Transcript Clinical Slide Set. Substance Use Disorders

In the Clinic
Substance Use
Disorders
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (4): ITC4-1.
How common are substance use disorders?
 Alcohol use
 ~30% Americans ≥18 years old exceed recommended limits
 Smaller percentage have alcohol use disorder
 Illicit drugs
 ~9% Americans ≥12 years use
 Marijuana (7.5%)
 Prescription drugs (2.5%, mostly opioids), Heroin (0.1%)
 Cocaine (0.6%), Hallucinogens (0.5%), Inhalants (0.2%)
 Methamphetamine a major problem in some regions
 Designer drug use increasing (synthetic cannabinoids)
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (4): ITC4-1.
What are the risk factors?
 Genetic polymorphisms
 May contribute 40% to 60% of an individual’s risk
 Environmental factors in childhood or adolescence
 Age of first exposure to alcohol or drugs
 Adverse childhood experiences
 Psychiatric comorbidities
 Depression, anxiety, bipolar disorder
 May contribute to vulnerability to addiction
 Anxiety and depressive symptoms may be a consequence
of long-term substance use
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (4): ITC4-1.
Unhealthy substance use
 Alcohol: consumption at a level that has negative health
consequences
 Men ≤65 years: risky use >4 drinks per occasion or >14
drinks per week
 Men >65 years and women, risky use >3 drinks per
occasion or >7 drinks per week
 Unhealthy alcohol becomes a disorder when person
experiences negative consequences and/or loss of control
around their drinking
 Drugs: ANY use
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (4): ITC4-1.
What personal, community, and health
system measures are effective in
preventing substance use disorders?
 Modeling abstinence or modest alcohol consumption
 Awareness of risks of early drug or alcohol use
 Policy measures that reduce underage drinking and
other adverse drinking-related outcomes at all ages
 Disposal of leftover controlled substance prescriptions
 Education for physicians on safe opioid prescribing
 Restrictions on dispensing opioid analgesics
 Limits on quantity given in first opioid prescription
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (4): ITC4-1.
What health system measures are effective
in reducing or preventing unhealthy
substance use?
 Risky alcohol use: brief interventions can be effective
 SBIRT: screening, brief intervention, referral to treatment
 If screening positive: assess further and refer for treatment
 Clinical cues should trigger investigation about alcohol
use (pancreatitis, elevated liver function test results)
 For drug use, brief interventions not shown effective
 Use safe practices when prescribing opioids for pain
 Ask about use: when social functioning deteriorates, family
history is present, or associated comorbidities diagnosed
(hep C, upper extremity abscess)
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (4): ITC4-1.
How can opioids for chronic pain be
prescribed safely and effectively?
 Monitor for behaviors that indicate opioid use disorder
 Predictors of opioid use disorder include
 History or family history of substance use disorders
 Mental health diagnosis
 Current cigarette smoking
 History of legal problems
 Concurrent benzodiazepines, and higher opioid doses
 Only consider long-term opioid treatment when
 Moderate to severe pain affects function and/or QOL
 Potential therapeutic benefits outweigh risks
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (4): ITC4-1.
 Use risk management strategies
 Optimize alternatives to opioid treatment for chronic pain
 Assess for risk for aberrant drug-related behaviors
 Structure appropriate treatment and monitoring plan
 Consider a medication agreement
 Regularly assess opioid benefit and decision to use
 Regularly assess drug-related behaviors, using urine drug
testing, pill counts, state prescription monitoring data
 Discontinue (tapering) if benefits are not commensurate
with risks or if drug taking behaviors are aberrant
 Seek appropriate specialist assistance
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (4): ITC4-1.
CLINICAL BOTTOM LINE: Prevention...
 Unhealthy alcohol use
 Screening and brief interventions can reduce alcohol use
 When managing chronic pain

