Clinical Care Guideline: Substance Use Disorders (SUD)

Substance use disorders are defined by cognitive, behavioral, and physiological symptoms that indicate the individual has experienced problems or hardship related to their substance use and continued using despite this. Based on the severity of symptoms and functional impairment, substance use disorders can be characterized as mild, moderate, or severe. According to SAMHSA’s 2024 National Survey on Drug Use and Health, 16.8% of people age 12 or older in the United States had a past-year substance use disorder (1).

This care guideline offers a brief summary of the evidence-based best practices for the effective treatment of substance use disorders in adults.

Diagnostic considerations for SUD

Is your client experiencing problematic substance use characterized by two or more of the following symptoms occurring during a 12-month period?

  • Using larger amounts of a substance or over a longer period than intended?
  • Persistent desire or unsuccessful efforts to cut down or control their use?
  • Spending a lot of time on activities to obtain, use, or recover from the effects of the substance?
  • Cravings, strong desires, or urges to use the substance?
  • Use of the substance causing repeated problems with the client’s roles or responsibilities at work, school, or home?
  • Continuing to use the substance despite it repeatedly causing or worsening social or interpersonal problems?
  • Giving up or reducing involvement in social, recreational, or work-related activities that are important to the client?
  • Using the substance in physically hazardous situations?
  • Using despite a physical or psychological problem the client knows is caused or worsened by the substance?
  • Tolerance for the substance, meaning either needing more to become intoxicated or experiencing less effect when using the same amount?
  • Withdrawal from the substance, meaning either the specific withdrawal symptoms noted in the DSM or using the same or another substance to avoid withdrawal symptoms?

It’s important to note, depending on the substance(s) the client is using, some of the symptoms and experiences may also be attributable to an alternative disorder. It is also important to distinguish substance use disorders from substance-induced disorders, as well as substance intoxication or withdrawal. Providers should also bear in mind that using a particular substance does not necessarily mean that the client meets criteria for a substance use disorder, as their use might not result in any of the above problems. 

Best practice is to engage in a differential diagnostic assessment prior to determining if a substance use disorder is the clinically indicated diagnosis. For complete diagnostic criteria, consult the Diagnostic and Statistical Manual of Mental Disorders (5th ed., text rev.). American Psychiatric Association. (2022). https://doi.org/10.1176/appi.books.9780890425787

noun-lightbulb-1262995.png When documenting care, be sure to include the specific substance(s) used and symptoms of SUD experienced by the client. This ensures your notes reflect alignment with the diagnosis and demonstrates medical necessity for the service.

Symptom Screening and Monitoring

The TAPS (Tobacco, Alcohol, Prescription medications, and other Substances) is a brief validated, two-part screening tool used to assess the client’s patterns of substance use, risk related to their use, and guide collaborative care. Routine use of this measure can be useful in providing effective care for individuals who experience substance use disorders, as it reduces stigma and supports open conversation about substance use, which can, in turn, lead to more accurate diagnoses, identification of appropriate treatment plan goals and referrals, and implementation of effective clinical interventions. 

You can learn more about the TAPS and strategies for incorporating Measurement Informed Care (MIC) into your practice here.

Evidence-Based Approaches to Treatment 

Psychotherapy 

The American Psychological Association (APA) (2) and the Substance Abuse and Mental Health Services Administration (SAMHSA) (3) have available resources on recommended evidence-based psychotherapy interventions for the treatment of SUD in adults. 

Therapists are encouraged to become familiar with each of the different evidence-based approaches, as well as engage in shared decision-making with the client to determine which intervention is right for each clinical situation.

Individual Psychotherapy

  • Cognitive-behavioral therapy (CBT)
  • Motivational interviewing (MI) / Motivation enhancement therapy (MET)
  • Community reinforcement approach (CRA)
  • 12-Step facilitation therapy 
  • Contingency management
  • Acceptance and commitment therapy (ACT)
  • Mindfulness-based approaches, such as Mindfulness based relapse prevention (MBRP)
  • Harm reduction strategies

Couples and Family Therapy 

Couples and family therapy can strengthen communication, rebuild trust, and create a healthier support system for individuals with substance use disorders. Involving loved ones in treatment often improves recovery outcomes by addressing relationship patterns that may contribute to or be impacted by substance use.

SAMHSA provides resources on evidence-based interventions for couples and families (4):

  • Psychoeducation
  • Behavioral couples therapy (BCT) and Behavioral family therapy (BFT)
  • Community reinforcement and family training (CRAFT)
  • Systemic-motivational therapy (SMT)

Medications for Substance Use Disorders

Currently, there are medications approved to treat Alcohol Use Disorder and Opioid Use Disorder (5). These medications may be used alone, or in conjunction with outpatient psychotherapy or participation in a substance use disorder treatment program. 

