Addiction Treatment Protocol

Addiction Treatment Protocol

Withdrawal from drugs (illicit or pharmaceutical) and alcohol can cause serious complications like sweating, tremors, delirium, or seizures in dependent patients. If a patient has a history of such symptoms when reducing intake and lacks medical supervision, a referral is recommended. Referral is advised with other medical or psychiatric conditions, or poly-substance use[1] Refer to the Alcohol and Drug Withdrawal Guidelines.

Definition and Pathophysiology:

Addiction Overview:

Definition: Addiction involves craving, temporary relief or pleasure, and difficulty quitting despite serious health and social consequences.[2]

Compulsive Use: The hallmark of addiction is the inability to control substance use or behavior despite significant reasons to stop, such as health issues or legal problems.[3]

Key neurobiological changes underpin addiction/dependence.[4] Changes that occur in the brain in response to addiction are categorised into three stages:

Neurobiological Changes:

Binge and Intoxication: Consumption of addictive substances or behaviors triggers a rapid release of dopamine in the brain’s reward systemn (Figure 1), reinforcing cravings and addiction-seeking behaviour.[5]

Withdrawal/Negative Affect: Abstinence leads to a decline in dopamine and other neurotransmitters, causing irritability, emotional pain, and heightened stress sensitivity.[6-9]

Preoccupation/Anticipation: Cues related to the addiction activate the prefrontal cortex, which is involved in self-control and decision-making, but becomes hyper-reactive to addiction cues and less effective at impulse control.[10-13]

Patient Signs and Symptoms

Substance Use Disorder (SUD)

Defined by the DSM-V as a pattern of cognitive, behavioral, and physiological symptoms indicating continued substance use despite significant problems.[14]

Categories:

  • Mild: 2-3 criteria
  • Moderate: 4-5 criteria
  • Severe: 6-11 criteria

Criteria:

Impaired Control: Using more than intended, unsuccessful attempts to cut down, spending a lot of time on substance use, cravings.
Social Impairment: Failing to meet major obligations, continuing use despite social problems, giving up important activities.
Risky Use: Using in hazardous situations, continuing despite physical or psychological problems.
Pharmacological: Tolerance (needing more for the same effect), withdrawal symptoms.

    Withdrawal

    Symptoms that occur when reducing or stopping heavy and prolonged substance use.

    Criteria:

    • Reduction/Cessation: Heavy and prolonged use is reduced or stopped.
    • Symptoms: At least two of the following: sweating, rapid heartbeat, insomnia, tremors, nausea, agitation, anxiety, seizures, hallucinations.
    • Impact: Causes significant distress or impairment.
    • Exclusion: Not due to another medical condition or mental disorder.

    Substance Intoxication

    Occurs after recent ingestion of a substance.

    Criteria:

    • Ingestion: Recent use of a substance.
    • Behavioral Changes: Problematic behavior or psychological changes (e.g., aggression, mood swings, impaired judgment).
    • Symptoms: At least one of the following: slurred speech, incoordination, unsteady gait, nystagmus, impaired attention/memory, stupor/coma.
    • Exclusion: Not due to another medical condition or mental disorder.

    Risk Factors:

    Chronic stress:Stress is a major trigger for cravings and relapse, often resulting in poorer outcomes. Our HPA axis, sympathetic nervous system and reward pathways are interconnected,[15] with acute stress increasing dopamine. However, chronic stress blunts dopamine release, similar to repeated drug use.[16]

    Brain effects: Chronic stress increases amygdala reactivity and reduces prefrontal cortex connectivity, leading to cravings, negative emotions, and poor self-control.

    Common stressors can exacerbate addiction: guilt, stigma, job stress, unemployment, low socioeconomic status, financial issues, relationship conflicts, and loneliness.

    Childhood stress is a significant risk factor:Early life stressors such as parental separation, neglect, and abuse (physical and sexual) are linked to adult substance use problems.[7]

    History of Trauma: Trauma reduces the volume of certain brain regions and decreases dopamine activity, making individuals more susceptible to addiction.[11,17] Trauma, abuse, and neglect, significantly increase the risk and severity of addiction. Trauma-exposed individuals often have a heightened response to stimulants, which contributes to addiction.[18]

    Genetics:Genetic risk for addiction varies between 20% to 60% for different substances. Identifying specific genetic variants is challenging due to the complexity of addiction phenotypes. Individuals adopted early in life tend to resemble their biological parents in patterns of substance use, particularly alcohol.[7]

