Transcript Monitored Abstinence - Alcohol Medical Scholars Program

Monitoring Abstinence
Martin H. Plawecki MD, PhD
Indiana University School of Medicine
Department of Psychiatry
Alcohol Medical Scholars Program
Introduction
• Many diseases: chronic, relapsing, remitting
• Controlled, not cured
• Examples
• Type I diabetes: 30-50% relapse rate
• High blood pressure: 50-70% relapse rate
• Substance use disorders (SUDs): 40-60% relapse rate
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Goals of SUD Treatment
• Harm reduction
• Abstinence
• Abstinence monitoring has a role in both
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This Lecture Covers
• Definition/course of Substance Use Disorders (SUDs)
• Goals of monitoring abstinence and detection
• Abstinence monitoring substance examples
• Efficacy of monitored abstinence
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This Lecture Covers
• Definition/course of Substance Use Disorders (SUDs)
• Goals of monitoring abstinence and detection
• Abstinence monitoring substance examples
• Efficacy of monitored abstinence
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Substance Use Disorder
In Same Year, ≥2 of:
• Tolerance
• Withdrawal
• Use longer/more
• Unable to ↓
• Lots time use
• ↓ Activities
• Use despite probs
• Craving
• Failed roles
• Hazardous use
• Social problems
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Substance Use Disorder II
Abstinence
Controlled
Use
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Problems
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This Lecture Covers
• Definition/course of Substance Use Disorders (SUDs)
• Goals of monitoring abstinence and detection
• Abstinence monitoring substance examples
• Efficacy of monitored abstinence
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Goals of Monitoring Abstinence
• Improve treatment outcomes by:
• Improving treatment compliance
• Verifying prescribed substance usage
• Detecting problematic usage
• Safety
• Objective is NOT punitive
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Detection
• When and how are dependent on what
• Both are determined by drug
• Absorption – how and how much drug enters
• Distribution – where drug goes in body
• Metabolism – what body does to drug
• Elimination – how drug is eliminated
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Detection II
• Strategies
• Detect chemical itself
• Detect metabolites
• Detect secondary effects
• Detection can be chemical or electrical within
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Blood
Breath
Sweat
Hair
Urine
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This Lecture Covers
• Definition/course of Substance Use Disorders (SUDs)
• Goals of monitoring abstinence and detection
• Abstinence monitoring substance examples
• Efficacy of monitored abstinence
© Alcohol Medical Scholars Program
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Monitoring Abstinence - Breath
• Advantages
• Easy, non-invasive
• Cost – reusable device
• Disadvantages
• Must be done properly
• Possibly non-specific
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Draeger Alcotest
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Monitoring Breath - Alcohol
• Alcohol is water soluble & appears in breath
• Electrochemical detection (burns alcohol)
• Deep breath is proportional to blood level
• Detects low [alcohol] (1 drink in past hour)
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Monitoring Breath - Nicotine
• CO from burning tobacco in breath
• Electrochemical detection (burns CO)
• Detected up to 2 dys; “smoker” sensitivity < 10 hrs
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Monitoring Abstinence - Urine
• Advantages
• Easy to obtain/non-invasive
• Detection via specific antibodies
• Common and inexpensive
• Disadvantages
• Positive test → expensive replication
• Replication takes weeks to get results
• Specific drugs detected for different time lengths
• Cheating
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Monitoring Abstinence – Urine II
• Urine drug screen
• Specific antibody screening for substances/byproducts
• Many substances can be screened in a single test
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Times for Useful Urine Monitoring
Detection Times
• Opioids – 1-3 days
• Cocaine – 2-4 days
• Cannabinoids
• PCP – 8 days
• Single use – 3 days
• Alcohol – ¼ - ½ day
• Daily – 10-15 days
• Sedatives
• Heavy – >30 days
• Amphetamines – 2 days
• Short-acting – 3 days
• Long-acting – 30 days
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A Problem With Urine Monitoring
• Cheating
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Adulterants - substances added to urine sample
Dilution - intentional fluid over-ingestion
Substitution - use of another’s, old, or synthetic urine
False attribution - claimed use of one to hide another
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Monitoring Abstinence - Blood
• Advantages
• Highly specific → confirm other tests
• Difficult to cheat, low false positives
• Direct and indirect measurements possible
• Disadvantages
• Invasive – requires a blood draw
• Expensive – includes testing and procedure fees
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Monitoring Blood - Alcohol
• Alcohol: Blood Alcohol Concentration
• Direct detection of alcohol
• Limited to recent consumption only
• Alcohol: Carbohydrate deficient transferrin (CDT)
• Indirect marker - ↑ alcohol > 2 wks → ↑ CDT
