Download 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
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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
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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
time in a 12-month period:
3 or more of the following at the same
time in a 12-month period:
•
•
Tolerance
•
Withdrawal
Recurrent use resulting in failure to fulfill
major role obligations
•
Recurrent use in situations that are
physically hazardous
•
Taken in larger amounts or over longer period
than intended
•
Recurrent legal problems resulting from
use
•
Persistent desire or unsuccessful efforts to cut
down
•
Continued use despite having persistent
social or interpersonal problems caused or
exacerbated by the substance
•
Great deal of time spent in obtaining, using, and
recovering from substance
•
•
Does not meet criteria for Dependence
Important activities are given up as a result of
substance use
•
Use continues despite knowledge of physical or
psychological problem that is caused or
exacerbated by the substance
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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 substanceinduced 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
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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
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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 of 5%
• death usually from arrhythmias or complicating
illnesses such as pneumonia
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Treatment
• Inpatient vs outpatient
• For all patients:
1. Thiamine 100mg oral/IV daily (before
glucose containing fluids to avoid Wernicke
encephalopathy)
2. Folate 1 mg oral for 3 days
Outpatient Pharmacotherapy
for ETOH Dependence
• Three agents approved by FDA for adjunctive
therapy for the treatment of alcohol
dependence (other agents exist)
– Naltrexone
• Pure opioid receptor antagonist
• Blunts pleasurable effects of alcohol and reduces
cravings
• Reduces relapse and number of drinking days
• CAUTION: Will cause opiate withdrawal !
• BLACK BOX WARNING-acute hepatic toxicity
Naltrexone
PO (ReVia®) / IM Depot (Vivitrol®)
• Typical starting and maintenance oral dose is 50mg
daily
• High risk patients should start at 12.5mg or 25mg and
titrate up
OR
• 380mg IM q 4 weeks
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Outpatient Pharmacotherapy
for ETOH dependence
– Acamprosate (Campral)
• Structural analog of GABA
• Decreases excitatory glutameric neurotransmission
during withdrawal
• 666 mg TID. May need to adjust if pt has diarrhea
– Disulfiram (Antabuse)
• Deterrent- causes flushing, nausea, vomiting,
tachycardia, dyspnea, HA, blurred vision, vertigo and
anxiety 15-30 minutes after ingestion of ETOH
Indications for inpatient alcohol
detoxification
Indications for inpatient alcohol detoxification
- History of severe withdrawal symptoms
- History of alcohol withdrawal seizures or DTs
- Multiple past detoxifications
- Other medical or psychiatric illness
- Recent high levels of alcohol consumption
- Lack of reliable support network
- Pregnancy
Myrick,H. Treatment of alcohol withdrawal. Alcohol Health and Research World, 1998, Vol.22 Issue 1, 38-46.
Treatment
• Gradual Tapering Regimen
- predetermined dosing schedule for several
days as the medication is gradually
discontinued (mostly used outpatient)
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Treatment
One of the following:
1. Chlordiazepoxide (Librium®) 50-100mg every 6 hours for 4 doses then 25-50 mg
every 6 hours for 8 doses
2. Diazepam (Valium®) 10-20mg every 6 hours for 4 doses then 5-10mg every 6
hours for 8 doses
3. Lorazepam (Ativan®) 2-4 mg every 6 hours for 4 doses then 1-2 mg every 8 hours
for 8 doses (medication of choice with hepatic dysfunction)
4. Carbamazepine (Tegretol®)
200 mg QID x 1 day
200 mg TID x 1 day
200 mg BID x 1 day
200 mg BID x 1 day
200 mg daily x 2 days
Asplund.C. Three regimens for alcohol withdrawal and detoxification. The Journal of Family Practice. July 2004. Vol. 53.
