Survey
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Monitored Abstinence - Alcohol Medical Scholars Program
Document related concepts
Transcript
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 © Alcohol Medical Scholars Program 2 Goals of SUD Treatment • Harm reduction • Abstinence • Abstinence monitoring has a role in both © Alcohol Medical Scholars Program 3 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 4 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 5 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 © Alcohol Medical Scholars Program 6 Substance Use Disorder II Abstinence Controlled Use © Alcohol Medical Scholars Program Problems 7 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 8 Goals of Monitoring Abstinence • Improve treatment outcomes by: • Improving treatment compliance • Verifying prescribed substance usage • Detecting problematic usage • Safety • Objective is NOT punitive © Alcohol Medical Scholars Program 9 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 © Alcohol Medical Scholars Program 10 Detection II • Strategies • Detect chemical itself • Detect metabolites • Detect secondary effects • Detection can be chemical or electrical within • • • • • Blood Breath Sweat Hair Urine © Alcohol Medical Scholars Program 11 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 12 Monitoring Abstinence - Breath • Advantages • Easy, non-invasive • Cost – reusable device • Disadvantages • Must be done properly • Possibly non-specific © Alcohol Medical Scholars Program Draeger Alcotest 13 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) © Alcohol Medical Scholars Program 14 Monitoring Breath - Nicotine • CO from burning tobacco in breath • Electrochemical detection (burns CO) • Detected up to 2 dys; “smoker” sensitivity < 10 hrs © Alcohol Medical Scholars Program 15 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 © Alcohol Medical Scholars Program 16 Monitoring Abstinence – Urine II • Urine drug screen • Specific antibody screening for substances/byproducts • Many substances can be screened in a single test © Alcohol Medical Scholars Program 17 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 © Alcohol Medical Scholars Program 18 A Problem With Urine Monitoring • Cheating • • • • 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 © Alcohol Medical Scholars Program 19 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 © Alcohol Medical Scholars Program 20 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 © Alcohol Medical Scholars Program 21 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 © Alcohol Medical Scholars Program 22 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 © Alcohol Medical Scholars Program 23 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 © Alcohol Medical Scholars Program 24 Monitoring Sweat - Electronic • Advantages • Continuous monitoring • Data can be monitored remotely • Disadvantages • Intrusive and highly visible • Expensive • Optimized for forensics © Alcohol Medical Scholars Program 25 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 © Alcohol Medical Scholars Program 26 Monitoring Abstinence - Other Hair Saliva • Advantages • Advantages • • • • Chemical detection Long-term use patterns Non-invasive Limited cheating • Disadvantages • • • • Limited substances No acute intoxication 1 week until detection + → $$$ confirmation • • • • • Chemical detection Acute intoxication Non-invasive Limited Cheating Sensitive • Disadvantages • Short detection time • + → $$$ confirmation © Alcohol Medical Scholars Program 27 Monitoring Other - Examples Hair Saliva • Drug → follicles → hair • ~100 hairs cut by scalp • Detects • Drug → blood → saliva • Pad placed in cheek • Detects • • • • • • Cocaine Amphetamines Opiates PCP THC Ecstacy • • • • • • Cocaine Amphetamines Opiates PCP THC Sedatives © Alcohol Medical Scholars Program 28 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 29 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 © Alcohol Medical Scholars Program 30 Methadone Maintenance Efficacy • 3x ↑ Remain in Rx vs no opiate replacement • 2/3x ↓ Positive opioid hair/urine samples • 2 ½x ↓ Crime involvement © Alcohol Medical Scholars Program 31 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 © Alcohol Medical Scholars Program 32 Chronic Pain Management Efficacy • Urine drug testing → ↓ illicit drug usage • ↑ Urine drug tests → ↑ prescription adherence ↓ non-Rx medications © Alcohol Medical Scholars Program 33 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 © Alcohol Medical Scholars Program 34 Court Mandated Rx Efficacy • 12% ↓ Criminal relapse • No clear effect on SUD outcomes • Difficult to quantify • Highly variable population • Different Rx approaches/referral networks © Alcohol Medical Scholars Program 35 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 © Alcohol Medical Scholars Program 36 Soberlink Blue Device System © Alcohol Medical Scholars Program 37 Physicians Health Programs Efficacy • Only ~20% w/ +UDS at any time during 5 yrs • 70-80% Physicians still licensed/employed at 5 yrs © Alcohol Medical Scholars Program 38 Summary • SUDs are chronic relapsing/remitting conditions • Abstinence monitoring is therapeutic • Monitoring can be chemical and electronic • Monitored abstinence → better outcomes © Alcohol Medical Scholars Program 39 Questions © Alcohol Medical Scholars Program 40
