initial treatment plan, and in 

selecting specific treatment goals, regardless of the level of care selected (See Table C – 1). 

7. If the patient is not willing to engage in any addictions focused care, provide motivational 

intervention and determine whether treatment for medical and psychiatric problems can be 

effectively and safely provided. Continue to try to engage the patient in addictions treatment (see 

annotation K). 

Table C- 1. Treatment Goals and Expected Outcomes 

Treatment Goals Expected Outcomes 

Patient seeking to achieve 

remission 

Complete and sustained remission of all substance use disorders (SUDs) 

Resolution of, or significant improvement in, all coexisting 

biopsychosocial problems and health-related quality of life 

Patient seeking help but 

not committed to 

abstinence 

Short- to intermediate-term remission of SUDs or partial remission of 

SUDs for a specified period of time 

Resolution or improvement of at least some health-related quality of life 

Patient not willing to 

engage in treatment and 

not yet ready to abstain 

Engagement in general health treatment process, which may continue for 

long periods of time or indefinitely 

Continuity of care (case management) 

Continuous enhancement of motivation to change 

Availability of crisis intervention 

Improvement in SUDs, even if temporary or partial 

Improvement in coexisting medical, psychiatric, and social conditions 

Improvement in quality of life 

Reduction in the need for high-intensity healthcare services 

Maintenance of progress 

Reduction in the rate of illness progression 

F. Referral to Specialty SUD Care 

BACKGROUND 

Referral should be offered to patients who are open to assessment or who are ready for assistance from 

a specialty addictions provider or program. 

RECOMMENDATIONS 

1. Offer referral to specialty SUD care for addiction treatment if the patient: [A] 

a. May benefit from additional evaluation or motivational interviewing regarding his/her 

substance use and related problems 

b. Has tried and been unable to change substance use on his/her own or does not respond to 

repeated brief intervention 

Module C: Page - 31 
Guideline Summary VA/DoD Clinical Practice Guideline 

For Management of Substance Use Disorder

c. Has been diagnosed with substance dependence 

d. Has previously been treated for an alcohol or other substance use disorder 

e. Has an AUDIT-C score of > 8. 

For active duty members, coordinate care with the unit commander. 

2. DoD active duty members involved in an incident in which substance use is suspected to be a 

contributing factor are required to be referred to specialty SUD care for evaluation. Command 

should be contacted to discuss administrative and clinical options if the member refuses to be 

evaluated (see Appendix D to the full guideline). 

G. Treatment: Consider Addiction-Focused Pharmacotherapy 

BACKGROUND 

Currently, the Food and Drug Administration (FDA) has approved pharmacotherapy for patients 

diagnosed with alcohol or opioid dependence. While non-pharmacologic treatment has been the 

mainstay of treatment for SUD, recent scientific advances have encouraged the use of pharmacologic 

treatments. Pharmacologic treatments can serve as an effective adjunct to non-pharmacologic 

treatments to help patients reduce or eliminate alcohol consumption. 

RECOMMENDATIONS 

1. Discuss pharmacotherapy options with all patients with opioid and/or alcohol dependence. 

2. Initiate pharmacotherapy if indicated and monitor adherence and treatment response. 

(See Module P for specific recommendations and evidence.) 

H. Treatment: Medical Management and Monitoring 

BACKGROUND 

The provider in general healthcare settings can and should provide evidence-based medical 

management to reduce substance use. A structured, focused format can provide an initial pathway 

towards recovery. Brief interventions are effective in the initial phase and may be repeated as part of 

medical monitoring. For patients who do not respond to brief intervention, comprehensive medical 

management and monitoring as well as opportunistic referral to specialty SUD care are the emphases 

of general healthcare treatment. In some cases, medical management will lead to remission of the 

SUD or referral for specialty SUD care, while in others it serves a more palliative function. 

RECOMMENDATIONS 

1. Provide a brief intervention (counseling) for Unhealthy Alcohol Use , which includes the 

following components: [A] 

a. Express concern that the patient is drinking at unhealthy levels known to increase his/her 

risk of alcohol-related health problems 

b. Provide feedback linking alcohol use and health, including: 

• Personalized feedback (i.e., explaining how alcohol use can interact with the 

patient’s medical concerns [e.g., hypertension, depression/anxiety, insomnia, 

injury, diabetes, breast cancer risk, interactions with medications]) OR 

• General feedback on health risks associated with drinking. 

Module C: Page - 32 
Guideline Summary VA/DoD Clinical Practice Guideline 

For Management of Substance Use Disorder

c. Advise: 

• To abstain (if there are contraindications to drinking) OR 

• To drink below recommended limits (specified for the patient by gender, age 

and health status) 

d. Support the patient in choosing a drinking goal, if he/she is ready to make a change. 

2. Provide medical management in the treatment of alcohol use disorder and consider medical 

management for other substance use disorders that includes: [C] 

• Monitoring self-reported use, laboratory markers and consequences 

• Use of medication, adherence monitoring, response to treatment and adverse effects 

• Education and referral to community support for recovery (e.g., Alcoholics Anonymous). 

3. Offer referral to a specialty addictions program when indicated. 

I. Treatment: Psychosocial Support for Recovery 

BACKGROUND 

Psychosocial rehabilitation services can be an important part of the treatment of SUD when indicated. 

Negative life events and stressful circumstances may contribute to the onset or relapse of a substance use 

disorder. They also may influence treatment adherence and outcome. 

RECOMMENDATIONS 

1. Referral to psychosocial rehabilitation services should be offered to individuals with identified, 

unmet psychosocial needs, regardless of the population or setting, and regardless of the type of 

pharmacotherapy or psychotherapy being administered. 

2. Prioritize and address other coexisting biopsychosocial problems with services targeted to these 

problem areas, rather than increasing intensity of addiction-focused psychosocial treatment alone. 

[B] 

a. Address transitional housing needs to facilitate access to treatment and promote a 

supportive recovery environment 

b. Provide social/vocational/legal services in the most accessible setting to promote 

engagement and coordination of care 

c. Address deferred problems as part of treatment plan updates and monitor emerging 

needs 

d. Coordinate care with other social service providers or case managers. 

J. Treatment: Management of Medical and Psychiatric Co-occurring Conditions 

BACKGROUND 

In addition to the standard addiction-focused services, providers should address psychiatric and general 

medical conditions that exist in association with the SUD. Treatment services directed toward these 

additional problems, when they exist, are associated with improvement. Problems typically show little 

spontaneous improvement if services are not provided. 

Module C: Page - 33 
Guideline Summary VA/DoD Clinical Practice Guideline 

For Management of Substance Use Disorder

RECOMMENDATIONS 

1. Prioritize and address co-occurring medical and psychiatric conditions. 

2. Recommend and offer cessation treatment to patients with nicotine dependence. Use the Clinical 

Practice Guideline: Treating Tobacco Use & Dependence: 2008 Update from the U.S. 

Department of Health and Human Services at: 

http://www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pdf and the VA/DoD Clinical 

Practice Guideline for Management of Tobacco Use 

3. Treat concurrent psychiatric disorders consistent with VA/DoD clinical practice guidelines (e.g., 

Major Depressive Disorder, Post Traumatic Stress, Bipolar Disorder, Psychoses) including 

concurrent pharmacotherapy. 

4. Provide multiple services in the most accessible setting to promote engagement and coordination 

of care. 

5. Monitor and address deferred problems and emerging needs through ongoing treatment plan 

updates. 

6. Coordinate care with other providers. 

K. Assess Response to Treatment / Monitor Biological Indicators 

BACKGROUND 

Periodic monitoring of progress toward treatment goals helps to coordinate care and to motivate the 

patient and members of the treatment team to accomplish interim steps. Periodic reassessment also 

provides opportunities to address emerging problems and change treatment strategies when the initial 

plan is not fully successful. 

There is no uniformly successful treatment plan. Some patients may respond to psychosocial 

interventions, others to pharmacotherapy. Some patients may respond to one medication and not to 

another. The provider should be flexible in modifying the medical regimen based on the patient’s 

needs or preferences. 

RECOMMENDATIONS 

1. Reassess response to treatment periodically and systematically, using standardized and valid 

instrument(s) whenever possible. Indicators of treatment response include ongoing substance use, 

craving, side effects of medication, emerging symptoms, etc. 

2. Consider obtaining biological markers of recent substance use. 

3. Assess co-occurring medical problems associated with substance use through history, physical 

exam and appropriate laboratory evaluation.

L. Follow-Up 

BACKGROUND 

For many patients, substance use disorders are chronic conditions that warrant extended efforts at 

relapse prevention and encouragement by multiple providers for progress. 

RECOMMENDATIONS 

1. Ask the patient about any use, craving, or perceived relapse risk. 

Module C: Page - 34 
Guideline Summary VA/DoD Clinical Practice Guideline 

For Management of Substance Use Disorder

2. Provide feedback to patient regarding improvement or deterioration in laboratory assessments 

affiliated with substance use. 

3. Encourage abstinence or reduced use, consistent with the patient’s motivation and agreement. 

4. Convey openness to discuss any future concerns that may arise and encourage the patient to 

discuss them with you. 