Treatment
•
Fixed Schedule Regimen
1. Diazepam (Valium®)
–
–
Dose: 10-25 mg PO q1h prn while awake
Endpoint: until adequate Sedation
2. Lorazepam (Ativan®)
–
–
Dose: 1-2 mg IV q1h prn while awake for 3-5 days
Endpoint: until adequate Sedation
3. Chlordiazepoxide (Librium®)
–
–
Dose: 50 to 100 mg PO/IM/IV q4h (max: 300 mg/day)
Endpoint: until adequate Sedation
Associated with overmedication
Moses,S. Alcohol Withdrawal. www.fpnotebook.com
Treatment
• Symptom-Triggered Regimen
- Pt withdrawal score is determined hourly or
bihourly and the medication is administered
only when the score is elevated >8 on clinical
withdrawal scale
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Treatment
Clinical Institute Withdrawal Assessment
Revised Scale (CIW-Ar)
<10: Very mild withdrawal
10-15: Mild withdrawal
16-20: Modest withdrawal
>20: Severe withdrawal
Smith,M. Management of alcohol intoxication and withdrawal. Principles of Addiction Medicine. 4th edition. 559-572.
Additional Interventions
• Phenobarbital or propofol for refractory DTs
– May require mechanical ventilation and ICU admission
• Phenothiazines and butyrophenones (including
Haldol) –AVOID- lower seizure threshold
• Anticonvulsants- controversial if effective.
– Most seizures are self limited and do not require
medication
– Consider phenytoin
Question # 3
The “five A’s Model” for treating tobacco abuse and
dependence include all of the following except
A – Ask about tobacco use on every patient
B – Advise to quit
C – Assess willingness to made a quit attempt
D – Assist in the quit attempt
E – Arrange for nicotine support group
13
Nicotine
Nicotine
• Tobacco is the chief avoidable cause of illness
and death in our society
• Accounts for more than 435,000 deaths/yr
• 45 million smokers in the United States
– 70% of them want to quit
– 20 million attempt to quit each year, unaided
– only 4-7% are successful
Dependence
among users
nicotine>heroin>cocaine>alcohol>caffeine
Difficulty achieving (alcohol=cocaine=heroin=nicotine)>caffeine
abstinence
Tolerance
(alcohol=heroin=nicotine)>cocaine>caffeine
Physical
alcohol>heroin>nicotine>cocaine>caffeine
withdrawal severity
Deaths
nicotine>alcohol>(cocaine=heroin)>caffeine
Importance in
user's daily life
(alcohol=cocaine=heroin=nicotine)>caffeine
Prevalence
caffeine>nicotine>alcohol>(cocaine=heroin)
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The “5 A's” Model for Treating Tobacco Use and
Dependence
• Ask about tobacco on every patient
• Advise to quit.
• Assess willingness to make a quit
attempt.
• Assist in quit attempt
• Arrange follow up
First-Line Medications
• Nicotine Replacement Therapy (NRT)
-Patch (OTC)
-Gum (OTC)
-Lozenge (OTC)
-Oral Inhaler (Rx)
-Nasal Spray (Rx)
• Non-Nicotine Medications
-Varenicline (Chantix, Rx)
-Bupropion Hydrochloride (Rx)
NRT Medications
•
•
•
•
•
•
•
Use high enough dose
Scheduled dosing better than PRN
Can be combined with Bupropion
Don’t combine with Varenicline
Can be combined with each other
Have very few contraindications
Have no drug-drug interactions
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Nicotine Patch
Dosing:
< 10 cigs/day: 14 mg patch
≥ 10 cigs/day: 21 mg patch
Length of Treatment:
-Up to 12 weeks
Pros:
-Easy, good compliance
-Continuous nicotine delivery
-OTC
Cons:
-Slow onset of action
-Skin reaction
-Insomnia
Nicotine Gum
Dosing:
2mg < 25 cigarettes/day
4mg > 25 cigarettes/day
Length of Treatment:
8-10 weeks
Use:
- Chew and park (Slow, buccal absorption)
- Acidic foods ↓ absorption
Pros:
-Flexible dosing (every 1-2 hours, up to 24
pieces/day)
-Keeps mouth busy
-OTC
Cons:
-Need to use correctly (chew and park)
-Nausea, Heartburn Mouth and throat burning
Nicotine Lozenge
Dosing:
Based on Time To First
Cigarette (TTFC)
4 mg ≤ if 30 mins TTFC
2mg > if 30 mins TTFC
Length of Treatment:
12 weeks
Use:
-Allow to dissolve (Don’t Chew but Suck like a
hard candy.)