    Family Environment: Social and environmental factors influence substance use during childhood and adolescence, while genetic factors become more influential in adulthood. Parents’ substance use behaviors can significantly impact their children’s likelihood of substance use.[7]

    Parenting Practices: Lack of parental supervision increases the risk of children associating with substance-abusing peers. Inconsistent and harsh parenting is linked to early initiation of alcohol use, conduct problems, and poor self-regulation.Warm yet firm parenting styles protect adolescents from developing alcohol problems.[7]

        Red Flags:

        Comorbid Psychiatric Illnesses: 50-60% of substance abuse disorder patients have coexisting psychiatric diagnoses, with higher rates of mood, anxiety, and personality disorders.[19]
        • Alcohol disorder: triples the risk of major depression; drug addiction increases it sevenfold.
        • Personality Disorders:3% with antisocial personality disorder have drug disorders; 72.4% have alcohol disorders.[7]
        • Other Disorders: Schizophrenia, bipolar disorder, and ADHD increase substance abuse risk.[20] Use MSQ and DASS questionnaires; refer to specialists if needed. Refer immediate help if there’s a risk of self-harm or harm to others. Call Triple Zero (000) in case of emergency


        Pregnancy: Use of substances can increase risk of low birth weight, miscarriage, infant mortality, placental abruption, preterm birth, cognitive and behavioral deficits in children.[21] Some babies may experience withdrawal after birth. Management requires a multidisciplinary approach involving obstetrician-gynaecologists, primary care providers, addiction medicine specialists, behavioural health providers, and, in some cases, child welfare services and social services.

        Severe Malnutrition: Substance abuse disorder patients may have poor nutritional intake, preference for sweetened and easily digestible foods. Deficiencies Vitamins E, C, A, iron, thiamine (B1), magnesium, and zinc may be common.[22,23] Assess signs of deficiency and use lab tests as needed. Refer to dietary recommendations for recovery. Refer to the Dietary and Lifestyle section for overall dietary recommendations for recovery from SUDs.

          Screening and investigations

          Clinical Screening

          Rationale

          Depression Anxiety Stress Scales (DASS)

          A self-report questionnaire designed to measure the three related negative emotional states of depression, anxiety and tension/stress.

          Mood and Stress Questionnaire (MSQ)

          A questionnaire designed to help Practitioners establish levels of stress, anxiety and mood concern.

          Health Appraisal Questionnaire (HAQ)

          The HAQ provides a comprehensive assessment of physical health, allowing Practitioners to gain insight into patient symptoms.

          Metagenics Sleep Assessment Questionnaire (SAQ)

          A questionnaire designed to help Practitioners screen patients for sleep disorders, past and current interventions and potential comorbidities that may negatively impact their health.

          Metagenics Patient Sleep Tracker

          A symptom tracker to allow patients to track their response to treatment and provide Practitioners insight into patient sleep routines and habits.

          Pathology Testing

          Rationale

          Cortisol Awakening Response Profile (CAR)

          A non-invasive saliva test that serves as a reliable marker of the stress response to evaluate the overall function of the HPA axis.

          Adrenocortex stress profile

          Non-invasive saliva test that evaluates bioactive levels of the body’s important stress hormones. This test examines four saliva samples over a 12-hour period for levels of cortisol and DHEA at 8am, 12pm, 4pm, and 8pm.

          Iron studies

          Assessment of iron deficiency anaemia.

          Vitamin B1

          Assessment may be indicated in suspected alcoholism or in Wernicke-Korsakoff syndrome.

          Vitamin B12

          B vitamin deficiency is commonly associated with addiction/malnutrition.

          Magnesium

          Magnesium deficiency is commonly associated with addiction/malnutrition.

          Zinc

          Zinc deficiency is commonly associated with addiction/malnutrition.

          Treatment recommendations

          Core Treatment:

          Optimise the stress response to promote resilience

          For daytime cravings and anxiety:

          Herbal Support for Hyper HPA and Stress

          Dosage: Take 1 tablet three times daily.

          Anxiolytic herbs, ziziphus, passionflower, magnolia and kudzu vine to enhance GABAergic neurotransmission, thereby reducing hyperarousal associated with abstinence and withdrawal.