M. Educate About Substance Use, Associated Problems, and Prevention of Relapse 

BACKGROUND 

Expert opinion supports optimistic, empathetic interventions that note the importance of the changes 

patients have made to their health, provide positive feedback and encourage continued drinking below 

recommended limits. 

RECOMMENDATIONS 

1. Discuss the patient’s current use of alcohol and other drugs and address any potential problem 

areas, such as recent initiation of use, increase in use, and use to cope with stress. 

2. Inform patient about potential age- and gender-related problems, such as: 

a. Hazardous drinking or other drug use in the young adult 

b. Alcohol and other drug use during pregnancy 

c. Medication misuse or heavy drinking in the older adult. 

3. Convey openness to discuss any future concerns that may arise and encourage the patient to 

discuss them with you. 

4. Periodically inquire about alcohol and drug use at future visits. 

N. Reevaluate Treatment Plan Regarding Setting and Strategies 

BACKGROUND 

Patients’ goals may change over time, and providers should adapt to new objectives that the patient 

may express. Partial remission may be common and requires an ongoing reevaluation of the treatment 

plan rather than evidence that the patient cannot succeed or that the patient was not sufficiently 

motivated. Even after examining the reasons for partial remission and intensifying or modifying 

psychosocial treatment or pharmacotherapy, some patients may not reduce alcohol consumption. 

Treatment of chronic relapsing patients is difficult. For those willing to accept referral, treatment 

should be undertaken by addiction professionals in specialty treatment settings that employ a multifaceted approach incorporating social, environmental, medical, behavioral, and motivational 

interventions. 

RECOMMENDATIONS 

1. For patients who are not improving, providers should consider either: 

a. Changing to another medication or intervention; or 

b. Changing treatment intensity by: 

• Increasing the intensity of care, or 

• Increasing the dose of the medication, or 

Module C: Page - 35 
Guideline Summary VA/DoD Clinical Practice Guideline 

For Management of Substance Use Disorder

Module C: Page - 36 

• Adding a medication. 

2. For patients who do not stabilize and refuse to engage in any type of ongoing care with any 

provider, (e.g., medical, psychiatric, or addiction specialty) episodic attention to substance use 

may be accomplished by the following: 

a. Provide crisis intervention, as needed 

b. At any contact initiated by the patient: 

• Assess current substance use 

• Recommend that the patient accept ongoing care in the most appropriate setting 

• Designate a single provider to coordinate care for patients who repeatedly 

present in crisis 

• Consider involving supportive family members or significant others, if the 

patient agrees. For DoD active duty members, this may include first line 

supervisor when appropriate and will necessarily include the unit commander 

• Initiate involuntary treatment procedures, if imminent threat to safety occurs 

(e.g., suicidal, violent, or unable to care for self). 

c. Continue to reinforce and endorse increased appropriate engagement and adherence. 

3. Consider consultation with mental health or SUD specialty. 
Guideline Summary VA/DoD Clinical Practice Guideline 

For Management of Substance Use Disorder

Module P: Page - 37 
Guideline Summary VA/DoD Clinical Practice Guideline 

For Management of Substance Use Disorder

MODULE P: ADDICTION-FOCUSED PHARMACOTHERAPY 

A. Patient with Substance Use Disorder (SUD) 

BACKGROUND 

Patients managed within this module meet the criteria for DSM-IV-TR substance abuse or dependence 

and are considered for addiction-focused pharmacotherapy. 

B. Does the Patient Meet DSM-IV Criteria for Opioid Dependence? 

BACKGROUND 

Addiction focused pharmacotherapy is indicated for patients who meet DSM-IV-TR opioid 

dependence criteria. The American Academy of Pain Medicine, the American Pain Society, and the 

American Society of Addiction Medicine issued a consensus statement that distinguished addiction 

from physical dependence. References to opioid dependence elsewhere in this module are based on 

the diagnostic condition reflecting addiction rather than physical dependence alone. 

See Introduction: Definitions (page 5) 

RECOMMENDATION 

1. Assess opioid dependence using DSM-IV-TR criteria. 

PHARMACOTHERAPY FOR OPIOID DEPENDENCE 

C. Is Opioid Agonist Treatment (OAT) Medication Appropriate for, and Acceptable to, the Patient? 

BACKGROUND 

Opioid agonist treatment (OAT) is the first line treatment for chronic opioid dependence that meets 

DSM-IV-TR criteria. For DoD active duty members, OAT is generally not a treatment option. 

RECOMMENDATIONS 

1. Provide access to opioid agonist treatment (OAT) for all opioid dependent patients, under 

appropriate medical supervision and with concurrent addiction-focused psychosocial treatment as 

indicated. [A] 

2. Strongly recommend methadone or sublingual buprenorphine/naloxone maintenance as first line 

treatments due to their documented efficacy in improving retention and reducing illicit opioid use 

and craving. [A] 

 Note: In pregnancy, buprenorphine monotherapy is preferred. 

See Table P-1 for indications, contraindications, side effects, and drug interactions of methadone and 

sublingual buprenorphine/naloxone. 

Refer to Appendix C: Addiction-Focused Psychosocial Treatment 

Module P: Page - 38 
Guideline Summary VA/DoD Clinical Practice Guideline 

For Management of Substance Use Disorder

Table P- 1. Agonist Therapy for Opioid Dependence 

Methadone Buprenorphine / Naloxone or Buprenorphine* 

Indications Opioid dependence (DSM diagnosis) and 

patient meets Federal Opioid 

Treatment Standards (42 CFR 8.12)

 

Opioid dependence (DSM diagnosis) plus one or 

more of the following: 

1 New patients not currently receiving OAT 

AND who meet at least one of the following 3 

criteria: 

a. Do not have timely access to a VAsupported OAT center. 

b. Do not meet regulatory criteria for treatment 

in an OAT program. 

(http://www.dpt.samhsa.gov/) 

c. Will have difficulty adhering to scheduled 

visits at a VA supported OAT program (e.g., 

because of restrictive clinic hours). 

2 Appropriately selected patients on stable 

methadone maintenance who have difficulty 

adhering to scheduled visits at a VA-supported 

OAT center or may not need close supervision. 

3 Patients who have a documented severe, 

uncontrollable adverse effect or true 

hypersensitivity to methadone. 

Contraindications Hypersensitivity Hypersensitivity 

Warnings / 

Precautions 

Concurrent enrollment in another OTP 

Significant liver failure 

Use of opioid antagonists (e.g., naloxone, 

nalmefene, or naltrexone) 

Concurrent benzodiazepines or other CNS 

depressants (potential respiratory 

depression) 

Cardiac arrhythmias with prolonged QTc 

interval 

Buprenorphine/naloxone may precipitate 

withdrawal in patients on full agonist opioids 

Concurrent benzodiazepines or other CNS 

depressants, including active alcohol abuse 

/dependence (potential respiratory depression) 

Use caution in patients with respiratory, liver, or 

renal impairment 

Use of opioid antagonists (e.g., naloxone, 

nalmefene, or naltrexone) 

Baseline evaluation Consider baseline ECG and physical 

examination for patients at risk for QT 

prolongation or arrhythmias 

Liver transaminases 

Dosage and 

Administration 

Initial dose: 15–20 mg single dose, max. 

30 mg. 

Daily dose: Max. 40 mg/d on first day. 

Usual dosage range for optimal effects: 

60–120 mg/d. 

Titrate carefully, consider methadone’s 

delayed cumulative effects 

Give orally in single dose 

Individualize dosing regimens (AVOID 

same fixed dose for all patients) 

Induction dose: 2–8 mg sublingually once daily 

Day 2 and onward: Increase dose by 2–4 mg/d; 

target dose in first week, 12–16 mg/d. 