Medication for Alcohol Use Disorder (MAUD)

There are three types of medication shown to be safe and effective for treating Alcohol Use Disorder (6). Keep in mind that it is considered out of scope for licensed therapists to suggest specific medications. This is for informational purposes only: 

  • Disulfiram (previously known by the brand name Antabuse) causes unpleasant physical reactions when alcohol is consumed. 
  • Acamprosate restores neurochemical balance and reduces post-acute withdrawal symptoms and cravings. 
  • Naltrexone (Vivitrol) inhibits the euphoric or pleasurable effects of alcohol in the brain. 

Medication for Opioid Use Disorder (MOUD)

There are three types of medication shown to be safe and effective for treating Opioid Use Disorder (7). Keep in mind that it is considered out of scope for licensed therapists to suggest specific medications. This is for informational purposes only: 

  • Methadone (Methadose) prevents withdrawal and cravings while stabilizing receptor activity so illicit opioids are less reinforcing.
  • Buprenorphine (Subutex, Sublocade, Brixadi) eases cravings and withdrawal while also preventing stronger opioids from producing a high. 
  • Buprenorphine-naloxone (Suboxone, Zubsolv) combines the effects of buprenorphine, which reduces cravings and withdrawal, with the effects of naloxone, which discourages misuse by blocking opioid effects if the medication is crushed, snorted, or injected. 
  • Naltrexone (Vivitrol) blocks opioid receptors in the brain so opioids cannot produce euphoric or reinforcing effects.

When should I refer my client for medication evaluation? 

Patients with moderate to severe alcohol or opioid use disorder may benefit from discussing the use of medication with a prescriber, as it can be a powerful adjunctive to therapy and can maximize treatment response and support patient safety. This step by step guide walks you through how to easily refer your client for a medication management evaluation at Rula. 

noun-lightbulb-1262995.png As a reminder, the selection of a medication should be part of a shared decision-making conversation between the client and their prescribing provider. It is beyond the scope of a psychotherapist to suggest specific medications, groups of medications, specific supplements, or advise on the frequency of taking or stopping medications. These discussions must only be carried out by a medical provider.

Stigma and Medications for SUDs

Though MAUD and MOUD are FDA-approved and found to be safe and effective, patients may still encounter stigma about their use. Therapists can reduce stigma by educating themselves about these medications, using person-first language (8), creating a safe and nonjudgmental therapy space, and using clinical interventions to help clients identify and address internalized shame or stigma associated with their substance use and recovery process. 

Naloxone to Support Patient Safety

Naloxone nasal spray is a ready-to-use formulation that is designed to rapidly reverse a life-threatening opioid overdose by displacing opioids at brain receptors and restoring breathing (9). It is approved for over-the-counter use, safe for people of all ages, and can be administered by anyone, with no special training required.

For patients, keeping naloxone on hand empowers them with a simple, life-saving tool that can prevent fatal overdose and support harm-reduction and recovery efforts for themselves and their communities. 

Assessing Risk and Higher Level of Care Needs

Research has consistently identified substance use as a risk factor for suicide, with statistics showing that alcohol use disorder is the the second most common mental health problem among people who complete suicide (10). 

It is imperative that therapists engage in and document thorough risk assessment, completion of a safety plan, and referral for additional services if clinically indicated. This is especially important for clients who respond affirmatively to thoughts of suicide or self-harm on the PHQ-9 (Question #9) or any item on the C-SSRS (Columbia Suicide Severity Rating Scale) Screener.

While substance use disorder treatment at higher levels of care, such as IOP, PHP, residential, and inpatient, are appropriate for some clients, others can achieve their recovery goals while in outpatient therapy. When determining whether a client is appropriate for outpatient psychotherapy, consider factors such as:

  • Risk for suicide, substance withdrawal, and overdose
  • Severity of problems and functional impairments related to their substance use
  • Stability of any co-occurring physical and mental health conditions
  • Availability of natural recovery supports & other recovery capital (11)
noun-lightbulb-1262995.png Rula’s care coordination team is available to support your client in accessing these additional clinical services outside of Rula. Click here to learn more about how to easily refer your client for a Higher Level of Care (HLOC).

Co-Occurring Substance Use and Mental Health Disorders

Diagnosing Co-Occurring Disorders

Individuals with substance use disorders often have symptoms of co-occurring disorders, such as Generalized Anxiety Disorder, Major Depressive Disorder, and Attention-Deficit/Hyperactivity Disorder (12). Diagnosing co-occurring disorders is challenging because substance use and mental health conditions influence one another bidirectionally and often present with overlapping or mimicked symptoms, such as mood, anxiety, or behavioral changes related to intoxication, withdrawal, or substance using behavioral patterns. This can obscure underlying disorders and complicate accurate identification. 

