Substance Use Disorder Evaluation & Medication Management

Substance Use Disorder Evaluation and Medication Management

Comprehensive evaluation is the foundation of effective substance use disorder treatment. At KwikPsych, Dr. Monika Thangada conducts thorough assessments using evidence-based screening tools, followed by ongoing medication management to support sustained recovery.

The Comprehensive Substance Use Evaluation

A thorough evaluation accomplishes multiple goals:

• Confirms diagnosis using DSM-5 criteria
• Assesses severity to guide treatment intensity
• Identifies co-occurring conditions (depression, anxiety, PTSD, bipolar disorder)
• Evaluates medical safety and detoxification risk
• Determines appropriate medications
• Develops individualized treatment plan

Initial Assessment Components

1. Substance Use History

We gather detailed information about:

Current use:

• Primary substance(s) of concern
• How much you use (grams, drinks, pills, etc.)
• How often you use (daily, binges, sporadic)
• Route of administration (swallowing, smoking, injecting, snorting)
• When you last used
• What triggers urges to use

Pattern of use:

• Age when use began
• Progression over time
• Periods of abstinence
• Consequences of use (legal, medical, social, occupational)

Previous treatment:

• Prior treatment attempts and outcomes
• Medications tried and responses
• Length of sobriety after previous treatments
• What worked and what didn't

2. Withdrawal Assessment

Withdrawal risk guides whether inpatient detoxification is necessary:

Substance-specific withdrawal danger:

• High-risk withdrawal (potentially life-threatening): Alcohol, benzodiazepines, baclofen
• Moderate withdrawal (very uncomfortable but not medically dangerous): Opioids, cannabis, stimulants
• Risk factors: Heavy daily use, multiple prior withdrawals, medical conditions, medications

Typical withdrawal symptoms we assess:

• Autonomic symptoms: Tremor, sweating, elevated heart rate and blood pressure, fever
• Neurological: Seizures, confusion, hallucinations
• Gastrointestinal: Nausea, vomiting, diarrhea, abdominal pain
• Mood: Anxiety, dysphoria, irritability, insomnia

3. Co-Occurring Psychiatric Conditions

Between 35-60% of people with substance use disorders also have mental health conditions. We screen for:

Mood disorders:

• Major depressive disorder
• Bipolar disorder
• Dysthymia

Anxiety disorders:

• Panic disorder
• Generalized anxiety disorder
• Social anxiety disorder
• Specific phobias

Trauma and PTSD:

• History of trauma
• PTSD symptoms
• Abuse history

Attention-deficit/hyperactivity disorder (ADHD):

• Childhood symptoms
• Current impulsivity, inattention
• Impact on substance use

Psychotic disorders:

• Hallucinations, delusions (from substance use vs. primary psychosis)
• Substance-induced vs. independent

Personality disorders: Particularly antisocial personality disorder, which co-occurs in 35-60% of people with substance use disorder

These conditions require concurrent treatment for recovery to be successful.

4. Medical History and Physical Examination

Medical conditions that affect treatment planning:

• Chronic pain (influences opioid use and treatment options)
• Liver disease (hepatitis C, cirrhosis—affects medication metabolism)
• Heart disease (cardiac effects of stimulants or alcohol)
• Pregnancy (affects medication choices and dosing)
• Seizure disorder (affects withdrawal management)
• Hypertension, diabetes, kidney disease
• Current medications and drug interactions

Physical examination includes:

• Vital signs (heart rate, blood pressure, temperature, respiration)
• Assessment of acute intoxication or withdrawal
• Track marks or injection sites (for IV substance use)
• Signs of liver disease (jaundice, ascites)
• Cardiac assessment

5. Psychosocial Assessment

Living situation and stability:

• Safe housing?
• Living with substance users?
• Family support or conflict?
• Homelessness or housing instability?

Employment and finances:

• Employment status
• Financial stability
• Impact of substance use on employment
• Legal financial obligations

Legal system involvement:

• Arrests or convictions
• Probation or parole status
• DUI or other substance-related charges
• Court-mandated treatment?

