Download Medical Consequences - GOAL Global Addiction Recovery Partners

Peter Kenneth Ndege, MD
Consulting Physician Kenyatta National Hospital
Honorary Lecturer University of Nairobi School of Medicine
Founder and Executive Director, Center for Addiction Studies in Africa
Email: [email protected]
Tel: +254 722 642 744
Medical Comorbidities
Medical Co-Morbidities in the
Substance Using Patient
GOALS
• Understand that alcohol and drug use can
become disorders, that are chronic medical
conditions
• Understand the epidemiology and harm
associated with alcohol and other drug use
• Understand the complex relationship between
alcohol and other drug use with other disease
processes
Medical Comorbidities
OUTLINE
• Discuss the harm and other diseases
associated with the use of the “big three”
substances:
– Alcohol
– Opioids
– Cocaine
• Discuss (briefly!) the harm and other
diseases associated with the use of “non-bigthree” substances
• Discuss the complexity of defining and
clinically dealing with co-morbidities
• Summarize and further discussion
Medical Comorbidities
BACKGROUND
• Alcohol and other drug use patients who
present for treatment often have other
medical problems
• These medical conditions are consequences
– of both their current and their past high risk
behaviors
– Injection or route of drug use
– direct toxic effects of illicit drugs or caustic agents
• Clinicians should screen for and treat (or refer
for treatment) common comorbid medical
conditions
Medical Comorbidities
BACKGROUND
• Treating alcohol and other drug use in an
office based settings provides a unique
opportunity to integrate the delivery of
substance abuse treatment with screening
and management, increasing effectiveness
and patient compliance
• Clinicians should know the common comorbid
medical conditions found in alcohol and other
drug use patients and promote preventive
health care for these patients
Medical Comorbidities
Medical Comorbidities
ALCOHOL USE and DISORDERS:
HARM and
MEDICAL CO-MORBIDITIES
Medical Harm of Hazardous Drinking
• Hazardous drinking is
associated with an
increased risk for:
–
–
–
–
–
–
–
All-cause mortality
Hypertension
Cardiomyopathy
Diabetes
Trauma
Stroke
More serious alcohol
disorders
– Cancers
~ particularly upper GI
and breast cancers
Medical Comorbidities
Figured from Babor et al (World Health Organization), AUDIT Guidelines for Use in Primary Care, 2001
Brief Primer of Physical Exam Features
for Alcohol Use
•
•
•
•
•
•
•
•
Tachycardias
Tremor
Hypertension
Hepatosplenomegaly and a tender liver edge
Peripheral neuropathy
Spider angiomata
Conjunctival injection
Unexplained trauma
Medical Comorbidities
Some Associations with Hazardous
Drinking
•
•
•
•
•
•
Injuries
Infections
Gastritis and duodenitis
Hematologic effects
Early hepatic injury
Cardiac effects
Medical Comorbidities
Injuries
• Due to
– Fights and homicide attempts
– Auto accidents
~ 50% of injuries involve some alcohol consumption
– Drowning and other accidents
– Suicide attempts
• Patient neglects injuries until the next day
– Injuries not painful until the following day
Medical Comorbidities
Infections
• Heavy drinkers are more susceptible to
pneumonia and other infections
– Pneumococcal infections
– Pseudomonas infections
– Gram-negative infections
• Heavy drinkers have impaired immunity
–
–
–
–
Increased sequestration of neutrophils
Decreased fixed macrophage phagocytic capacity
Decreased white blood cell production
Decreased cell mediated immunity
Medical Comorbidities
Gastritis and Duodenitis
• Most commonly observed effects
–
–
–
–
Epigastric pain
Morning nausea and vomiting
Melena
Gastric Esophageal Reflux Disease (GERD)
• Eventually
– Consequences of liver disease including varices
and portal hypertension
Medical Comorbidities
Hematologic Effects
• Macrocytosis
– Due to direct cytotoxic effects
– Due to vitamin deficencies
• Decreased platelets (may be down to 30,000
to 50,000)
• Anemia usually due to
– Bleeding from gastrointestinal tract
– Folic acid deficiency
– Also remember other vitamin deficiencies
Medical Comorbidities
Hepatic Effects
• Alcoholic hepatitis in 10% to 15% of alcoholics
–
–
–
–
Increased liver enzymes and bilirubin
Enlarged tender liver
80% can progress to cirrhosis
20% result in liver failure
• Cirrhosis
– 40% have a 5-year survival if they continue to drink
– 77% have a 5-year survival if they stop drinking
• Liver cancer (also esophageal, laryngeal, and
nasopharyngeal cancers)
Medical Comorbidities
Early Hepatic Markers
• Increased gamma-glutamyl transpeptidase
(GGT) up to 3 times normal in 20% to 30% of
heavy drinkers
• Liver enzymes
– AST/SGOT > ALT/SGPT
• Production Problems
– Coagulopathies in end stage alcoholic liver
disease
• Don’t forget the pancreas!