Stabilization / Maintenance: Titrate by 2–4 mg 

per week; usual dose 12–16 mg/d (up to 

32 mg/d) 

Individualize dosing regimens 

Alternative Dosing 

Regimens 

Give in divided daily doses based on peak 

and low levels that document a 

metabolic rate that justifies divided 

doses 

Give equivalent weekly maintenance dose divided 

over extended dosing intervals (2 or 3 times a 

week or every 2, 3, or 4 days) 

Dosing in Special 

Populations 

Renal or Hepatic Impairment: Reduce 

dose

Elderly or Debilitated: Reduce dose

Hepatic Impairment: Reduce dose 

Module P: Page - 39 
Guideline Summary VA/DoD Clinical Practice Guideline 

For Management of Substance Use Disorder

Module P: Page - 40 

Methadone Buprenorphine / Naloxone or Buprenorphine* 

Adverse Effects Major: respiratory depression, shock, 

cardiac arrest, possible prolongation of 

QTc interval on ECG and torsades de 

pointes ventricular tachycardia 

Common: lightheadedness, dizziness, 

sedation, nausea, vomiting, sweating, 

constipation, edema 

Less common: sexual dysfunction 

Major: hepatitis, hepatic failure, respiratory 

depression (usually when misused 

intravenously with other CNS depressants) 

Common: headache, pain, abdominal pain, 

insomnia, nausea, vomiting, sweating, 

constipation 

Drug Interactions Drugs that reduce serum methadone 

levels: ascorbic acid, barbiturates, 

carbamazepine, ethanol (chronic use), 

interferon, phenytoin, rifampin, 

efavirenz, nevirapine, other 

antiretrovirals with CYP3A4 activity 

Drugs that increase serum methadone 

level: amitriptyline, atazanavir, 

atazanavir / ritonavir, cimetidine, 

delavirdine, diazepam, fluconazole, 

fluvoxamine, ketoconazole, 

voriconazole 

Opioid antagonists may precipitate 

withdrawal 

Drugs that reduce serum buprenorphine level: 

ascorbic acid, barbiturates, carbamazepine, 

ethanol (chronic use), interferon, phenytoin, 

rifampin, efavirenz, nevirapine, other 

antiretrovirals with CYP3A4 activity 

Drugs that increase serum buprenorphine level: 

amitriptyline, atazanavir, atazanavir / ritonavir, 

cimetidine, delavirdine, diazepam, fluconazole, 

fluvoxamine, ketoconazole, voriconazole 

Opioid agonist: buprenorphine/naloxone or 

buprenorphine may precipitate withdrawal 

Opioid antagonists may precipitate withdrawal 

Patient Education Strongly advise patient against selfmedicating with CNS depressants 

during methadone therapy 

Serious overdose and death may occur if 

benzodiazepines, sedatives, 

tranquilizers, antidepressants, or 

alcohol are taken with methadone 

Store in a secure place out of the reach of 

children 

Strongly advise patient against self-medicating 

with CNS depressants during buprenorphine 

therapy 

Serious overdose and death may occur if 

benzodiazepines, sedatives, tranquilizers, 

antidepressants, or alcohol are taken with 

buprenorphine 

Store in a secure place out of the reach of children 

D. Is Treatment in a Specialized Opioid Agonist Treatment Program (OATP) Setting Appropriate for 

the Patient? 

BACKGROUND 

In general, patients requiring greater structure and intensity of comprehensive treatment services 

including mental health, medical, and social services, may be better served in an Opioid Agonist 

Treatment Program (OATP). Provision of care at OATPs is highly regulated, with provider and 

patient-level requirements including limited take home medications provided, mandated laboratories 

and assessments, appropriate psychosocial intervention, and formal agreements for the provision of 

OAT. In office-based opioid treatment (OBOT) for medical maintenance by credentialed physicians, 

patients usually receive less intensive services (e.g., less psychosocial services needed to prevent 

relapse) either within an addiction specialty care program or in a setting similar to treatment of other 

medical conditions. 

Deciding on whether a patient requires opioid agonist treatment in a specialized OATP depends on 

matching treatment resources to each individual patient’s needs. 
Guideline Summary VA/DoD Clinical Practice Guideline 

For Management of Substance Use Disorder

RECOMMENDATIONS 

1. Individualize the choice of setting based on patient characteristics and availability of facilities to 

treat patients with opioid agonist therapy (OAT). See Table P-2.

2. Appropriate psychosocial interventions should be provided as part of the opioid agonist therapy 

(OAT). [A] 

Table P- 2. Patient Suitability for Office-Based Opioid Treatment versus Opioid Agonist Treatment 

Program* 

Criteria Office-Based Opioid 

Treatment (OBOT) 

Opioid Agonist 

Treatment Program 

(OATP) 

Can an office-based setting provide needed resources 

for the patient Yes No 

Patient’s psychosocial supports Good Poor 

Severity of opioid dependence Mild to Moderate High 

Co-occurring psychiatric disorders Stable Unstable (e.g., chronically 

suicidal) 

Co-occurring medical disorders Stable Unstable 

Dependence on CNS depressants (e.g. alcohol, 

benzodiazepines) No Yes 

Pregnant No Yes 

Previous failed treatment attempts, especially with 

opioid agonists None/Few Many 

Response to sublingual buprenorphine in the past Good Poor 

Expected to be reasonably compliant in treatment Yes No 

* A considerable amount of medical decision-making is required to determine the best setting for each 

individual patient. If the setting chosen initially is not appropriate, the patient can be switched to the 

alternative setting with appropriate monitoring. 

E. Initiate Opioid Agonist Treatment in an Opioid Agonist Treatment Program (OATP) or OfficeBased Opioid Treatment (OBOT) with Patient Education and Monitoring 

RECOMMENDATIONS 

1. Opioid Agonist Treatment Program (OATP) and office-based opioid treatment (OBOT) must be 

provided in the context of a complete treatment program that includes: 

a. Appropriate adjustment of opioid agonist doses to maintain a therapeutic range between 

signs/symptoms of overmedication (e.g., somnolence, miosis, itching, hypotension, and 

flushing) and opioid withdrawal (e.g., drug craving, anxiety, dysphoria, and irritability) 

• Usual dosage range for optimal effects: 60–120 mg/day [A] 

• Buprenorphine target dose is generally up to 16mg daily; doses above 32mg are 

rarely indicated. In all cases, except pregnancy, the combination product of 

buprenorphine/naloxone should be used. 

Module P: Page - 41 
Guideline Summary VA/DoD Clinical Practice Guideline 

For Management of Substance Use Disorder

b. Relapse monitoring to promote effective outcomes 

c. Adequate frequency of toxicology for alcohol and other drugs of abuse 

d. Appropriate psychosocial interventions. [A] 

F. Is Naltrexone Therapy Appropriate for and Acceptable to the Patient? 

BACKGROUND 

Naltrexone is an FDA approved alternative to opioid agonist treatment for patients with opioid 

dependence who are highly motivated and have psychosocial support for treatment and medication 

adherence. However, the number of individuals maintained on naltrexone continues to be low and its 

usefulness in the treatment of opioid dependency has been limited. It has no opioid agonist effects. 

Patients may continue to experience cravings and may thereby not be motivated to maintain adherence 

to the medication regimen. Patients addicted to opioids must be fully withdrawn for up to 7-10 days 

from all opioids before beginning naltrexone treatment. Unfortunately, during this period, many 

patients relapse to use of opioids and are unable to start on naltrexone. 

RECOMMENDATIONS 

1. Consider monitored administration of naltrexone maintenance in highly motivated opioid 

dependent patients. [C] See Table P-3.

2. Consider opioid agonist treatment (OAT) or long-term therapeutic community before naltrexone 

as first line approaches for chronic opioid dependent patients. 

Table P- 3. Pharmacotherapy with Naltrexone for Opioid Dependence 

Indications Opioid dependence with ability to achieve at least 7-10 days of abstinence to prevent 

precipitated withdrawal with first dose 

Engagement in comprehensive management program that includes measures to ensure 

medication adherence 

Note: Most effective when the patient is engaged in addiction-focused counseling with 

monitored administration 

Contraindications Acute hepatitis or liver failure 

Hypersensitivity to naltrexone or product components 

Current physiological dependence on opioids with use within past 7 days 

Ongoing acute opioid withdrawal or failed naloxone challenge test 

Receiving opioid agonists 

Positive urine opioid screen 

Warnings / 

Precautions 

Active liver disease 

Severe hepatic dysfunction (i.e., transaminase levels > 3 times normal and abnormal 

bilirubin) 

Severe renal failure 

Pregnancy Category C 

Baseline Evaluation Consider naloxone challenge test 

Transaminase levels 

Urine toxicology 

Module P: Page - 42 
Guideline Summary VA/DoD Clinical Practice Guideline 

For Management of Substance Use Disorder

G. Assure Patient is Withdrawn from Opioids and Opioid Free Before Continuing 

BACKGROUND 

Avoid an adverse opioid withdrawal reaction precipitated by naltrexone during lingering physiological 

dependence. Such reactions can result in extreme reluctance to trust treatment of any modality. 

RECOMMENDATIONS 

1. Prior to starting naltrexone, ensure that the patient is opioid-free as naltrexone is an opioid 

antagonist and may precipitate withdrawal. 

2. Consider pharmacologically assisted withdrawal (See Module S: Stabilization and Withdrawal 

Management, Annotation F), unless the patient successfully completed a naloxone challenge 

and/or has had at least 7-10 days of verified abstinence. 

H. Initiate Naltrexone for Opioid Dependence with Patient Education and Monitoring 

BACKGROUND 

Patients who have successfully completed a naloxone challenge and/or have had at least 7 to 10 days 

of verified abstinence and who lack contraindications can be safely started on naltrexone maintenance 

therapy. 

RECOMMENDATIONS 

1. Provide appropriate dosing, treatment retention- and adherence-enhancing techniques, and relapse 

monitoring to promote effective outcomes. 

2. Carefully start oral naltrexone at a dose of 25 mg once daily. If no signs of withdrawal occur, the 

dose may be increased to 50 mg daily on the following day. Extended dosing intervals, using 

equivalent weekly doses, may be used for supervised administration (see Table P-4). 