Family and relationships:

• Family history of substance use or mental illness
• Relationship support
• Children or custody issues
• Trauma history

Motivation for change:

• Readiness for treatment
• Goals
• Understanding of addiction
• Commitment to recovery

Standardized Screening Tools

We use evidence-based screening instruments to assess severity and monitor progress:

AUDIT (Alcohol Use Disorders Identification Test)

When used: For anyone reporting alcohol use

The 10-item AUDIT asks about:

1. Frequency of alcohol use
2. Quantity consumed per drinking occasion
3. Frequency of heavy drinking (6+ drinks for women, 6+ for men)
4. Inability to stop drinking
5. Failure to meet role obligations
6. Guilt or remorse
7. Blackouts
8. Injuries from drinking
9. Others concerned about use
10. Drinking alone

Scoring:

• 0-7: Abstinence or low-risk use
• 8-15: Hazardous use (at-risk drinking without dependence)
• 16-19: Harmful use (some dependence)
• 20+: Probable alcohol dependence

Use: Identifying alcohol use disorder, assessing severity, monitoring change with treatment

DAST-10 (Drug Abuse Screening Test)

When used: For anyone reporting non-alcohol substance use

The 10-item DAST asks about:

1. Substance use other than alcohol
2. Difficulty controlling use
3. Continued use despite problems
4. Legal problems from use
5. Relationship problems
6. Psychological/medical problems
7. Hospitalization or rehab
8. Substance-induced feelings
9. Overdose or poisoning
10. Desire to reduce use

Scoring:

• 0-2: No apparent problems
• 3-5: Low-level problems
• 6-8: Moderate problems
• 9-10: Substantial problems (likely SUD)

Use: Screening for non-alcohol substance use disorder, severity assessment

CAGE Questionnaire (Brief Alcohol Screening)

When used: Quick screening for alcohol problems

Four questions:

1. Have you felt you should Cut down on your drinking?
2. Have people Annoyed you by criticizing your drinking?
3. Have you felt Guilty about your drinking?
4. Have you had a drink as an Eye-opener in the morning?

Scoring: 2+ affirmative responses suggest alcohol problem

Use: Brief primary care screening; quick assessment in busy settings

Clinical Institute Withdrawal Assessment for Alcohol Scale Revised (CIWA-Ar)

When used: Assessment of alcohol withdrawal severity for patients stopping heavy drinking

10 items assess:

• Tremor
• Sweating
• Anxiety
• Agitation
• Tactile disturbances
• Auditory disturbances
• Visual disturbances
• Headache
• Orientation

Scoring:

• 0-9: Mild withdrawal
• 10-18: Moderate withdrawal
• 19+: Severe withdrawal (medical emergency)

Use: Guides inpatient vs. outpatient detoxification; guides medication dosing; monitors withdrawal progression

Clinical Opioid Withdrawal Scale (COWS)

When used: Assessment of opioid withdrawal severity

11 items assess:

• Resting pulse rate
• Sweating
• Restlessness
• Pupil size
• Bone or joint aches
• Runny nose or tearing
• GI upset
• Tremor
• Yawning
• Anxiety or irritability
• Gooseflesh skin

Scoring:

• 5-12: Mild withdrawal
• 13-24: Moderate withdrawal
• 25-36: Moderately severe withdrawal
• >36: Severe withdrawal

Use: Guides medication dosing; tracks withdrawal progression; determines inpatient vs. outpatient management

Addiction Severity Index (ASI)

When used: Comprehensive multimodal assessment

Domains assessed:

• Medical status
• Employment and support
• Drug use
• Alcohol use
• Legal status
• Family/social relationships
• Psychiatric status

Use: Baseline assessment; identifies problem areas needing intervention; measures treatment progress across multiple life domains

Laboratory Testing

Lab testing confirms substance use, assesses medical safety, and monitors treatment progress:

Urine Drug Screen (UDS)

Standard panel typically includes:

• Amphetamines (methamphetamine, MDMA)
• Benzodiazepines
• Cannabinoids (marijuana)
• Cocaine
• Opioids (heroin metabolites, morphine, codeine)
• Phencyclidine (PCP)

Extended panels may add:

• Barbiturates
• Methadone
• Propoxyphene
• Tramadol
• Buprenorphine
• Tricyclic antidepressants

Cutoff values: Standardized thresholds distinguish occasional use from regular use

Monitoring: UDS may be conducted randomly or at regular intervals to monitor medication compliance and abstinence during treatment

Important: Patients on MAT (buprenorphine or methadone) will test positive for those medications; this is expected and monitored

Breath Alcohol Testing (Breathalyzer)

When used: For patients with alcohol use disorder to verify abstinence

Timeline: Can detect alcohol consumed within last 2-3 hours

Monitoring: May be done randomly during treatment

Blood Testing

Standard labs include:

• Liver function: AST, ALT, bilirubin, alkaline phosphatase (assess for alcohol-related liver disease)
• Complete blood count (CBC): Anemia, infection, effects of chronic substance use
• Comprehensive metabolic panel (CMP): Kidney function, electrolytes
• HIV testing: Assess risk (especially for IV opioid users)
• Hepatitis B and C testing: IV drug use carries risk

Monitoring labs: Liver function and metabolic panel repeated during treatment to monitor for medication side effects and organ function

Pregnancy Testing

When indicated: For women of childbearing age starting medication (MAT medications require individualized risk-benefit assessment during pregnancy)

Medication-Assisted Treatment Medications

Opioid Use Disorder Medications

Buprenorphine (Suboxone, Subutex)

Classification: Partial opioid agonist (partial activation of opioid receptors)

Mechanism:

• Reduces withdrawal symptoms
• Reduces cravings for opioids
• Produces mild euphoria at low/moderate doses, then plateaus (ceiling effect)
• Blocks intoxication from additional opioids

Advantages:

• Lower overdose risk (ceiling effect on respiratory depression)
• Convenient: can be prescribed in office-based practice (the DEA X-waiver requirement was eliminated in December 2022; any licensed prescriber can now prescribe buprenorphine)
• Available in sublingual tablets, films, and buccal formulations
• Can be started sooner after last opioid use than naltrexone
• Can be managed via telehealth
• No daily clinic visits required
• Easier transition off if desired

Disadvantages:

• Less potent than methadone (may not be ideal for severe heroin addiction)
• Some potential for misuse (sold on street, injected)

Dosing:

• Induction: Start 2-4 mg, can give second dose after 2+ hours if withdrawal continues, titrate up by 2-4 mg daily
• Maintenance: Typically 8-24 mg daily (usual range); some patients need up to 32 mg
• Formulations: Tablets, films, sublingually; monthly extended-release injection (Sublocade) available
• Timeline to stabilization: 5-7 days typically

Pregnancy: The FDA eliminated letter-category pregnancy labeling in 2015; buprenorphine requires individualized risk-benefit assessment during pregnancy. Most data supports safety; many women with opioid use disorder have maintained buprenorphine through pregnancy with good outcomes

Cost: Usually covered by insurance; generics available (lower cost)

Methadone

Classification: Full opioid agonist (full activation of opioid receptors)

Mechanism:

• Relieves withdrawal symptoms completely
• Blocks euphoria from other opioids
• Very long half-life (24+ hours) allows once-daily dosing
• Produces stronger euphoria than buprenorphine at therapeutic doses

Advantages:

• More potent than buprenorphine for severe addiction
• Long duration allows once-daily dosing
• Most effective treatment for very severe opioid addiction
• Once stabilized, maintenance is very stable

Disadvantages:

• Requires daily clinic visits for witnessed ingestion (severe restriction on freedom)
• Slower induction (overdose risk if dosed too quickly)
• Longer, more difficult withdrawal if discontinuing
• More potential for misuse and diversion
• Greater overdose risk if combined with other opioids
• QT prolongation (rare but serious cardiac effect)

Dosing:

• Induction: Start 10-30 mg, with gradual titration over 1-2 weeks; typical stabilization dose 60-120 mg
• Maintenance: Usually 60-120 mg daily (range 40-200 mg)
• Timeline to stabilization: 2-4 weeks typically

Availability: Only available through licensed methadone clinics (more regulated)

Cost: Often covered by insurance; may have higher copays

Naltrexone (Vivitrol—Extended-Release Injectable)

Classification: Opioid antagonist (blocks opioid effects)

Mechanism:

• Completely blocks opioid receptors
• Prevents euphoria if additional opioids are used
• Reduces cravings

Advantages:

• No opioid activity; no overdose risk
• No addiction potential of the medication itself
• Non-stigmatized (doesn't appear to be "opioid replacement")
• Once-monthly injection: good adherence
• Can work, drive normally

Disadvantages:

• Requires 7-10 days abstinence before starting (precipitated withdrawal risk if given while opioids in system)
• Requires good motivation (no reinforcing effect like other medications)
• Less effective for heavy users
• Requires monthly clinic visits (extended-release injectable)
• More expensive

Dosing:

• Extended-release injectable (Vivitrol): 380 mg IM monthly
• Oral naltrexone: 50 mg daily (less effective; requires daily adherence)

Timeline: Can be given immediately after 7-10 days abstinence; effects begin immediately

Cost: More expensive than buprenorphine or methadone; may require prior authorization

Alcohol Use Disorder Medications

Naltrexone (Oral or Vivitrol Injectable)

