Special Populations, Comorbidity, and Systems of Care
Pregnancy and postpartum
No amount of alcohol is known safe. Treat opioid use disorder with methadone or buprenorphine; withdrawal increases relapse and fetal risk. Neonatal opioid withdrawal syndrome requires monitoring, not discontinuation of the parent’s medication. Screen for tobacco and offer NRT with counseling. Postpartum relapse risk is high; maintain treatment.
Adolescents and older adults
Adolescents need CRAFFT screening, confidentiality, and family-based treatment; no medication is FDA-approved for adolescent AUD. Older adults have lower tolerance, more drug interactions, and cognitive risk; start low and screen with AUDIT-C.
Comorbidity
Integrated treatment of co-occurring disorders is superior to sequential care. Depression, PTSD, ADHD, and anxiety commonly coexist. Avoid benzodiazepines in AUD where possible; they worsen outcomes and withdrawal risk. Suicide risk rises during withdrawal and early abstinence.
Systems of care
Know SBIRT, collaborative care, medication-first approaches, harm reduction (naloxone, syringe services), and justice-system linkage to MOUD. ASAM levels range from outpatient to medically managed inpatient. Confidentiality under 42 CFR Part 2 is stricter than HIPAA for substance use records.
Traps
Do not stop buprenorphine during pregnancy; do not assume older adults drink less; do not treat comorbid anxiety with long-term benzodiazepines in AUD; do not withhold lifesaving MOUD because of criminal justice status.
Rule of thumb
When a special population has a treatable addiction, the default is to intensify treatment and adapt dosing-not to withdraw treatment.