• Timing: abstinence → ↓ CDT in 2-5 weeks
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Monitoring Blood - Cannabis
• Direct detection of cannabinoids
• Acute use: peaks in min, ↓ <1 hr but > 0 for 1 day
• Chronic: detectable up to 30 days
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Monitoring Abstinence - Sweat
• Advantages
• Largely non-invasive
• Relatively tamper resistant
• Can be done chemically and electronically
• Wide variety of substances can be detected
• Disadvantages
• Positive test → expensive replication
• Difficult to quantify
• Unclear effects of exercise → ↑sweat
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Monitoring Sweat - Chemical
• Swab collection
• Primarily to verify intoxication
• Detects recent usage only (<24 hours)
• Patch collection
PharmaChem Patch
• Detection over longer time window (1-2 wks)
• May provide a cumulative measure of the interval
• Possible for drugs to be re-absorbed
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Monitoring Sweat - Electronic
• Advantages
• Continuous monitoring
• Data can be monitored remotely
• Disadvantages
• Intrusive and highly visible
• Expensive
• Optimized for forensics
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Sweat Monitoring - Alcohol
• Alcohol → sweat
• Samples every 30 minutes
• Automatic alerts
• Tamper Resistant
• Cost
• Lease: $6-8/day lease
• Purchase: $1,400-1,800 + $5/day
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Monitoring Abstinence - Other
Hair
Saliva
• Advantages
• Advantages
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Chemical detection
Long-term use patterns
Non-invasive
Limited cheating
• Disadvantages
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Limited substances
No acute intoxication
1 week until detection
+ → $$$ confirmation
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Chemical detection
Acute intoxication
Non-invasive
Limited Cheating
Sensitive
• Disadvantages
• Short detection time
• + → $$$ confirmation
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Monitoring Other - Examples
Hair
Saliva
• Drug → follicles → hair
• ~100 hairs cut by scalp
• Detects
• Drug → blood → saliva
• Pad placed in cheek
• Detects
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Cocaine
Amphetamines
Opiates
PCP
THC
Ecstacy
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Cocaine
Amphetamines
Opiates
PCP
THC
Sedatives
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This Lecture Covers
• Definition/course of Substance Use Disorders (SUDs)
• Goals of monitoring abstinence and detection
• Abstinence monitoring substance examples
• Efficacy of monitored abstinence
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Methadone Maintenance
• Goal: ↓ health risk, ↓ crime, ↑ family/job
• Replacement: methadone vs heroin
• Lasts >24hours → 1x/day dosing
• Allows work; avoids withdrawal and prevent “high”
• Cheaper & from clinic → ↓ risky acts, ↓crimes
• Highly structured and federally regulated
• Administer methadone daily, usually at clinic
• Monitor for abstinence – urine drug screens
• Requires counselling
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Methadone Maintenance Efficacy
• 3x ↑ Remain in Rx vs no opiate replacement
• 2/3x ↓ Positive opioid hair/urine samples
• 2 ½x ↓ Crime involvement
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Chronic Pain Management
• Goal: control pain, minimize substance misuse
• Adherence monitoring and risk minimization
• Explicit behavior agreements
• Estimate risk
• Use difficult-to-misuse medications
• Rx drug monitoring programs
• Urine drug screens
• Success → continue in program
• Failure → lose access to prescription opioids
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Chronic Pain Management Efficacy
• Urine drug testing → ↓ illicit drug usage
• ↑ Urine drug tests → ↑ prescription adherence
↓ non-Rx medications
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Court Mandated Rx
• Goal: ↓ drug use → ↓ crime
• Links highly structured Rx to legal system
• Residential and outpatient treatment
• Random urine drug screens
• Routine judicial interaction and progress monitoring
• Success → avoid jail
• Failure→
• ↑ Monitoring frequency/intensity
• ↑ Punishment up to jail
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Court Mandated Rx Efficacy
• 12% ↓ Criminal relapse
• No clear effect on SUD outcomes
• Difficult to quantify
• Highly variable population
• Different Rx approaches/referral networks
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Physician Health Programs
• Goal: ↓ patient harm
• Links highly structured Rx to medical license
• Residential and outpatient treatment
• Random urine drug screens
• +/- Random office visit
• ≥5 Yr follow-up
• Success → practice medicine, keep job
• Failure →
• Treatment, ↑monitoring frequency/intensity
• Referral to medical licensing board
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Soberlink Blue Device System
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Physicians Health Programs Efficacy
• Only ~20% w/ +UDS at any time during 5 yrs
• 70-80% Physicians still licensed/employed at 5 yrs
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Summary
• SUDs are chronic relapsing/remitting conditions
• Abstinence monitoring is therapeutic
• Monitoring can be chemical and electronic
• Monitored abstinence → better outcomes
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Questions
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