Mechanism: Blocks opioid receptors; reduces rewarding effects of alcohol; reduces cravings

Advantages:

• Evidence-based; FDA-approved
• Not addictive
• Can improve outcomes when combined with therapy
• Oral form: easy to take; inexpensive
• Vivitrol injection: once-monthly dosing

Disadvantages:

• Modest effects compared to behavioral therapy
• Oral form requires daily adherence
• Cannot use if also on opioid agonist MAT
• May increase liver enzyme (risk with advanced liver disease)

Dosing:

• Oral: 50 mg daily
• Vivitrol: 380 mg IM monthly

Contraindication: Cannot use if person is opioid-dependent (would cause withdrawal)

Acamprosate (Campral)

Mechanism: Restores glutamate neurotransmission balance disrupted by chronic alcohol use; reduces protracted withdrawal symptoms and cravings

Advantages:

• Effective for maintaining abstinence
• Particularly good for protracted withdrawal (anxiety, anhedonia, insomnia lasting weeks-months)
• Can be used with any other medication (no interactions)
• Safe even in advanced liver disease
• Can be started immediately

Disadvantages:

• Requires three times daily dosing
• Modest effect size
• Gastrointestinal side effects common

Dosing:

• 666 mg three times daily (2 tablets three times daily)
• Adjusted for renal function

Pregnancy: The FDA eliminated letter-category pregnancy labeling in 2015; acamprosate requires individualized risk-benefit assessment during pregnancy

Disulfiram (Antabuse)

Mechanism: Creates an aversive reaction if alcohol is consumed (acetaldehyde accumulation)

Reaction if alcohol consumed:

• Severe facial flushing and chest flushing
• Nausea, vomiting
• Headache, chest pain
• Hypotension (dangerous drop in blood pressure)
• Shortness of breath
• Confusion, anxiety
• Rare: myocardial infarction, arrhythmias, death

Advantages:

• Strong deterrent to drinking
• Very inexpensive
• Been in use for 60+ years
• Works only if person wants it to (motivation required)

Disadvantages:

• Requires daily adherence
• Dangerous reaction (requires education about avoiding alcohol in all forms, including cough syrup, mouthwash)
• Only works if person remembers to take it
• Not effective for people with low insight or high impulsivity
• Requires baseline liver function testing

Dosing:

• 250 mg daily
• Baseline liver function tests required
• Patient education essential

Important: Requires written informed consent; patient must understand aversive reaction can occur up to 2 weeks after last dose

Topiramate

Mechanism: Anticonvulsant; exact mechanism in alcohol use disorder unclear but appears to reduce cravings and improve abstinence

Advantages:

• May reduce co-occurring depression
• Can be used off-label
• Modest additional benefit to therapy

Disadvantages:

• Off-label use (not FDA-approved for AUD)
• Side effects: cognitive effects, weight loss, tingling
• Requires contraception (birth defect risk)

Dosing: Usually 100-300 mg daily

Co-Occurring Condition Medications

For people with co-occurring depression, anxiety, or bipolar disorder, medications may include:

For depression:

• SSRIs (sertraline, paroxetine, escitalopram)
• SNRIs (venlafaxine, duloxetine)
• Bupropion (often helpful, has some anti-craving effects)
• Mirtazapine

For anxiety:

• SSRIs or SNRIs (first-line)
• Buspirone (non-addictive; good for sustained anxiety)
• Hydroxyzine (for acute anxiety; short-term only)
• Avoid benzodiazepines (high addiction risk in people with substance use disorder) except during acute withdrawal/detoxification with close monitoring

For bipolar disorder:

• Lithium (gold standard; requires blood level monitoring)
• Valproic acid (Depakote)
• Lamotrigine
• Atypical antipsychotics (quetiapine, olanzapine, risperidone, aripiprazole)

For PTSD:

• Prazosin (for nightmares)
• Sertraline or paroxetine (SSRI)
• Trauma-focused therapy

Ongoing Medication Management

Regular Monitoring During Treatment

Frequency of appointments:

• Weeks 1-4: Weekly (in-person or telehealth)
• Weeks 5-12: Bi-weekly
• Month 3+: Monthly (typical)

What we monitor:

Medication response:

• Reduction in cravings
• Decreased substance use
• Improved mood and anxiety
• Better sleep
• Functional improvement (work, relationships, self-care)

Medication side effects:

• Buprenorphine: constipation, headache, insomnia, sexual dysfunction
• Naltrexone: nausea, joint pain, fatigue, vivid dreams
• Acamprosate: GI upset (nausea, diarrhea)
• Disulfiram: metallic taste, peripheral neuropathy, liver function
• Antidepressants: sexual dysfunction, activation vs. sedation, weight change

Substance use:

• Self-reported use
• Random urine drug screens (if indicated)
• Missed doses or medication adherence issues

Psychiatric status:

• Mood and anxiety
• Sleep
• Suicidality risk assessment
• Functioning at work, school, relationships

Medical status:

• Vital signs
• Weight
• Physical health symptoms

Psychosocial factors:

• Housing stability
• Employment
• Legal issues
• Family relationships
• Engagement in therapy and support groups

Medication Adjustments

Dose changes:

• Increasing doses if cravings persist (buprenorphine typical range 8-24 mg; some need 32 mg)
• Decreasing doses if side effects are problematic
• Tapering if person is ready to discontinue MAT after sustained recovery

Adding medications:

• Antidepressants if depression emerges
• Anti-anxiety medications if anxiety develops
• Sleep aids if insomnia is problematic
• Anti-diarrheal medications for opioid withdrawal-related bowel issues

Switching medications:

• Changing from buprenorphine to methadone if insufficient response
• Switching from oral naltrexone to Vivitrol injection for better adherence
• Switching antidepressants if side effects or inadequate response

Duration of Medication Treatment

Minimum duration: 1 year (may be longer)

Factors in continuing MAT:

• Quality of recovery and stability
• Relapse risk if medication discontinued
• Co-occurring conditions requiring medication
• Personal preference and goals
• Time since last use (longer is generally better for discontinuing)

Many people benefit from indefinite maintenance on medication, particularly those with:

• Severe opioid addiction
• Multiple prior relapses
• Ongoing high-risk environments
• Strong family history of addiction
• Co-occurring mental health conditions

Discontinuation: If person wants to discontinue MAT, this is done gradually with medical supervision, not abruptly.

Drug Testing During Treatment

Purpose of Drug Testing

• Confirms abstinence from substances of abuse
• Identifies relapse early so treatment can be adjusted
• Monitors medication compliance (buprenorphine and methadone should appear on UDS)
• Accountability: Helps maintain commitment

Testing Protocols

Frequency:

• Can range from random tests to scheduled tests
• Typical: 1-2 per month during initial treatment

Supervised vs. unsupervised:

• Unsupervised specimen collection: Patient provides urine sample in private bathroom
• Supervised collection: Staff observes collection if there's concern about tampering
• Observed collections are more reliable but less private

Specimen validity testing:

• Temperature, creatinine, specific gravity checked to detect dilution or substitution

Interpreting Results

Positive tests:

• Expected substances: Buprenorphine (if on buprenorphine), methadone (if on methadone), prescribed benzodiazepines (if prescribed)
• Unexpected substances: Opioids, cocaine, methamphetamine, or other non-prescribed drugs indicate relapse

Negative results:

• If expected medication absent: Adherence problem? Metabolism issue?

Response to positive tests:

• Non-punitive; rather, a sign that treatment needs adjustment
• Increased counseling
• More frequent testing
• Possible medication adjustment
• Addressing relapse triggers

Getting Started With Evaluation and Medication Management

Step 1: Call us at 737-367-1230 to schedule your initial evaluation

Step 2: Comprehensive assessment appointment (60-90 minutes)

• Detailed history
• Screening with validated instruments
• Medical evaluation and labs
• Discussion of treatment options

Step 3: Treatment planning

• Medication recommendations discussed
• Behavioral therapy referrals
• Monitoring plan outlined
• Insurance/cost explained

Step 4: Ongoing appointments

• Regular medication management
• Monitoring and adjustment as needed
• Lab work as indicated
• Coordination with therapist and support services

Contact Information

KwikPsych Psychiatry

Dr. Monika Thangada, MD

12335 Hymeadow Dr, Ste 450

Austin, TX 78750

Phone: 737-367-1230

Telehealth: Available across Texas

Insurance: Aetna, BCBS, Cigna, UnitedHealthcare, Superior HealthPlan/Ambetter, Baylor Scott & White, Oscar, First Health Network, Optum, Medicare

Self-pay: $299 initial evaluation, $179 follow-up appointments

Crisis Support:

• Suicide & Crisis Lifeline: 988
• SAMHSA National Helpline: 1-800-662-4357

Disclaimer: This content is for education and is not a substitute for professional medical advice. All treatment decisions are individualized and made in consultation with your medical provider.