Substance Use Disorders
Guidance for information about substance use disorders.
Issued by: Centers for Medicare & Medicaid Services (CMS)
Issue Date: August 20, 2020
Substance use disorders can result from all types of substance use—alcohol, marijuana, opioids, heroine, etc.—that interferes with being able to meet life's responsibilities, interferes with physical health, or is an illegal substance.
There are many resources out there to help people with substance use disorders. Just like behavioral health has a specific tribal approach, many of the medication-assisted treatments now have a tribal approach as well.
Addiction is a chronic illness, just like diabetes or asthma. Like other chronic illnesses, it is very hard for someone to manage their illness without help.
Addiction is a brain disorder that makes someone want to use something despite the harm it may cause. A person can be addicted to almost anything—drugs, alcohol, food, shopping, etc. It is not the focus of the compulsion that makes addiction, but rather the motivating factors.
- How does addiction start?
What may start as a choice can turn into an addiction when the person can no longer quit the behavior. As addiction is a brain disorder; the wiring within the brain changes as someone develops an addiction. The person is no longer able to make a choice around the addiction. Meeting the need becomes the person's priority.
- Can you recover from an addiction?
People who receive treatment learn how to cope with their addiction, but the addiction never goes away. Relapse is common, and many behavioral health providers consider it part of the healing process. It doesn't mean the person isn't trying. People with diabetes are never cured from it, but they can have it under control. Addiction is the same way.
- How do you help someone with an addiction?
Admitting there is a problem is the hardest part of treatment. If someone you know has taken this critical first step, supporting them without judgement is the best way to help them get better.
- Does opioid use always result in addiction?
Many people take opioids without getting addicted. A doctor may prescribe opioids after surgery, a major injury, or for chronic pain. Doctors then monitor the patient closely to ensure they use the opioids safely and as prescribed.
Physical Dependence v. Addiction
People can become physically dependent on something, like medication, when their bodies require it to live comfortably. Addiction is when someone needs to have something no matter what it does for them. A person can have a physical dependence without having an addiction.
To help understand—think of shoes in the winter. Everyone needs to wear shoes so their feet don't get frostbite or injured. Your body physically depends on shoes to protect your feet and walk properly. A shoe addiction is when you begin buying more shoes that you could ever use, when money for your responsibilities goes to shoes. When you have to start hiding shoes from others and you get pleasure from buying new shoes, even though it only lasts a moment, that is when it's become an addiction.
Signs of Addiction
Addiction interferes with rational thought. People with an addiction may act without much thought and secretively, by lying about or hiding their behavior. It can ultimately affect their ability to go to school or hold a job, pay rent, keep friendships, stay healthy, and more. Addiction is a chronic illness.
It may be difficult to tell whether someone has an addiction. If you aren't sure, these questions may help.
- What happens if they don't take it?
- How long can they go without it?
- Do they need to take more to have the same relief?
- Are they being honest about how much they take?
- Have they been dishonest to those close to them about it?
- Are they able to perform well at work/school/etc. while on it?
- Have they ever been shocked about how much they want it?
- Do they feel like they crave it?
- Do they feel guilty about it?
- Have they tried to quit but been unsuccessful?
- What you can do if you think someone has an addiction?
If you are worried that someone has an addiction, ask them to talk to their health care provider. Health care providers are there to help without judgement. They can provide an evaluation and recommend treatment options.
Medication-Assisted Treatment 101
MAT stands for Medication-Assisted Treatment. MAT combines prescribed medicine with a behavioral health provider to treat opioid use disorder while avoiding an overdose.
- What is tribal MAT?
Tribal MAT was developed to provide culturally competent care to American Indian and Alaska Native populations. It was created to honor and recognize the values, traditions, and culture of each tribe. Rather than approaching MAT from a medical perspective only, tribal MAT provides ways to bring culture and tradition into the treatment plan. An example would be adding a traditional medicine appointment or provider to the MAT team. That person would then have a medical doctor to monitor the medicine used to help, a behavioral health practitioner to help guide the behavioral choices, as well as a traditional health provider to supplement the person's recovery. This is one example, but the concept is the same: the person's culture, history, and traditions become an important component of their recovery and treatment plan.
- What is tele-MAT?
Tele-MAT uses audio and video to allow providers to connect with those in need who may live far away from a MAT provider. Tele-MAT breaks distance and transportation barriers and allows patients to be served where they are most comfortable.
- What is the medication in MAT?
The most common medication used for MAT is currently buprenorphine, with the brand name of Suboxone®. Other medications may be methadone or naltrexone. The medication used varies for each person and is a decision they make with their provider.
- How is buprenorphine different than methadone?
There are many differences between buprenorphine and methadone. Please check with your behavioral health practitioner to discuss options and products.
- It doesn't cause the same reaction in the brain as an opioid or heroine. It works to lessen the physical symptoms of withdrawal without creating the feeling of being "high."
- It stays in your blood stream longer than opioids, which means you feel relief for a longer time. Buprenorphine lasts, on average, 24 to 60 hours, depending on several health factors. Each person is different.
- It reaches a ceiling effect – The ceiling effect is a maximum amount a drug will affect someone no matter how much is taken. As a result, it is very hard to abuse or become addicted to this medication.
- It can be prescribed and taken outside of a clinical setting as a tablet or as a sublingual strip, which is a small piece you put under your tongue that dissolves. You can receive a prescription for it and take it at home, rather than having to come into the clinic to receive the medicine.
- It has the same reaction as opioids or heroin in your brain. It recreates the feelings of relief and euphoria created by the original substance.
- It lasts longer than a standard opioid medicine, lasting anywhere from 8 to 59 hours, but the effects are not as steady as some other options.
- It does not reach a ceiling effect, meaning that the more you take, the more effect it has on your body. This means an overdose could occur as well as there is a chance someone could become addicted to it.
- It must be administered in a structured clinic, meaning it must be provided in a doctor's office or clinic rather than having a prescription that can be taken at home. (This may vary depending on location and the rules regulating methadone use.)
- What is naloxone?
Naloxone is a medicine used to resuscitate a person experiencing an opioid overdose. It works very fast to reverse the effects of the overdose. Naloxone restores regular breathing that has slowed or stopped due to opioids or heroin use.
It is most commonly given in a nasal spray, often with the brand name Narcan, but can also be provided as a prefilled auto-injection device, often with the brand name Evzio. The auto-injection works similar to an epi-pen, but it comes with a case that provides audio directions on how to administer it. Depending on where you live, this option may require a prescription.
Naloxone has a proven track record of helping revive people who have overdosed. It is important to note that like someone who has had an epi-pen, anyone who has had naloxone should be seen in the emergency room as soon as possible, as overdoses are life-threatening emergencies.
Many tribal MAT programs have trainings and resources to help ensure naloxone is available to anyone who may be at risk or know someone who is at risk for an overdose of opioids or heroin. Talk with your health care provider or behavioral health practitioner to learn more.
- How does MAT work?
MAT provides a treatment plan that helps remove the pain from withdrawals while supporting recovering from a substance use disorder. MAT is a collaboration between the person with a substance use disorder, a behavioral health practitioner, and often a primary or medical care provider.
Tribal MAT may include additional components, such as traditional health providers or community groups. Ultimately MAT addresses the physical and behavioral components of addiction.
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