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Early Evaluation and Treatment of Substance Abuse

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Early Evaluation and Treatment of Substance Abuse Addiction Medicine - Substances of Abuse Bradley J. Miller, DO Practical Approaches to Managing Substance Abuse and Nicotine Addiction ACOFP Intensive Update and Board Review in Osteopathic Family Medicine Bradley J. Miller, DO, FAAFP Williamsport Family Medicine Residency Objectives • Review current statistics and disease burden of substance abuse in the United States. • Describe importance of screening for, provide brief intervention for, and recognize when to refer to treatment for substance abuse disorders in the primary care setting. • Review specific substances of abuse (alcohol, nicotine, MJ, opiates) and accepted pharmacologic treatments Question # 1 In patients who die from an opioid overdose, a second substance is often present that contributes to the patient’s death. Which one of the following additional substances is most likely to be found in conjunction with a fatal opioid overdose? A) THC (Marijuana) B) Antidepressants C) Cocaine D) Benzodiazepines E) Alcohol 1 Current Statistics and Disease Burden 2012 National Survey on Drug Use and Health • 23.9 million people over 12 years are current illicit drug users • 52.1% of individuals over 12 years report being current drinkers • Of all individuals over 12 years who drink – 23% binged in the last month – 6.5% participate in heavy drinking Current Statistics and Disease Burden • 2.1 M ED visits associated with drug misuse or abuse in • 53% of all ED visits involved pharmaceuticals – Pain relievers- most common • Other pharmaceuticals included BZDs – alprazolam most reported Substance Abuse and Mental Health Services Administration, Drug Abuse Warning Network, 2009: National Estimates of Drug-Related Emergency Department Visits. HHS Publication No. (SMA) 11-4659, DAWN Series D-35. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2011. SAMHSA National Survey Past Month Use of Selected Illicit Drugs among Youths Aged 12 to 17: 2002-2012 Substance Abuse and Mental Health Services Administration, Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-46, HHS Publication No. (SMA) 13-4795. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013 2 SAMHSA National Survey Past Month Nonmedical Use of Types of Psychotherapeutic Drugs among Persons Aged 12 or Older: 2002-2012 Substance Abuse and Mental Health Services Administration, Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-46, HHS Publication No. (SMA) 13-4795. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013 Mokdad et al., 2004 SAMHSA National Survey Source Where Pain Relievers Were Obtained for Most Recent Nonmedical Use among Past Year Users Aged 12 or Older: 2011-2012 Substance Abuse and Mental Health Services Administration, Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-46, HHS Publication No. (SMA) 13-4795. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013 3 Top Medications Prescribed 2011 Enough opiate pain medications were prescribed in 2010 to medicate every American adult with 5 mg of hydrocodone taken every 4 hours… for an entire MONTH Warner M, Chen LH, Makuc DM. Increase in fatal poisonings involving opioid analgesics in the United States, 1999-2006. NCHS data brief, no 22. Hyattsville, MD: National Center for Health Statistics. 2009 Vital Signs: Overdoses of Prescription Opioid Pain Relievers – United States, 1999-2008. MMWR Volume 60, No. 43. pp. 1487-1492. November 4, 2011 Death Rates* for Three Selected Causes of Injury†— National Vital Statistics System, United States, 1979–2012 Center for Disease Control, Morbidity and Mortality Weekly, November 21, 2014 4 The Neurochemistry of Addiction – Dopamine: Amphetamines, cocaine, alcohol – Serotonin: LSD, alcohol – Endorphins: Opioids (heroin and narcotics), alcohol – GABA: Benzodiazepines, alcohol – Glutamate: Alcohol – Acetylcholine: Nicotine, alcohol – Endocannabinoids: Marijuana, alcohol SCREENING Alcohol • What is Low-Risk Drinking?: • Females < 7 drinks per week < 3 drinks per occasion • Males < 14 drinks per week < 4 drinks per occasion • Adults over 65 years of age < 7 drinks per week < 3 drinks per occasion 5 Alcohol What constitutes “1 drink”?