Table P- 4. Pharmacotherapy Management with Naltrexone for Opioid Dependence 

Dosage and 

Administrati

on 

25 mg orally once daily initially; if no withdrawal reaction, increase to 50 mg once daily 

Observed administration improves adherence 

Alternative 

Dosing 

Schedules 

- 25 mg orally twice daily with meals to reduce nausea, especially during the first week 

- 100 mg on Monday and Wednesday, 150 mg on Friday 

Adverse 

Effects 

Common: nausea 

Other: headache, dizziness, nervousness, fatigue, insomnia, vomiting, anxiety, somnolence 

Drug 

Interactions 

Opioid-containing medications, including over-the-counter (OTC) preparations 

Thioridazine 

Oral hypoglycemics 

Antiretrovirals 

Monitoring Monitor for opioid use with urine toxicology at least weekly during early recovery 

Repeat transaminase levels monthly for the first 3 months and every 3 months thereafter 

Discontinue or reduce naltrexone if transaminase levels rise significantly 

Patient 

Education 

Discuss compliance-enhancing procedures 

Negotiate commitment from the patient regarding monitored ingestion, if necessary 

Side effects, if any, tend to occur early in treatment and can typically resolve within 1-2 

weeks after dosage adjustment 

If signs and symptoms of acute hepatitis occur, discontinue naltrexone and contact provider 

immediately 

Module P: Page - 43 
Guideline Summary VA/DoD Clinical Practice Guideline 

For Management of Substance Use Disorder

Module P: Page - 44 

PHARMACOTHERAPY FOR ALCOHOL DEPENDENCE 

I. Is the Patient Alcohol Dependent? 

BACKGROUND 

For the purposes of this guideline, alcohol dependence is defined via DSM-IV-TR criteria. 

RECOMMENDATION 

1. Identify patients with alcohol dependence who should be offered addiction-focused 

pharmacotherapy. 

See Introduction: Definitions (page 5) 

J. Initiate Pharmacotherapy for Alcohol Dependence with Patient Education and Monitoring 

BACKGROUND 

Established pharmacologic treatments, notably disulfiram and naltrexone, (see Table P-5) combined 

with addiction-focused counseling may reduce the amount of drinking, the risk of relapse, the number 

of days of drinking, and craving in some alcohol-dependent individuals. For many patients, however, 

these treatments are not effective. Research in molecular and behavioral genetics are guiding the 

development of new drugs seeking to identify pharmacologic pathways relevant to alcohol dependence 

and to more effectively match treatments to individuals according to their genetic characteristics. 

Medications such as ondansetron, topiramate, sertraline, aripiprazole, quetiapine and baclofen 

represent novel lines of research and are currently being tested for use in the treatment of alcoholism. 

RECOMMENDATIONS 

1. Routinely consider oral naltrexone, an opioid antagonist, and acamprosate for patients with 

alcohol dependence. [A] 

Note that in VA, acamprosate is currently a non-formulary medication with criteria for use posted 

at http://vaww.national.cmop.va.gov/PBM/Clinical%20Guidance/Forms/AllItems.aspx 

2. Medications should be offered in combination with addiction-focused counseling. 

3. Injectable naltrexone should be considered when medication adherence is a significant concern in 

treating alcohol dependence and should be combined with addiction-focused counseling. [A] 

Note that in VA, injectable naltrexone is currently a non-formulary medication with criteria for 

use posted at http://vaww.national.cmop.va.gov/PBM/Clinical%20Guidance/Forms/AllItems.aspx 

4. If patient does not respond to one of the approved medications, a trial on one of the other approved 

medications is warranted. 

5. Because of the risk of significant toxicity and limited evidence of effectiveness, risk and benefits 

of disulfiram should be considered and disulfiram should only be used when abstinence is the goal 

and when combined with addiction-focused counseling. [B] The informed consent discussion with 

the patient should be documented. 

6. Dosing of these pharmacotherapies should be consistent with medication trials and 

recommendations in appropriate drug references (see Table P-5). 
Guideline Summary VA/DoD Clinical Practice Guideline 

For Management of Substance Use Disorder

Table P- 5. Pharmacotherapy of Alcohol Dependence 

Naltrexone Oral Naltrexone Injectable Acamprosate Disulfiram 

Indications Alcohol dependence 

(DSM diagnosis) 

with: 

- At least 3-5 days of 

pretreatment 

abstinence (1) 

- Engagement in a 

comprehensive 

management 

program that 

includes 

psychosocial therapy 

Alcohol dependence 

(DSM diagnosis) with: 

- Pretreatment abstinence 

not required but 

improves response (2) 

- Willingness to receive 

monthly injections 

- Difficulty adhering to an 

oral regimen 

- Engagement in a 

comprehensive 

management program 

that includes 

psychosocial therapy 

Alcohol dependence 

(DSM diagnosis) 

with: 

- Abstinence at treatment 

initiation 

- Engagement in a 

comprehensive 

management 

program that includes 

psychosocial therapy. 

Alcohol dependence 

(DSM diagnosis) with: 

- Abstinence > 24 hours 

and BAL equal to 0 

- Combined cocaine 

dependence 

- Failure of or 

contraindication to 

naltrexone 

- Previous response to 

disulfiram 

- Capacity to appreciate 

risks and benefits and 

to consent to treatment 

Note: More effective with 

monitored administration 

(e.g., in clinic or with 

spouse or probation 

officer.)

Contraindications 

-Receiving opioid 

agonists 

Physiologic opioid 

dependence with use 

within past 7 days 

Acute opioid 

withdrawal 

Failed naloxone 

challenge test 

Positive urine opioid 

screen 

Acute hepatitis or liver 

failure 

Hypersensitivity 

Receiving opioid agonists 

Physiologic opioid 

dependence with use 

within past 7 days 

Acute opioid withdrawal 

Failed naloxone challenge 

Positive urine opioid 

screen 

Acute hepatitis or liver 

failure 

Hypersensitivity 

Inadequate muscle mass 

Discontinue intramuscular 

naltrexone if there is NO 

detectable benefit within 

3 months 

Hypersensitivity 

Severe renal impairment 

(CrCl ≤ 30 mL/min). 

Severe cardiovascular, 

respiratory, or renal 

disease 

Severe hepatic 

dysfunction (i.e., 

transaminase levels > 3 

times upper limit of 

normal or abnormal 

bilirubin) 

Severe psychiatric 

disorders, especially 

psychotic and 

cognitive disorders and 

suicidal ideation 

Poor impulse control 

Metronidazole or 

ketoconazole therapy 

which already induce a 

similar reaction to 

alcohol 

Hypersensitivity 

Warnings / 

Precautions 

Active liver disease 

Severe renal failure 

Pregnancy Category C 

 Active liver disease 

Moderate to severe renal 

insufficiency (no data) 

Injection site reactions 

Use intramuscular 

injections with caution 

in patients with 

thrombocytopenia or 

coagulation disorders 

Pregnancy Category C 

Monitor for emergence 

of depression or 

suicidality 

Reduce dose in patients 

with renal 

impairment, including 

elderly 

Pregnancy Category C Pregnancy Category C 

Module P: Page - 45
Guideline Summary VA/DoD Clinical Practice Guideline 

For Management of Substance Use Disorder

Module P: Page - 46

Naltrexone Oral Naltrexone Injectable Acamprosate Disulfiram 

Baseline 

Evaluation 

Liver transaminase 

levels 

Bilirubin within normal 

limits 

Urine beta-HCG for 

females 

Liver transaminase levels 

Bilirubin within normal 

limits 

Creatinine clearance 

(estimated or 

measured) 50 ml/min 

or greater 

Ensure patient has 

adequate muscle mass 

for injection 

Urine beta-HCG for 

females 

Creatinine clearance 

(estimated or 

measured) 

Urine beta-HCG for 

females 

Liver transaminase levels 

Physical assessment 

Psychiatric assessment 

Electrocardiogram 

Verify abstinence with 

breath or blood alcohol 

level 

Urine beta-HCG for 

females 

Dosage and 

Administration

50 to 100 mg orally 

once daily 

380 mg once monthly by 

deep intramuscular 

injection 

666 mg orally three 

times daily, 

preferably with meals 

250 mg orally once daily 

(range, 125–500 mg 

daily) 

Alternative 

Dosing 

Schedules 

25 mg once or twice 

daily with meals to 

reduce nausea, 

especially during the 

first week 

100 mg on Monday and 

Wednesday and 150 

mg on Friday 

None None Reduce dose to 125 mg to 

reduce side effects 

For monitored 

administration, 

consider giving 500 mg 

on Monday, 

Wednesday, and Friday 

Dosing in 

Special 

Populations 

Hepatic or renal 

impairment: Use 

caution 

Mild renal impairment 

(CrCl 50–80 ml/min): 

No dosage adjustment 

necessary 

Moderate–Severe renal 

impairment: No data 

Moderate renal 

impairment (CrCl 30–

50 ml/min): 333 mg 

three times daily 

Do not administer to 

patients with severe 

renal impairment 

(CrCl ≤ 30 ml/min) 
Guideline Summary VA/DoD Clinical Practice Guideline 

For Management of Substance Use Disorder

Module P: Page - 47

Naltrexone Oral Naltrexone Injectable Acamprosate Disulfiram 

Adverse Effects 

Common: nausea 

Other: headache, 

dizziness, 

nervousness, fatigue, 

insomnia, vomiting, 

anxiety, somnolence 

Major: Eosinophilic 

pneumonia, depression, 

suicidality 

Common: Injection-site 

reaction, injection-site 

tenderness, injectionsite induration, nausea, 

headache, asthenic 

conditions 

Major: suicidality 2.4% 

(vs. 0.8% on placebo 

during the first year in 

clinical trials) 