Pros:
-Flexible dosing (Up to 20 lozenges/ day) More
discreet than gum
-Keep mouth busy
-OTC
Cons:
Need to use correctly (don’t chew, suck)
May cause insomnia, some nausea, hiccups,
heartburn, coughing
16
Nicotine Nasal Spray
Dosing:
1-2 doses per hour
1 does = 2 spays (1 spray/nostril)
Use enough to control withdrawal symptoms
Length of Treatment:
3-6 months weeks (PDR)
Use:
-Spray (don’t sniff, swallow, or inhale)
-PRN or fixed-schedule (1-2 doses/hour)
Pros:
-Rapid delivery though nasal mucosa
-Flexible dosing (up to 40 doses)
Cons:
-Nasal irritation, rhinitis, coughing, & watering eyes.
-Rx needed
Non-Nicotine Pharmacotherapy
• First-line non-NRT medications
• FDA approved
-Bupropion (Zyban/Wellbutrin)
-Varenicline (Chantix)
• Others (nortriptyline, clonidine)
Bupropion Hydrochloride
• Dopamine and norepinephrine
(noradrenaline) effects
• Reduces cravings, withdrawal
• Improved abstinence rates in trials
• Less weight gain while using
• Start 7-10 days prior to quit date
• Continue 7-12 weeks or longer
( > 6 months)
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Bupropion Precautions
• Contraindicated: seizure disorder, eating
disorders, electrolyte abnormalities, MAO
use
– OK with SSRIs
• NOT dangerous to smoke while taking
• Monitor blood pressure
• Side effects:
– Insomnia (40%)
– Dry mouth
– Headaches
– Rash
Varenicline (Chantix)
• Action at 42 nicotine receptor
• Partial agonist/antagonist
• Releases lower amounts of dopamine into
brain than smoke
– Reduces withdrawal
– Not as addictive as smoke
• Blocks nicotine from binding to receptor
– Prevents reward of smoking
Varenicline (Chantix)
•
•
In 2008 FDA added a warning regarding the use of
varenicline noting that depressed mood, agitation,
changes in behavior, suicidal ideation, & suicide have
been reported in patients attempting to quit smoking
while using varenicline .
FDA recommends that:
1.
2.
Patients tell their healthcare provider about any history of
psychiatric illness prior to starting this medication
Clinicians monitor patients for changes in mood and behavior
when prescribing this medication
18
Electronic Cigarettes
• Introduced into US in 2007
• Use has tripled among teens from 2013-14
• No FDA regulations (yet)
– Can be purchased online
– No age restrictions
• Solvents used to dissolve nicotine are irritants
and may be carcinogenic
• Companies don’t disclose all ingredients of their
electronic cigarette
Electronic Cigarettes
• E-cigs vs. placebo – helped with abstinence
from smoking traditional cigs 30 days or
less but not long term
• Surpasses all other forms of tobacco in
youth population
• Flavors that might appeal to younger age
group (chocolate, bubble gum…)
Question # 4
Which of the following is the most commonly
abused illicit drug in the US?
A – lorazepam
B – cannabinoids (marijuana)
C – opiates (heroin and pain medication)
D – alcohol
E – cocaine
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Marijuana
Marijuana
• Marijuana is the most commonly abused illicit drug in the
United States
• Long-term marijuana abuse can lead to addiction;
– compulsive drug seeking and abuse despite its known
harmful effects upon social functioning
– Long-term marijuana abusers trying to quit report
irritability, sleeplessness, decreased appetite, anxiety, and
drug craving, all of which make it difficult to quit
• Effect on Mental Health:
– Causes increased rates of anxiety, depress, SI, and
schizophrenia.
National Institute on Drug Abuse (NIDA) Website; http://www.nida.nih.gov/infofacts/costs.html
Question # 5
An intoxicated patient is brought to the emergency
department. Ocular examination reveals mydriasis.
This patient was most likely using which of the
following substances?
(A) alcohol
(B) cocaine
(C) opioids
(D) PCP
(E) sedatives
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Opiates
Opiate Addiction Pharmacologic
Interventions
• Opiate Agonists
– Methadone
• Partial Agonist, Partial agonist/antagonist
– buprenorphine
– buprenorphine/naloxone
• Antagonist
– Naltrexone (Vivtrol®)
Why are opioid medications used to treat opioid
addictions?