          • Zizyphus has been shown to modify the GABAA receptors [24], while Passionflower binds to GABAA and GABAB receptors.[25]
            • In n=154 with prolonged nervous tension, 1,020 mg/d of passionflower for 12 weeks improved stress-associated symptoms including restlessness, sleep disturbances, exhaustion and anxiety.[26]
          • Kudzu has demonstrated β-adrenoceptor blocking activity , which may help reduce the physical effects of anxiety and stress such as palpitations, tremor and sweating.[27]
          • Magnolia exhibits muscle relaxing effects via GABAergic mechanisms,as well as neuroprotective properties.[28,29]

          Gamma-Aminobutyric Acid (GABA)

          Dosage: Take 250 mg to 500 mg twice daily.

          Gamma-Aminobutyric Acid to enhance inhibitory neurotransmission, reducing neuronal hyperexcitation that contributes to symptoms of anxiety and negative affect (the underlying experience of feeling, emotion and mood).

          • GABA is effective for withdrawal and abstinence in cocaine, heroin, alcohol, nicotine, and methamphetamine addictions.[30,31]
          • GABA helps regulates neuronal excitability through alpha, beta, and gamma receptor subunits,[32] with passage across the blood-brain barrier, reducing excitatory amino acids.[33]
          • Critical in pain transmission, GABA regulates sensory processing in the spinal cord, altering pain perception.[34]
          • Caution: Use discretion with patients dependent on substances with direct GABA agonist activity (e.g., alcohol, benzodiazepines, barbiturates).

          For low mood:

          BCM-95™ Turmeric & Saffron for Depression

          Dosage: Take 1 capsule twice daily with food

          BCM-95™ Turmeric and saffron to support brain plasticity, essential to neurogenesis and the formation of new synaptic pathways, while also alleviating HPA axis dysfunction and sympathetic drive associated with addictive relapse.

          • Turmeric and saffron inhibit NFκB and pro-inflammatory cytokines (TNF-α, IL-1β, IL-6), affecting synaptic plasticity and neurotransmitter metabolism.[35,36]
            • In 123 participants taking 500 mg of BCM-95™ Turmeric and 30 mg of saffron daily showed significant reductions in depression and anxiety after 12 weeks.[37]
          • Safranal has anxiolytic and sedative effects via the GABAergic pathway.[38] Curcumin enhances neurogenesis through BDNF, blocks stress-induced decreases in brain-derived neurotrophic factor (BDNF), and reduces oxidative stress and inflammation.[39]

          Magnesium with Lutein and Zeaxanthin for Sleep Pattern Support

          Dose: Add 1 scoop (5.7 g) in 200 mL of water once daily in the evening.

          Meta Mag® magnesium bisglycinate, ornithine, withania, lutein and zeaxanthin to address disrupted sleep cycle patterns and improve sleep quality.

          • Magnesium deficiency, common in alcoholics due to increased elimination and reduced dietary absorption, linked to chronic stress. Magnesium intake improves resistance to neuropsychological stressors.[40]
            • 732 mg/d of magnesium for 12 weeks has been found to reduce opiate use in methadone-maintained patients.
          • 500 mg/d of magnesium over eight weeks increased sleep time, efficiency, and latency (p<0.03).Serum cortisol levels decreased (p<0.008) in correspondence with increased in melatonin (p<0.007).[41]
          • 400 mg ornithine improves sleep quality, as well as reducing stress markers through the regulation of cortisol and dehydroepiandrosterone sulfate (DHEAS) production.[42]
          • 250 mg/d and 600 mg/d of withania over eight weeks improves perceived stress scores, reduces morning cortisol and enhance sleep quality (p<0.05).[43]
          • Lutein and zeaxanthin support the production and release of melatonin. Supplementation of 20 mg/d of lutein and 4 mg/d of zeaxanthin reduced sleep disturbances and the need for sleep-enhancing medications.[44]

            Support positive neurotransmission and a resilient stress response:

            Lipids and Tocotrienols for Healthy Cell Membranes and Cognition

            Dosage: Take 1 metric teaspoon (5.0 mL or by measuring cap) twice daily.

            A high potency fish oil rich in eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA) vitamin D3 and phosphatidylserine to support healthy brain function, cognition and neuronal regeneration, mitigating substance-induced damage.