Common: diarrhea 

(16%) 

Other: anxiety, asthenia, 

depression, insomnia 

Major: Hepatotoxicity, 

peripheral neuropathy, 

psychosis, delirium, 

severe disulfiramethanol reaction 

Common: somnolence, 

metallic taste, 

headache 

Drug 

Interactions 

Opioid-containing 

medications, 

including OTC 

preparations 

Thioridazine (increased 

lethargy and 

somnolence) 

Opioid-containing 

medications, including 

OTC preparations 

Thioridazine (increased 

lethargy and 

somnolence) 

Naltrexone: 33% 

increase in Cmax of 

acamprosate (no 

dosage adjustment is 

recommended) 

Antidepressants: weight 

gain and weight loss 

more common than 

with either 

medication alone 

Alcohol containing 

medications, including 

OTC preparations 

Drug-drug interactions 

may occur with 

phenytoin, warfarin, 

isoniazid, rifampin, 

diazepam, 

chlordiazepoxide, 

imipramine, 

desipramine, and oral 

hypoglycemic agents. 

Monitoring Repeat liver 

transaminase levels 

at 6 and 12 months 

and then every 12 

months thereafter 

Repeat liver transaminase 

levels at 6 and 12 

months and every 12 

months thereafter 

Monitor serum creatinine 

/ CrCl, particularly in 

patients with renal 

impairment and the 

elderly 

Repeat liver transaminase 

levels in 10 to 14 days 

and every 12 months 

thereafter 
Guideline Summary VA/DoD Clinical Practice Guideline 

For Management of Substance Use Disorder

Module P: Page - 48

Naltrexone Oral Naltrexone Injectable Acamprosate Disulfiram 

Patient 

Education 

Discuss complianceenhancing methods 

Negotiate commitment 

from the patient 

regarding monitored 

ingestion 

Side effects, if any, tend 

to occur early in 

treatment and can 

typically resolve 

within 1-2 weeks 

after dosage 

adjustment 

Report any concerning 

injection-site reactions 

Report any new or 

worsening depression 

or suicidal thinking 

May cause allergic 

pneumonia; contact 

provider if patient 

develops signs and 

symptoms of 

pneumonia 

Report any new or 

worsening depression 

or suicidal thinking 

Avoid alcohol in food and 

beverages, including 

medications 

Avoid disulfiram if 

alcohol intoxicated 

May cause sedation; 

caution operating 

vehicles and hazardous 

machinery 

Discuss complianceenhancing methods 

Family members should 

not administer 

disulfiram without 

informing patient 

Provide patients with 

wallet cards that 

indicate the use of 

disulfiram 

If signs and symptoms of acute hepatitis occur, 

discontinue naltrexone and contact provider 

immediately 

Very large doses of opioids may overcome the effects 

of naltrexone and lead to serious injury, coma, or 

death 

Small doses of opioids, such as in analgesic, 

antidiarrheal, or antitussive drugs, may be blocked by 

naltrexone and fail to produce a therapeutic effect 

Patients who have previously used opioids may be 

more sensitive to toxic effects of opioids after 

discontinuation of naltrexone 

(1) Most trials for oral NTX required as an inclusion criterion pretreatment abstinence of ≥ 4 or ≥ 7 days. This is the 

subgroup of patients in which oral NTX was shown to be efficacious. Expert opinion suggests a less restrictive 

requirement. This description of "appropriate" candidates is consistent with FDA-approved product information 

(2) While documented abstinence is not required for therapeutic benefit with injectable naltrexone, even greater benefit 

may be seen in patients who achieve some duration of alcohol abstinence (e.g. 2–4 days) prior to the initial injection 

of naltrexone. The evidence supports 7 days of prior abstinence for improved outcomes. 
Guideline Summary VA/DoD Clinical Practice Guideline 

For Management of Substance Use Disorder

Module S: Page 49 
Guideline Summary VA/DoD Clinical Practice Guideline 

For Management of Substance Use Disorder

MODULE S: STABILIZATION and WITHDRAWAL MANAGEMENT 

A. Substance-Using Patient Who May Require Physiological Stabilization 

This module addresses the management of patients who are physiologically dependent on alcohol 

and/or other substances and who are at risk of withdrawal symptoms, or for whom the provider is 

uncertain about the level of withdrawal risk and seeks further evaluation. 

B. Obtain History, Physical Examination, Mental Status Examination (MSE), Medication Including 

Over-The-Counter (OTC), and Lab Tests as Indicated 

BACKGROUND 

The provider should review or obtain clinical background information on the patient, including any 

prior assessment. 

RECOMMENDATIONS 

1. Interview the patient and other collateral informants, where appropriate, about medical and mental 

health history and use of prescription and non-prescription medications before initiating extensive 

diagnostic testing. 

2. Note any history of recent head trauma. 

3. Order laboratory tests selectively, aiming to detect potential medical causes for the presenting 

symptoms, where indicated by: 

a. Specific symptoms found on the medical review of systems 

b. Evidence of unusual symptom profiles 

c. History of atypical illness course 

d. Abnormal screen for cognitive status, particularly in the elderly patient. 

C. Is the Patient in Any Immediate Medical or Psychiatric Crisis or Intoxicated? 

BACKGROUND 

Emergency or urgent clinical situations include unstable medical problems (e.g., acute trauma, 

myocardial infarction, and stroke) or unstable psychiatric problems (e.g., imminent risk of harm to self 

and/or others and delirium, including alcohol-related delirium [withdrawal/intoxication]). 

RECOMMENDATIONS 

1. Refer patients with problems that require emergency care or urgent action to emergency care for 

further action as needed. 

Module S: Page 50 
Guideline Summary VA/DoD Clinical Practice Guideline 

For Management of Substance Use Disorder

D. Provide Appropriate Care to Stabilize Prior to Management of Withdrawal; 

Follow Policies For DoD Active Duty Members: Keep Commanding Officer Informed 

BACKGROUND 

Existing local policies and procedures with regard to threats to self or others reflect local and state laws and 

the opinion of the VA District Council and the DoD. Primary care, mental health, and administrative staff 

must be familiar with these policies and procedures. 

RECOMMENDATIONS 

1. Assure the patient’s immediate safety and determine the most appropriate setting 

2. Refer for mental health treatment or assure that follow-up appointment is made 

3. Inform and involve someone close to the patient 

4. Limit access to means of suicide 

5. Increase contact and make a commitment to help the patient through the crisis 

6. For comatose patients, maintain airway and adequate ventilation in order to preserve respiration 

and cardiovascular function. 

7. Emergency procedures should be considered, including the use of gastric lavage for sedative, 

hypnotic, and/or opioid intoxication. 

8. Emergency pharmacologic interventions should be utilized as appropriate, including the use of 

intravenous naloxone hydrochloride for opioid overdose and flumazenil for benzodiazepine 

overdose. 

9. Agitation secondary to intoxication from a variety of substances is best initially managed through 

decreasing sensory stimuli and interpersonal approaches rather than additional medications. If 

chemotherapeutic agents are necessary, the short acting IM benzodiazepines (e.g., lorazepam) and 

high potency neuroleptics should be considered. 

For DoD active duty members: follow DoD and Service-specific policies, as mental 

health/emergency referral is likely mandated. 

E. Assess Level of Physiological Dependence and Indications for Stabilization Including Risk of 

Withdrawal 

BACKGROUND 

Untreated severe alcohol and other sedative hypnotic withdrawal, in particular, can lead to autonomic 

instability, seizures, delirium, or even death. 

The opioid withdrawal syndrome can be protracted with intense symptoms, though the syndrome itself 

poses virtually no risk of mortality. However, there is significant mortality risk from overdose for 

those who relapse following unsuccessful medically supervised withdrawal attempts as a result of loss 

of opioid tolerance. 

The potential for a withdrawal syndrome can be gauged only imprecisely by asking the patient the 

pattern, type, and quantity of recent and past substance use. Systematic monitoring of withdrawal 

symptoms is indicated until patients are stabilized. 

Module S: Page 51 
Guideline Summary VA/DoD Clinical Practice Guideline 

For Management of Substance Use Disorder

RECOMMENDATIONS 

1. Obtain and document necessary information to classify level of withdrawal and factors that may 

influence the severity of the withdrawal (see Appendix B-6 for a list of withdrawal signs and 

symptoms for the different types of substances): 

a. Determine type of substance of use 

b. Determine time since last use 

c. Determine concurrent use of other substances or prescriptions 

d. Determine co-occurring medical and/or psychiatric disorders 

e. Consider past withdrawal experiences. 

2. Use laboratory results and patient observation to determine the level of tolerance (e.g., high blood 

level in patient who appears to be not intoxicated). 