• Common myth is that all medications used to treat addictions
are simply “substituting one addiction for another”
• Research has found that addiction to opioids results in
significant changes in brain chemistry and function.
• Some of these changes may be permanent, meaning some
individuals may require an opiate to bind to their changed
receptors in order to function normally.
• Medication therapy significantly helps individuals stay in
treatment more consistently, stay healthier, stay out of legal
trouble, and generally function well in society.
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Naltrexone (Vivitrol®)
• Naltrexone is a opiate antagonist
• Tightly blocks mu opioid receptors
• FDA approved for treating alcohol dependence
and opiate dependence
– Decreases cravings in patients who abuse alcohol
• Comes in oral and IM depot formulations
– oral used to trial naltrexone prior to committing to IM
– IM- (Vivitrol®) – depot formulation that is given
monthly. If patients use opiates while on, no high.
• CAUTION: Will cause opiate withdrawal
• BLACK BOX WARNING-acute hepatic
toxicity
What is buprenorphine?
• Buprenorphine is a partial agonist of the mu
opioid receptor
– Binds to and activates the receptor
– Partial agonists have a “ceiling effect:”
• larger doses do not produce greater highs-- has a very
low risk of abuse and overdose.
How does being a partial agonist safeguard
against abuse?
• Features of Suboxone include:
– buprenorphine mixed with the antagonist naloxone (not in pregnancy)
– It must be taken correctly (dissolved under the tongue) to work
correctly.
– If injected, the naloxone will bind to the receptors and put the person
into rapid withdrawal.
– If it is swallowed without dissolving, there is no effect.
– When taken correctly, will act as an agonist and reduce craving and
withdrawal symptoms. Once “ceiling effect” is achieved, other opioids
such as heroin, are not able to bind to the receptors and therefore will
produce no effects.
– If administered while using other opiates, it may act as an antagonist
and put the person into immediate withdrawal.
22
References
•
“Creating Opportunities for Reducing Alcohol Related Harm in the Veteran Community; Session 6: Brief Intervention.”
Version 2.3. Department of Veterans’ Affairs, Australia. December 2002
<http://www.dva.gov.au/health/younger/ mhealth/alcohol/training/session6.htm
•
Thomas Babor, John Higgins-Biddle. Brief Intervention for Hazardous and Harmful Drinking-A Manual for Use in Primary
Care. World Health Organization, Department of Mental Health and Substance Dependence. 2001
•
Gentilello et al. “Alcohol Interventions in a Trauma Center as a Means of Reducing Risk of Injury Recurrence”. Annals Surgery
1999;230:473-483
•
2012 National Survey on Drug Use and Health (NSDUH) sponsored by the U.S. Department of Health and Human Services,
Substance Abuse and Mental Health Services Administration (SAMHSA), Office of Applied Studies (OAS).
http://www.oas.samhsa.gov/nsduh/2k6nsduh/2k6Results.cfm#Ch1
•
National Institute on Drug Abuse (NIDA) Website; http://www.nida.nih.gov/infofacts/costs.html
•
Gold, MS and Aronson, MD. Treatment of Alcohol Use and Dependence. In: UpToDate, Rose, BD (Ed), UpToDate, Waltham,
MA, 2008.
•
Weinhouse, GL. Alcohol Withdrawal Syndromes. In: UpToDate, Rose, BD (Ed), UpToDate, Waltham, MA, 2008.
•
Motivational Interviewing: Resources for clinicians, researchers and trainers. Interaction
Techniques.http://www.motivationalinterview.otg/clinical/interaction.html
•
Fiore MC, Jaén CR, Baker TB, et al. Treating Tobacco Use and Dependence: 2008 Update. Clinical Practice Guideline.
Rockville, MD: U.S. Department of Health and Human Services. Public Health Service. May 2008.
•
American Academy of Family Physicians. Studies Suggest E-Cigarettes Don't Aid Long-term Smoking Cessation: American
Family Physician. http://www.aafp.org/news/health-of-the-public/20150605e-cigstudies.html , June 2015
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