Best practice for diagnosing co-occurring disorders is to conduct a thorough psychosocial assessment that considers the patient’s history of mental health symptoms and substance use as well as how substance use and mental health symptoms may be influencing, mimicking, or obscuring one another. Providers should gather longitudinal history, use validated screening tools, and revisit symptom presentations after periods of reduced use or abstinence when possible to avoid misdiagnosing mood, anxiety, or other mental health disorders. Ongoing monitoring, collaboration with other providers, and incorporating collateral information from natural supports help counselors arrive at more accurate, clinically useful diagnoses.

Integrated Clinical Approaches

Patients with co-occurring substance use and mental health disorders benefit from an integrated approach that addresses both diagnoses concurrently. Several evidence-based practices are commonly recommended for both substance use and mental health disorders (13), including:

  • Cognitive-behavioral therapy (CBT)
  • Motivational interviewing (MI)
  • Acceptance and commitment therapy (ACT)
  • Dialectical behavior therapy (DBT)

Trauma- and Stressor-Related Disorders

Individuals with substance use disorders frequently have a history of traumatic experiences, and there is a high rate of co-occurrence of SUDs and PTSD. SAMHSA recommends a number of evidence-based trauma-informed psychotherapy interventions that are appropriate for adults with a substance use disorder (14). These include:

  • Cognitive processing therapy (CPT)
  • Prolonged exposure (PE)
  • Eye movement desensitization and reprocessing (EMDR)
  • Accelerated resolution therapy (ART)
  • Seeking safety program

Clinical Resources to Support Treatment

To support your work with clients, Rula has developed a suite of evidence-based tools designed to complement your existing interventions. Feel free to download and share these worksheets that were selected are designed to support work with substance use disorders. 

Stages of Change - Based on the Transtheoretical Model, this resource helps both the provider and client identify the client's current readiness to modify their substance use (ranging from Precontemplation to Maintenance). 

Change Plan - This worksheet provides a structured roadmap for the recovery journey. It guides clients through identifying specific, actionable goals, defining the steps needed to achieve them, recognizing potential obstacles, and establishing a support network. It is particularly useful during the "Preparation" and "Action" stages of change. 

Building Discrepancy - Rooted in Motivational Interviewing (MI), this tool helps clients explore the gap between their current substance use behaviors and their deeply held values or long-term goals. 

Decision Matrix - this tool is essential for resolving ambivalence. It asks clients to systematically weigh the "pros and cons" of both continuing substance use and making a change.

Behavior Chain Analysis - this worksheet is used to "dissect" a specific episode of substance use or a high-risk "near-miss." It helps clients map out the sequence of events - including vulnerability factors, triggers, thoughts, and emotions - that led to the behavior.

As a Rula Therapist, you have access to the Tobacco, Alcohol, Prescription medications, and other Substances (TAPS) tool. This validated tool can be utilized through our Library of On-Demand Measures.

To learn more about utilizing worksheets in your clinical practice, and to view the full library of resources, visit the Help Center article Utilizing Worksheets to Support Progress in Therapy. 

Cultural Considerations

Cultural competence is essential for treating clients with substance use disorders because it helps ensure that care is respectful, relevant, and responsive to each person’s lived experience. Cultural identity, community norms, systemic inequities, stigma, and access to resources all shape individual thoughts, feelings, and beliefs about substance use and recovery (16).

Engaging the client in an open and nonjudgmental dialogue about their cultural background and how this informs their attitudes and behaviors related to substance use, treatment, and recovery can foster engagement and strengthen the therapeutic alliance. When therapists are culturally attuned, they can better recognize the impact of these factors, avoid misinterpretation of behaviors, reduce barriers to trust, and tailor interventions that align with the client’s values and worldview. This, in turn, contributes to more sustainable recovery outcomes. 

It can also be helpful to understand the client’s subcultural contexts related to substance use and recovery (17). Consider that some cultures consider substance use a normalized part of their culture and the harm it causes may not be viewed in the same way as other cultures. 

The Role of Natural Supports

Research on outcomes for people in recovery from substance use disorders consistently shows improved outcomes when the patient has a social support system that encourages recovery (15). These support systems, sometimes referred to as “natural supports”, may include family, friends, significant others, neighbors, coworkers, religious or spiritual communities, mutual support groups, and other social groups. While not all of these may be directly involved in the patient’s therapeutic process, clinical interventions that help individuals with substance use disorders identify and grow their natural support system can be helpful in the client achieving their goals for recovery and preparing for successful discharge. 

Mutual Support Groups

Patients with substance use disorders are often encouraged to participate in mutual support groups that focus on recovery. These groups are community-led and provide opportunities to connect with others who share similar experiences and build support networks focused on recovery. Some examples include:

Disclaimer: Children and Adolescents with SUD

This care guide focuses on best practice guidelines for treating adults with substance use disorders; however, substance use often begins in childhood or adolescence, making early intervention critical. For information on providing effective care for children and adolescents with SUDs, check out the below resources:

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