Optimize alternatives to opioids

When opioid treatment considered, evaluate patients for
risk factors for misuse

Regularly assesss opioid treatment

Monitor long-term use closely
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (4): ITC4-1.
Diagnosis
 Screening for alcohol use
 Single-item: How many times have you consumed alcohol
over the recommended limits?
 AUDIT-C: 3-item survey more specific for unhealthy use
 AUDIT: 10-item survey often used as follow-up to singleitem question or as initial screening tool
 CAGE: assesses lifetime rather than current use pattern
 Screening for drug use
 Single-item: How many times in the last year have you
used an illegal drug, or a prescription medication for a
nonmedical reason (bc of experience or feeling it caused)?
 DAST-10: initial screening or follow up on single-item
 Pay attention to key aspects of history
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (4): ITC4-1.
Diagnosis
 Assess withdrawal in patients with alcohol or opioid
disorder who report recently stopping use
 History and physical examination
 CIWA (Clinical Institute Withdrawal Assessment) for
alcohol withdrawal
 COWS (Clinical Opiate Withdrawal Scale) score for opioid
withdrawal
 To further assess for complications of substance use
 Laboratory evaluation often important
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (4): ITC4-1.
Complications
 Unhealthy alcohol use
 Liver disease
 Cardiovascular disease (hypertension, cardiomyopathy)
 Gastritis, esophagitis
 Bone marrow suppression, chronic infectious diseases
 Peripheral neuropathy
 Pneumonia
 Several types of cancer
 Increased morbidity in individuals with HIV, hep C
 Psychiatric and behavioral conditions
 Major risk factor for trauma and violence
 Withdrawal can be fatal
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (4): ITC4-1.
Complications
 Injection drugs
 Local infections (abscesses, cellulitis)
 Blood-borne infections (bacterial and viral)
 Opioids (in addition to complications of opioid injection)
 Nausea and constipation
 Effects of HPA axis suppression (amenorrhea, low
bone density, loss of libido
 Hyperalgesia
 Overdose
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (4): ITC4-1.
Complications
 Cocaine
 Cardiac ischemia, myocardial infarctions
 Cerebrovascular and renal disease
 Chronic rhinitis and perforation of the nasal septum
 Smoking crack: acute, chronic pulmonary complications
 Methamphetamine
 Cardiotoxicity
 Irritability; anger; panic; psychosis that may recur during
periods of abstinence
 Possible neurotoxicity and cognitive decline
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (4): ITC4-1.
Complications
 Marijuana
 Pulmonary complications (cough, bronchitis, asthma)
 Possible lung cancer or other cancers
 Hyperemesis
 In adolescents: abnormal development neural pathways
 Possble depression and anxiety, psychotic disorders
 Designer drugs
 Synthetic cannabinoids: seizures, acute renal failure,
myocardial infarction (long-term effects not well-known)
 “Bath salts”: muscle spasm, bruxism, palpitations,
tachycardia, hypertension; psychiatric effects
 Oral health problems common with substance disorders
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (4): ITC4-1.
CLINICAL BOTTOM LINE: Complications...
 Substance use disorders have myriad medical complications
 Unhealthy alcohol use: liver disease as well as causing or
contributing to a host of other medical conditions
 Injection drug use: local and systemic bacterial infections and
blood-borne viruses, including HIV and hepatitis C
 Cocaine: cardiovascular effects
 Marijuana: pulmonary complications, neurocognitive
impairment that may be particularly serious in adolescents
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (4): ITC4-1.
How should withdrawal be approached in
the outpatient setting?
 Goals of withdrawal management
 Manage symptoms
 Prevent serious complications
 Bridge to treatment to achieve long-term recovery
 Outpatient management may be appropriate for select,
highly motivated and supported patients
 Plan is needed for ongoing care
 Withdrawal management is not substance use treatment
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (4): ITC4-1.
 Alcohol: criteria for outpatient detoxification
 CIWA score 8 - 15 without seizures or delirium tremens
 Ability to take oral medications
 Presence of reliable support person who can stay
throughout the detox period and monitor symptoms
 Ability to commit to daily medical visits
 No unstable medical condition and not pregnant
 Not psychotic, suicidal, or cognitively impaired
 No concurrent substance use that may lead to withdrawal
 No history delirium tremens or alcohol withdrawal seizures
 Contraindications: >60 y, evidence alcohol-related endorgan damage
 Benzodiazepines may help manage symptoms and prevent
complications
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (4): ITC4-1.
 Opioids
 Treating as outpatients depends on treatment goals and
treatment availability
 Refer patients experiencing withdrawal and interested in
methadone / buprenorphine treatment for such care
 For oral naltrexone use, patient must be opioid abstinent
3–7 d before initiation; for intramuscular formulation ≥7 d
 Patients often require structure and supervision of
inpatient setting during this transition
 In outpatient setting, manage symptoms with nonopioid
medications for anxiety, cramps, diarrhea
 Benzodiazepines
 Manage severe withdrawal as inpatients so that IV
benzodiazepines can be given and titrated to effect
 Afterward, motivated patients can receive gradually
tapering dose in outpatient setting over several months
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (4): ITC4-1.
What medications are available for
treatment?
 Alcohol
 Naltrexone
 Acamprosate
 Disulfiram
 Opioids
 Methadone
 Buprenorphine
 Sustained-release naltrexone
 Cocaine
 No FDA-approved medication
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (4): ITC4-1.
What other treatments are available for
substance use disorders?
 Psychosocial treatment
 Helps achieve sobriety, rebuild other aspects of life
 Counseling
 Peer-support groups (Alcoholics Anonymous)
 Residential treatment
 Contingency management
 Motivational interviewing
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (4): ITC4-1.
For patients who continue to use substances,
how can physicians help reduce harms?
 Needle exchange services: injection drug users
 Intranasal naloxone: opioid use disorder
 Tetanus, hepatitis A & B vaccination: injection drug users
 Pneumonia vaccination: alcohol use disorders
 Preexposure prophylaxis against HIV: high-risk patients
 Counsel to avoid driving after unhealthy alcohol, drug use
 Offer birth control, condom counseling, frequent STI testing to
women with heroin use disorders
 Engage patients in discussions about readiness for change
 Address tobacco use just as with any other patient
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (4): ITC4-1.
What are the medical-legal issues of
substance use disorders?
 State legislation
 May affect how physicians prescribe opioids and other
controlled substances
 Federal regulations
 Title 42, part 2: requires higher degree of confidentiality
than standard medical information
 Practices should incorporate 42 CFR part 2-compliant
language into standard clinic release of information forms
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (4): ITC4-1.
What is the role of primary care physicians vs.
addiction physicians and other specialists?
 Primary care physicians
 Central roles in prevention, diagnosis, and management
 May treat patients with substance use disorders
 Referral to addiction specialist and/or treatment program
 Addiction specialists
 Complex patients with substance use disorders
 Addiction psychiatry subspecialists
 Patients with mental health condition
 Pain specialists
 Optimize nonopioid treatments of chronic pain
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (4): ITC4-1.
CLINICAL BOTTOM LINE: Management...
 Withdrawal management
 Necessary bridge to further treatment for many patients
 Outpatient management appropriate only for highly
motivated patients with ample support at home
 Treatment options
 Medications available for alcohol and opioid use disorders
 Psychosocial treatments effective for many patients
 Peer-support groups (Alcoholics Anonymous) may benefit
 Educate patients who are in early recovery or who are not
ready to stop substance use about harm reduction
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (4): ITC4-1.