3. Use standardized measures to assess the severity of withdrawal symptoms such as CIWA-Ar (see 

Box S-1) or COWS (see Box S-2). [B] 

4. Evaluate patients using multiple substances (e.g., opioids and sedative-hypnotics) for risk of 

withdrawal from each substance. 

Box S-1. Assessment of Alcohol Withdrawal (See Appendix B-7) 

The Clinical Institute Withdrawal Assessment for Alcohol-Revised (CIWAAr) has good reliability and validity for assessing severity of withdrawal 

symptoms from alcohol. 

CIWA-Ar has 10 provider ratings. Interpret total scores as follows: 

• Minimal or absent withdrawal: ≤ 9 

• Mild to moderate withdrawal: 10-19 

• Severe withdrawal: > 20. 

Box S-2. Assessment of Opioid Withdrawal (see Appendix B-8) 

The Objective, Subjective and Clinical Opiate Withdrawal Scales (OOWS, 

SOWS, and COWS) can be used for assessing severity of withdrawal 

symptoms from opioids 

COWS has 10 provider ratings. Interpret total scores as follows: 

• Mild withdrawal: 5-12 

• Moderate withdrawal: 13-24 

• Moderately severe withdrawal: 25-36 

• Severe withdrawal: > 36. 

F. Is the Patient in Need of Withdrawal Management? 

BACKGROUND 

Withdrawal management from a substance is defined as non-pharmacologic and/or pharmacologic 

medical care with a goal of safely transitioning a patient from active use to sustained treatment for the 

Module S: Page 52 
Guideline Summary VA/DoD Clinical Practice Guideline 

For Management of Substance Use Disorder

patient’s substance use disorder. Withdrawal management is an essential initial gateway in preparing 

many patients for additional treatment. 

Pharmacologically supervised withdrawal is warranted only for alcohol, sedative-hypnotics, and 

opioids; however, patients who use other illicit substances may find benefit in initiation of treatment 

during their withdrawal period. For nicotine dependence, refer to Clinical Practice Guideline: 

Treating Tobacco Use & Dependence: 2008 Update from the U.S. Department of Health and Human 

Services available at: http://www.surgeongeneral.gov/tobacco/treating_tobacco_use08.pdf and the 

VA/DoD Clinical Practice Guideline for the Management of Tobacco Use. Other substances do not 

require pharmacological management for withdrawal. 

It is important to distinguish patients with legitimate pain and/or anxiety disorders who develop only 

physiological tolerance during long-term use of prescribed medications from those with markers of 

prescription misuse. 

RECOMMENDATIONS 

1. Indications for withdrawal management from alcohol or sedative-hypnotics 

• Patient with alcohol dependence with observed withdrawal symptoms 

• CIWA-Ar score for at least mild withdrawal (>10) 

• Patients with dependence on central nervous system depressants, due to the risks of 

untreated withdrawal in severely dependent persons. 

2. Relative contraindication for medically supervised withdrawal management from alcohol 

• Patients with minimal withdrawal symptoms that are not accompanied by complicating 

co-occurring disorders. Such patients may respond sufficiently to generalized support, 

reassurance, and frequent monitoring. 

3. Potential indications for medically supervised opioid withdrawal: 

• Patient with physical dependence in the absence of clinical indications for ongoing 

treatment (e.g., severe pain disorder) 

• Patient with physical dependence accompanied by aberrant or non-adherent behavior 

(e.g., obtaining prescriptions from multiple providers, escalating doses without provider 

consultation, or buying medications on the street) 

• Agreement to provide naltrexone for treatment of opioid dependence 

• Patient who does not request or want opioid agonist medical therapy but wants nonpharmacologic treatment for opioid dependence 

4. Contraindication for opioid withdrawal management: 

• Chronic severe opioid dependence. For such patients, first line therapy is methadone or 

sublingual buprenorphine/naloxone maintenance treatment (see Module P - Addiction 

Focused Pharmacotherapy) 

• Two or more unsuccessful medically supervised withdrawal episodes within a 12-month 

period. Such patients should be assessed for opioid agonist therapy. 

5. Consider using a structured assessment tool to evaluate and track behaviors suggestive of 

addiction such as inappropriate medication use and to increase the provider's confidence in 

determinations of appropriate vs. inappropriate opioid use. 

6. Evaluate opioid dependent patients for severe acute or chronic physical pain that may require 

appropriate short-acting opioid agonist medication in addition to the medication needed to prevent 

opioid withdrawal symptoms (see also VA/DoD Clinical Practice Guideline for Management of 

Chronic Opioid Therapy at http://www.healthquality.va.gov). 

Module S: Page 53 
Guideline Summary VA/DoD Clinical Practice Guideline 

For Management of Substance Use Disorder

G. Does Patient Require Inpatient Medically Supervised Withdrawal? 

BACKGROUND 

Patients are more likely to complete an inpatient medically supervised withdrawal protocol; however, 

long-term outcomes do not differ between inpatient and outpatient medically supervised withdrawal 

programs. Relative advantages to consider include: 

Ambulatory withdrawal management has the potential advantages of: 

• Facilitating continuity of care in the outpatient setting 

• Reducing disruption to the patient’s life 

• Lowering costs in the outpatient setting. 

Inpatient withdrawal management has the advantages of: 

• Fewer logistic medical and legal concerns (e.g., arranging for patient transportation, driving 

during the course of medically supervised withdrawal, and the ability to give informed 

consent) 

• Allowing closer monitoring of withdrawal symptoms 

• Having higher likelihood of completing the withdrawal management protocol 

RECOMMENDATIONS 

1. Consider the following indications for inpatient medically supervised withdrawal: [C] 

a. Current symptoms of at least mild alcohol withdrawal (e.g., CIWA-Ar score ≥10) 

b. History of delirium tremens or withdrawal seizures 

c. Inability to tolerate oral medication 

d. Imminent risk of harm to self or others 

e. Recurrent unsuccessful attempts at ambulatory medically supervised withdrawal 

f. Reasonable likelihood that the patient will not complete ambulatory medically 

supervised withdrawal (e.g., due to homelessness) 

g. Active psychosis or severe cognitive impairment 

h. Chronic liver disease or cardiovascular disease, pregnancy, or lack of medical 

support system. 

H. Admit to Inpatient Withdrawal Management or 

Initiate Ambulatory Withdrawal Management 

BACKGROUND 

The objectives of withdrawal management from alcohol, sedative-hypnotics, or opioids in either 

inpatient or ambulatory settings are to prevent the patient from experiencing adverse events and 

prepare the patient for ongoing addiction treatment. 

Module S: Page 54 
Guideline Summary VA/DoD Clinical Practice Guideline 

For Management of Substance Use Disorder

RECOMMENDATIONS 

Alcohol Withdrawal Management 

Follow local alcohol withdrawal management pathways, taking into consideration the following 

principles: 

1. Use either of the following two acceptable pharmacotherapy strategies for managing alcohol 

withdrawal symptoms: 

a. Symptom-triggered therapy, where patients are given medication only when signs or 

symptoms of withdrawal appear (e.g., PRN dosing) [A] 

b. A predetermined fixed medication dose, with gradual tapering over several days may 

be considered for some patients, although it is inferior to symptom-triggered therapy. 

[B] 

2. Repeat standardized assessments, such as the CIWA-Ar scale for alcohol withdrawal, to guide 

dosing decisions (e.g., if and when to dose) until stabilized. 

3. Consider the following procedures for monitoring ambulatory alcohol withdrawal management as 

safe and effective alternatives to inpatient approaches: 

a. Medical or nursing staff should assess the patient in person, either daily or every 

other day (patient contact may be made by telephone on other days), to include: 

• Patient report of any alcohol use the previous day 

• Reported medication intake compared to the medication dispensed the 

previous day 

• Tremor, restlessness, and previous night’s sleep 

• Skin (e.g., color and turgor). 

b. Urine toxicology or a breathalyzer test or blood alcohol content should be completed. 

c. If the daily screening is positive for any one of the following, the patient should be 

medically evaluated before initiating or continuing outpatient withdrawal 

management, or hospital admission should be considered: 

• Blood sugar ≥ 400 or positive anion gap 

• History of recent hematemesis, melena, or other gastrointestinal 

bleeding disorder 

• Bilirubin ≥ 3.0 

• Creatinine ≥ 2.0 

• Systolic blood pressure ≥ 180 or diastolic blood pressure ≥ 110 

• Unstable angina 

• Temperature ≥ 101 degrees 

• BAC ≥ 0.08 on two outpatient visits. 

4. For inpatient treatment of alcohol withdrawal, use benzodiazepines over non-benzodiazepine 

sedative-hypnotics because of documented efficacy, and a greater margin of safety. 