* • Beer – 12 ounces • Shot – 1.5 ounces • Wine – 5 ounces * The definition of a standard drink varies from country to country and study to study; the above is the WHO definition, and is used by the SBIRT initiative What is a standard drink? One 12oz. Can/Bottle of Beer A single shot (1.5 oz.) of distilled spirits (gin, vodka, rum, etc…) A glass of wine (5 oz.) or a small glass of sherry DSM-IV SUD Substance Abuse Substance Dependence 1 or more of the following at the same 3 or more of the following at the same time in a 12-month period: time in a 12-month period: • Recurrent use resulting in failure to fulfill • Tolerance major role obligations • Withdrawal • Recurrent use in situations that are physically hazardous • Taken in larger amounts or over longer period than intended • Recurrent legal problems resulting from • Persistent desire or unsuccessful efforts to cut use down • Continued use despite having persistent • Great deal of time spent in obtaining, using, and social or interpersonal problems caused or recovering from substance exacerbated by the substance • Important activities are given up as a result of substance use • Does not meet criteria for Dependence • Use continues despite knowledge of physical or psychological problem that is caused or exacerbated by the substance 6 DSM-V Substance Related Disorders –A major overhaul of the DSM-IV criteria for substance use includes the following: •Substance Use Disorder (SUD) is a single disorder, measured on a continuum from mild to severe, that combines the DSM-IV abuse and dependence criteria with the following two exceptions: –DSM-IV recurrent legal problems has been removed –New criterion for craving or a strong desire or urge to use has been added •Each specific substance is addressed as a separate use disorder (e.g. alcohol use disorder, opiate use disorder) •Cannabis and Caffeine withdrawal are new for DSM-V •Gambling disorder has been added DSM-V Substance Use Disorder •SUD is accompanied by criteria for intoxication, withdrawal, substance/medication-induced disorders and unspecified substance- induced disorders. •The severity of SUD in DSM-V is based on criteria endorsed: –2-3 – mild disorder –4-5 – moderate disorder –6 or more – severe disorder •Helps define SUD as a continuum and removes confusion regarding dependence with “addiction” when in fact dependence can be a normal body response to a substance •Additional modifiers and specifies exist as well. •Substance INTOXICATION & WITHDRAWAL are different codes and are dependent on the severity of the SUD National Institute on Alcohol Abuse and Alcoholism www.niaaa.nih.gov NIH Publication No. 13–7999 November 2013 7 Question # 2 A 67 year old male with was brought to the emergency department after his friend found him confused at home. The patient typically drinks up to 12 cans of beer daily but has increased over the past 2 months. He has had some falls while intoxicated over the past year and has tried to cut down but hasn’t been able to do so. His family has been encouraging him to cut down and he has been unsuccessful. He decided to stop drinking and his last drink was about 20 hours ago. When found, the patient referred to his friend as his wife who has been deceased for 2 years. Which of the following is most accurate? (A) The patient meets diagnostic criteria for moderate alcohol use disorder and is beginning to have delirium tremens (B) The patient meets diagnostic criteria severe alcohol use disorder and is beginning to have delirium tremens (C)The patient meets diagnostic criteria for moderate to severe alcohol use disorder and is beginning to have alcohol hallucinations (D) Naltrexone, thiamine and folate should be given to the patient prior to treatment with lorazepam (E) None of the above Alcohol Alcohol Withdrawal Syndromes • Pathophysiology of ETOH withdrawal – Abrupt withdrawal unmasks compensatory over-activity of the nervous system. – Alters levels of GABA, Norepinephrine and Serotonin • Minor Withdrawal Symptoms – Due to CNS and sympathetic hyperactivity – Usually present within 6 hrs of drinking cessation – Insomnia, tremulousness, anxiety, GI upset, HA, diphoresis, palpitations, or anorexia – Resolve within 24-48 hours – consistent from one episode to the next 8 Alcohol Withdrawal Syndromes • Withdrawal Seizures – Usually tonic-clinic convulsions within 48 hours of last drink – 3% of chronic alcoholics have withdrawal seizures of which 3% develop status epilepticus – Usually a singe episode. Recurrent or prolonged seizures require investigation of another source Alcohol Withdrawal Syndromes • Alcoholic Hallucinations – Often mistaken for delirium tremens (DTs) – Hallucinations that develop 12-24 hrs from abstinence and resolve within 24-48 hrs (which is when DTs typically begin) – Usually visual but can be auditory and tactile – Usually associated with specific hallucinations and not global clouding of the sensorium (as with DTs) Alcohol Withdrawal Syndromes • Delirium Tremens – Occurs in 5% of pts experiencing withdrawal – Hallucinations, disorientation, tachycardia, HTN, low grade fever, agitation, and diaphoresis. – Typically begin between 48 & 72 hrs and last one to five days – Mortality rate
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