            Mechanism of Action/Clinical Research:

            • DHA and EPA are essential for normal brain function. Deficiency can impair neurons and reduce ATP production.[45] DHA supports brain function, cognitive development, membrane flexibility, and synaptic function, making up 30-40% of cerebral cortex, enhancing neurotransmission and synaptic plasticity.[46,47]
            • Vitamin D: Neuroprotective by reducing oxidative damage and modulating dopamine activity.[48]
            • Phosphatidylserine: Helps regulate the HPA axis. 200 mg/day for six weeks normalizes stress responses in chronically stressed men.[49]
            • Tocotrienols (Vitamin E): Powerful antioxidant for the central nervous system and mitochondria, correcting redox imbalances and protecting DNA.[50]

            Diet and Lifestyle Recomendations

            Diet:

            • Mediterranean Diet:Linked to lower psychological distress, anxiety, and depression. Includes high intake of fruits, vegetables, lean protein, essential fatty acids, and whole grains.[51] The Mediterranean diet is inclusive of high intake of fruits and vegetables, lean protein, quality essential fatty acids, and wholegrains (limiting starchy grains and vegetables).
            • Additional Tips for SUD Recovery[52]:
              • Drink 2-3 liters of water daily, avoid sweetened beverages.
              • Focus on plant proteins (beans, nuts, seeds).
              • Choose whole grains (oats, quinoa, barley) over refined grains.
              • Increase intake of vitamins A, C, E, selenium, iron, and omega-3s.
                • Vitamin A:Carrots, pumpkin, sweet potatoes, spinach.
                • Vitamin C:Capsicum, kiwi, broccoli, strawberries.
                • Vitamin E:Almonds, sunflower seeds, avocado, peanut butter.
                • Selenium:Brazil nuts, tuna, oysters, pork, beef, chicken, turkey.
                • Iron:Red meat, lentils, pumpkin seeds, kidney beans.
                • Omega-3s:Fatty fish, chia seeds, flax seeds, walnuts.
              • Gradually increase fiber intake to 25 g/day for women, 38 g/day for men. Fiber Sources:Beans, whole grains, berries, cruciferous vegetables, chia seeds.
              • Include a fruit or vegetable with every meal/snack.
              • Limit caffeine to 400 mg/day initially, then reduce to 100-200 mg/day. Prefer green tea over coffee.
              • Minimize artificial sweeteners.

            Lifestyle:

            • Exercise: May reduce addiction susceptibility and relapse through dopaminergic pathway modulation. Moderate exercise is more protective than high intensity.[53]
              • A 12-week aerobic exercise program with CBT reduced anxiety and cravings in smokers.[54]
            • Emotional Freedom Technique (EFT):Combines exposure and cognitive therapies with acupuncture point stimulation.[55]
            • Reduces hyperarousal in the amygdala and hippocampus,[56] regulates genes related to inflammation and immunity, reduces salivary cortisol within one hour.[96-98]
            • Effective for anxiety, depression, PTSD, pain, and cravings, with treatment gains persist over time.[59-63]
            • Find trained EFT practitioners at:
              • petastapleton.com
              • eftuniverse.com
              • eftinternational.org

            Pharmaceutical Treatment

            Contact Metagenics Clinical Support to ensure product recommendations are suitable for use in conjunction with pharmaceutical medications.

            • Long-acting Benzodiazepines: Used to prevent and treat withdrawal symptoms. Initial large doses (e.g., diazepam 20 mg, 4 times/day) are gradually reduced over 5-7 days.[64,65]
            • Pabrinex: High-dose thiamine to prevent Wernicke–Korsakoff syndrome
            • Acamprosate: Reduces alcohol cravings and helps maintain abstinence by acting on the NMDA receptor system.[64,65]
            • Disulfiram: Deterrent for alcohol use; causes unpleasant reactions (e.g., headache, nausea) when alcohol is consumed.[64,65]
            • Methadone: Manages withdrawal symptoms for those dependent on sedatives. Dosage is ideally reduced gradually, but some patients may need long-term maintenance.[64,65]

            Additional Resources

            Stigma and Addiction: The National Institute on Drug Abuse offers a guide to reduce stigma, which can hinder treatment seeking and increase relapse risk.[5]
            Motivational Interviewing and Compassionate Inquiry: Techniques to enhance self-efficacy and treatment success.
            Alcohol and Drug Withdrawal Guidelines: Provides evidence-based resources for managing withdrawal from various substances, tailored to individual needs and settings

              Additional information and support for Practitioners treating patients with addictions is also available from several organisations:

              • Australia wide: Alcohol and Other Drugs Information Service (ADIS) and Drug and Alcohol Clinical Advisory Services (DACAS)
              • NSW: Stimulant Treatment Line
              • VIC: DirectLine Victoria
              • QLD: QLD ADIS
              • SA: Drug and Alcohol Services South Australia
              • WA:The Alcohol and Drug Support Line
              • NT: NT ADIS
              • TAS: Alcohol and Drug Services
              • ACT: Canberra Health Services' Alcohol and Other Drugs Services
              • NZ: Alcohol Drug Helpline

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