Benzodiazepines are the drug of choice in this setting, given adequate monitoring, because they 

reduce withdrawal severity, incidence of delirium, and seizures. All benzodiazepines appear to be 

effective, but agents without active metabolites such as lorazepam or oxazepam may be preferred 

in patients with liver impairment. [A] 

Module S: Page 55 
Guideline Summary VA/DoD Clinical Practice Guideline 

For Management of Substance Use Disorder

5. Dose and withdrawal scales should be individualized for each patient. Geriatric patients should 

start with lower doses of benzodiazepines than younger adults. [A] 

6. For managing mild to moderate alcohol withdrawal, carbamazepine and valproic acid can be used 

as an effective supplement or alternative to benzodiazepines. They may be considered in patients 

that cannot use benzodiazepines (e.g., abuse liability or allergy/adverse reactions). [B] 

7. Other agents, such as beta-blockers, and clonidine, are generally not considered as appropriate 

monotherapy for alcohol withdrawal, [D] but may be considered in conjunction with 

benzodiazepines in certain patients. [C] 

8. During and after medically supervised withdrawal, emphasis should be placed on engagement in 

ongoing addiction treatment. [C] 

9. Use of alcohol as an agent for medically supervised withdrawal is contraindicated. [D] 

Sedative-Hypnotics Medically Supervised Withdrawal (e.g., Benzodiazepines) 

There are three general treatment strategies for patients withdrawing from other sedative-hypnotic 

medications at doses above the therapeutic range, for a month or more: 

1. Substitute phenobarbital for the addicting agent and taper gradually. [A] 

a. The average daily sedative-hypnotic dose is converted to a phenobarbital equivalent 

and divided into 3 doses per day for 2 days (see Appendix E for phenobarbital 

equivalencies for sedative hypnotics) 

b. Phenobarbital dose should be reduced by 30 mg per day, beginning on day 3. 

2. Substitution then tapering: For patients on a shorter acting benzodiazepine, substitute a longer 

acting benzodiazepine at an equivalent dose (e.g., chlordiazepoxide) and taper 10 percent per day, 

over 1 to 2 weeks. 

3. Simple tapering: Gradually decrease the dosage of the long-acting substance the patient is 

currently taking. 

Opioid Withdrawal Management 

1. Medically supervised opioid withdrawal is rarely effective as a long-term strategy for treatment of 

opioid dependence because of high relapse rates. Opioid maintenance with 

buprenorphine/naloxone or methadone is the definitive treatment of choice in most cases. [B] 

2. If pursuing medically supervised opioid withdrawal, the preferred approaches are initial 

stabilization and subsequent short or extended taper with opioid agonist therapy. 

3. Set the length of the outpatient taper period based on the treatment setting and severity of the 

dependence. 

4. Medically supervised withdrawal can usually be accomplished in 4 to 7 days in an inpatient 

setting, to quickly achieve opioid abstinence prior to treatment in a drug-free setting preferably 

with initiation of naltrexone. 

5. Withdrawal using buprenorphine/naloxone: 

a. Only physicians with a waiver from the US Department of Health and Human 

Services can prescribe buprenorphine/naloxone 

b. Initial stabilization is accomplished via induction with buprenorphine/naloxone just 

as it would be for maintenance with this agent. To reduce the risk of precipitated 

withdrawal, the patient must be in sufficient opioid withdrawal to be manifesting 

objective signs of withdrawal prior to starting buprenorphine/naloxone usually at 

least 8 hours since the patient’s last use of heroin or other short-acting opioid or at 

least 24 hours and preferably at least 48 hours have elapsed since the last use of 

methadone or other long-acting opioid 

Module S: Page 56 
Guideline Summary VA/DoD Clinical Practice Guideline 

For Management of Substance Use Disorder

c. Within 1-3 days, a daily dose of buprenorphine/naloxone should be achieved that 

eliminates signs and symptoms of opioid withdrawal, suppresses opioid craving, and 

eliminates illicit opioid use. This dose could range from 2/0.5 mg per day to 16/4mg 

per day and would rarely exceed that amount 

d. Once stabilization has been achieved the dose can be rapidly tapered over 5-7 days. 

There is little evidence that prolonging the taper leads to better results. (If the patient 

and physician prefer a longer taper, there is also no evidence that a longer taper is 

harmful). 

6. Withdrawal using methadone: 

a. Withdrawal using methadone can only be performed in the context of a federally 

licensed opioid treatment program where daily medication dispensing can occur. For 

patients not engaged in methadone maintenance through an opioid treatment 

program, withdrawal should be managed with buprenorphine 

b. Initial stabilization is accomplished via induction with methadone just as it would be 

for maintenance with this agent. Withdrawal signs do not have to be observed prior 

to starting methadone, but with methadone there is risk of medication accumulation, 

toxicity, and overdose. Initial dosing should be very conservative with careful daily 

observation of the patient. Initial daily doses can range from 5 mg to a maximum of 

30 mg 

c. Within days to weeks, a daily dose of methadone should be achieved that eliminates 

signs and symptoms of opioid withdrawal, suppresses opioid craving, and eliminates 

illicit opioid use. This dose could range from 30 mg per day to doses as high as 120 

mg per day 

d. Once stabilization has been achieved, the dose can be gradually tapered over a period 

of weeks to months. Dose decreases of more than 5 - 10 mg/day of methadone are 

generally poorly tolerated. [C] In contrast to the evidence with 

buprenorphine/naloxone, with methadone, longer taper periods should be used in the 

outpatient setting to minimize patient discomfort and maximize chances of success 

e. A period of two to three weeks is generally sufficient for short-term outpatient 

medically supervised withdrawal in the most stable and motivated individual. The 

higher the stabilization dose, the longer the taper is likely to take. The taper should 

proceed more gradually as the dose becomes lower. 

7. The 180-day stabilization/medically supervised withdrawal regimen should be considered to 

facilitate work on patients’ early recovery problems, while stabilized on sublingual buprenorphine 

or a relatively low dose (50-60 mg/day) of methadone. Stabilization is followed by short-term 

medically supervised withdrawal from buprenorphine or methadone and transition to a drug-free 

rehabilitation program. 

8. Clonidine, an alpha-adrenergic agonist, can be considered as an adjunctive agent for symptom 

relief during inpatient medically supervised opioid withdrawal; however, outpatient success is 

much lower. If using clonidine, adjunctive medications for anxiety, restlessness, insomnia, muscle 

aches, nausea, and diarrhea can also be prescribed. 

I. Was Withdrawal Management Successful? 

BACKGROUND 

Treatment of opioid withdrawal should focus on facilitating entrance into comprehensive long-term 

treatment, as well as alleviating acute symptoms. Withdrawal management can be attempted with 

patients who wish to detoxify from all opioids. There is a high relapse rate to heroin or other opioid use 

Module S: Page 57 
Guideline Summary VA/DoD Clinical Practice Guideline 

For Management of Substance Use Disorder

Module S: Page 58 

unless stabilization is combined with psychosocial interventions. As such, withdrawal management is 

not a stand-alone treatment modality. 

RECOMMENDATIONS 

1. Identify patients in need of additional withdrawal management or stabilization before proceeding 

with further evaluation or treatment. 

2. Medically supervised withdrawal is successful to the degree the patient: 

a. Is physiologically stable 

b. Avoids hazardous medical consequences of withdrawal 

c. Experiences minimal discomfort 

d. Reports being treated with respect 

e. Completes the medically supervised withdrawal protocol (e.g., no longer requires 

medication for withdrawal symptom management). 

J. Is Care Management Indicated? 

BACKGROUND 

Among patients for whom withdrawal management is unsuccessful or who decline engagement in 

specialty care for rehabilitation, some patients may benefit from implementation of an ongoing care 

management plan outside of specialty SUD care. 

RECOMMENDATIONS 

1. If medically supervised withdrawal is unsuccessful or treatment engagement is not achieved, 

consider one of the following: 

a. A more intensive level of care for withdrawal management (e.g., inpatient) 

b. Identify patients who can benefit from implementation of a care management plan, if 

acceptable to the patient (see Module C, Annotation K).
Guideline Summary VA/DoD Clinical Practice Guideline 

For Management of Substance Use Disorder

APPENDICES 

Note: Appendices A, B, D, E, G, and H will be included in the full guideline 

Table of Contents 

Appendix A: Guideline Development Process 

Appendix B: Screening and Assessment Tools 

Appendix C: Summary of Effectiveness of Psycho-Social Interventions 

Appendix D: Department of Defense Instruction (DoDI 1010.6) 

Appendix E: Sedative-Hypnotic Equivalent Oral Doses 

Appendix F: Acronym List 

Appendix G: Participant List 

Appendix H: References 

Appendices - Page 59
Guideline Summary VA/DoD Clinical Practice Guideline 

For Management of Substance Use Disorder

Appendix C: Addiction-Focused Psychosocial Interventions 

Summary of Effectiveness of Psychosocial Interventions during early recovery (first 90 days) on 

condition specific outcomes of SUD (use or consequences) or general psychosocial functioning 

First line alternatives at least as effective 

as other bona fide active interventions or 

treatment as usual (TAU) 

Added effectiveness as adjunctive 

interventions in combination with 

pharmacotherapy and/or other first line 

psychosocial interventions 

Interventions 

(alphabetical) 

Alcohol Opioids Stimulants/

mixed 

Cannabis Alcohol Opioids Stimulants/

mixed 

Cannabis Comments

C-1 Behavioral 

Couples Therapy 

+++ N/A +++ N/A +/- + ? N/A Effective for 

male or female 

patients with 

SUD and 

partners; 

improves marital 

satisfaction 

C-2 Cognitive 

Behavioral Coping 

Skills Training 

+++ N/A +++ ++ + +++ N/A ++ 

C-4 Contingency 

Management/ 

Motivational 

Incentives 

N/A N/A N/A N/A + +++ +++ N/A 

C-3 Community 

Reinforcement 

Approach 

+++ N/A + N/A N/A N/A + N/A Complex 

intervention 

C-5 Motivational 

Enhancement 

Therapy (MET) 

+++ N/A N/A ? +++ ? +/- + May improve 

treatment 

engagement as 

adjunct to TAU 

for stimulants; 

Some evidence 

for those with 

low readiness or 

high anger 

C-6 Twelve-Step 

Facilitation 

+++ N/A N/A N/A ++ N/A + N/A AA participation 

is correlated 

with outcome – 

appears to 

mediate TSF 

effects 

+++ based on meta analysis of comparison with bona fide alternative interventions 

+ or ++ Based on one (+) or more (++) individual trials in comparison with bona fide alternatives 

N/A: evidence not available; +/- evidence inconsistent across outcomes; ?: benefit questionable

Appendices - Page 60
Guideline Summary VA/DoD Clinical Practice Guideline 

For Management of Substance Use Disorder

C-1. Behavioral Couples Therapy (BCT) 

Most versions of behavioral couples therapy (BCT) are focused both on reducing alcohol or drug use 

in the identified patient and on improving overall marital satisfaction for both partners. In BCT 

sessions, the therapist arranges a daily Sobriety Contract in which the patient states his or her intent not 

to drink or use drugs that day, and the partner expresses support for the patient’s efforts to stay 

abstinent. The Sobriety Contract can also include urine drug screens for the patient, attendance at 

other agreed-to counseling sessions, or 12-step meetings by the patient and partner. To improve 

relationship functioning, BCT uses a series of behavioral assignments to increase positive feelings, 

shared activities, and constructive communication because these relationship factors are conducive to 

sobriety. 

C-2. Cognitive-Behavioral Coping Skills Therapy 

Cognitive-behavioral coping skills therapy consists of related treatment approaches for substance use 

disorders that focus on teaching patients to modify both thinking and behavior related not only to 

substance use, but to other areas of life functionally related to substance use. Patients learn to track 

their thinking and activities and identify the affective and behavioral consequences of those thoughts 

and activities. Patients then learn techniques to change thinking and behaviors that contribute to 

substance use, strengthen coping skills, improve mood and interpersonal functioning and enhance 

social support. Primary therapeutic techniques include education of the patient about the treatment 

model, collaboration between the patient and therapist to choose goals, identifying unhelpful thoughts 

and developing experiments to test the accuracy of such thoughts, guided discovery (facilitating the 

patient in identifying alternative beliefs through the use of questions designed to explore current 

beliefs), interpersonal skill building through communication and assertiveness training, behavioral 

rehearsal, and role-play. In addition, treatment incorporates structured practice outside of session, 

including scheduled activities, self-monitoring, thought recording and challenging, and interpersonal 

skills practice. 

C-3. Community Reinforcement Approach (CRA) 

Community Reinforcement Approach (CRA) is a comprehensive cognitive-behavioral intervention for 

the treatment of substance abuse problems by focusing on environmental contingencies that impact and 

influence the patient’s behavior. Developed in accordance with the belief that these environmental 

contingencies play a crucial role in an individual’s addictive behavior and recovery, CRA utilizes 

familial, social, recreational, and occupational events to support the individual in changing his or her 

drinking/using behaviors and promoting recovery. The goal is to rearrange multiple aspects of an 

individual’s life so that a sober lifestyle is more rewarding than one that is dominated by alcohol 

and/or drugs. CRA integrates several treatment components, including building the patient’s 

motivation to quit drinking/using, helping the patient initiate sobriety, analyzing the patient’s 

drinking/using pattern, increasing positive reinforcement, learning new coping behaviors, and 

involving significant others in the recovery process. 

C-4. Contingency Management for SUD Treatment 

Contingency Management (CM) approaches are based on behavioral principles of reinforcement that 

reward specific behavioral goals related to recovery. Either monetary or nonmonetary rewards are 

made contingent on objective evidence such as negative toxicology results (e.g., biological tests for 

recent drug or alcohol use), treatment adherence, or progress toward treatment goals. The most 

common form of contingencies provided to reinforce desired behaviors are vouchers with monetary 

value that can be redeemed for goods and services, specific material prizes, or draws from a “fishbowl” 

that contains cards which vary in their reinforcing value from simple praise to vouchers worth $1 to 

$100. Schedules (fixed or intermittent) and magnitude of reinforcement have varied and have 

implications for overall cost of clinical implementation. 

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Guideline Summary VA/DoD Clinical Practice Guideline 

For Management of Substance Use Disorder

C-5. Motivational Enhancement Therapy (MET) 

Motivational enhancement therapy (MET) is a less intensive form of specialized psychosocial 

intervention for patients with substance use disorders. MET uses principles of motivational 

interviewing including an empathic, client-centered, but directive approach intended to heighten 

awareness of ambivalence about change, promote commitment to change and enhance self-efficacy. 

MET differs from MI in that it is a more structured intervention that is based to a greater degree on 

systematic assessment with personalized feedback. The therapeutic style using motivational 

interviewing elicits client reactions to assessment feedback, commitment to change and collaboration 

on development of an individualized change plan. Involvement of a significant other is encouraged in 

at least one of the MET sessions. 

C-6. Twelve-Step Facilitation (TSF) 

Twelve Step Facilitation (TSF) therapy aims to increase the patient’s active involvement in Alcoholics 

Anonymous (AA) or other twelve-step based mutual- (self-) help groups. This approach was 

systematized in a manual for NIAAA’s Project MATCH and delivered as 12-sessions of individual 

therapy in which the therapist actively encourages engagement in AA, and walks the patient through 

the first four steps of the AA program. The therapist conveys the concept that addiction is a chronic, 

progressive and potentially fatal illness for which the only successful strategy is abstinence achieved 

one day at a time by following a 12-step program of recovery. Each therapy session is divided into 

three parts. The first part reviews relevant events of the last week (including urges to use, drinking 

behavior and recovery-oriented activities) and a homework assignment. The middle portion introduces 

new material related to the 12-steps. The conclusion of the session includes a homework assignment 

and development of a plan for recovery-oriented activities (meeting attendance, sponsor contact). 

Appendices - Page 62
Guideline Summary VA/DoD Clinical Practice Guideline 

For Management of Substance Use Disorder

Appendix F: Acronym List 

ASI Addiction Severity Index 

AUD Alcohol Use Disorders 

AUDIT-C Alcohol Use Disorders Identification Test Consumption Questions 

BAL Blood Alcohol Levels 

BCT Behavioral Couples Therapy 

BI Brief Interventions 

CDT Carbohydrate Deficient Transferrin 

CHF Congestive Heart Failure 

CIDI Composite International Diagnostic Interview 

CM Contingency Management 

CMEP Case Management Enhancement Program 

COD Co-Occurring Disorders 

CPG Clinical Practice Guideline 

CRA Community Reinforcement Approach 

DATA Drug Addiction Treatment Act of 2000 

DIS Diagnostic Interview Schedule 

DM Diabestes Mellitus 

EtG Ethyl Glucuronide 

EtS Ethyl Sulfate 

HIV Human Immunodeficiency Virus 

HR-QOL Health Related-Quality of Life 

ICMP Iowa Case Management Project 

IDU Injection Drug Use 

IOM Institutes of Medicine 

LFT Liver Function Test 

MET Motivational Enhancement Therapy 

MI Motivational Interviewing 

MM Medical Management 

MSE Medical Status Examination 

NCU National Comorbidity Survey 

NESARC National Epidemiologic Study on Alcohol and Related Conditions 

NIAAA National Institute on Alcohol Abuse and Alcoholism 

NIDA National Institute on Drug Abuse 

NSDUH National Survey on Drug Use and Health 

OAT Opioid Agonist Treatment 

OATP Opioid Agonist Treatment Program 

OBOT Office-Based Opioid Treatment 

OTC Over-The-Counter 

RCT Randomized Controlled Trial 

RT Response to Treatment 

SARRTP Substance Abuse Residential Rehabilitation Treatment Programns 

SASQ Single Item Alcohol Screening Questionnaire 

Appendices - Page 63
Guideline Summary VA/DoD Clinical Practice Guideline 

For Management of Substance Use Disorder

Appendices - Page 64

SBI Screening and Brief Intervention 

SCID Structured Clinical Interview for the DSM 

SUD Substance Use Disorders 

SUR Substance Use Report 

TRISARC Tri-Service Addiction Recovery Center 

TSF Twelve-Step Facilitation 

UDS Urine Drug Screen 

USPSTF U.S. Preventive Services Task Force 

VBRT Voucher-Based Reinforcement Therapy