– Acute and chronic pancreatitis
– Complications:
~ Diabetes, Steatorrhea, Pseudocyst
Medical Comorbidities
Cardiac Effects
• Increased blood pressure
– From withdrawal
– Without withdrawal
• Increased ischemic heart disease
• Cardiomyopathy
• Arrhythmias
–
–
–
–
Especially tachyarrhythmias
Atrial flutter
Atrial fibrillation – “Holiday Heart”
Paroxysmal Atrial Tachycardia
Medical Comorbidities
Nervous System Effects
•
•
•
•
•
Headaches
Sleep disorders
Wernicke syndrome
Korsakoff psychosis
Organic brain disease
– Cognitive
– Memory
• Peripheral neuropathy
Medical Comorbidities
Nervous System Effects
C – Confusion
O – Ophthalmalplegia
A – Ataxia
T – Early Thiamine Deficiency (Wernicke’s)
R – Retrograde Amnesia
A – Anterograde Amnesia
C – Confabulation and meager Conversation
K – Korsakoff Syndrome
(Also lack of INsight and Greater apathy)
Medical Comorbidities
Fetal Alcohol Spectrum
• Growth retardation
– Head circumference, height, and weight less than tenth
percentile
• Facial malformation
– Palpebral fissure
– Philtrum
– Thin upper lip
• Neurodevelopmental delay
–
–
–
–
–
–
Intelligence
Boundaries
Memory
Aggression
Motor skills
Right/wrong
Medical Comorbidities
Fetal Alcohol Spectrum
• Defects occur before most women know
they are pregnant
• No known safe level of drinking for pregnant
women
– Binging may be worse than daily drinking
– The higher the blood level of alcohol, the greater
the chance of damage
Medical Comorbidities
Associations with Other Diseases
• There exist many diseases that co-exist with
alcohol use disorders that may complicate the
treatment of either disorder
–
–
–
–
–
HIV
Major Depressive Disorder
Hepatitis
Cirrhosis
(Social morbidities – homelessness)
• Emerging research is examining treatment
modalities for co-morbid conditions
Medical Comorbidities
Alcohol Use of the Elderly
• Of the 80% of elderly persons who have ever
consumed alcohol, two-thirds continue to drink, often
at hazardous levels of consumption
• Of the elderly:
– 15% drink alcohol at levels considered hazardous
– 5% have diagnosis of abuse or dependence
– many more drink sporadically in binge episodes
• The problem drinking elderly consist of :
– 30% of the hospitalized elderly
– 10% of the elderly primary care
– 50% of the mentally ill elderly
Medical Comorbidities
Alcohol Use of the Elderly
• With mild alcohol consumption, compared to
the non-elderly, the elderly are at increased
risk for:
– greater numbers of harmful medication
interactions
– increased falls
– more cognitive deficits
– greater sleep impairments
– increased sexual dysfunction
– greater numbers of hip fractures
– more psychiatric problems compared to younger
populations
Medical Comorbidities
Alcohol and Breast Cancer
• More than 30 epidemiologic studies have evaluated a
possible association between alcohol intake and
breast cancer
• Alcohol consumption is associated with a linear
increase in breast cancer incidence in women over
the range of consumption reported by most women
(Smith-Warner)
• In a recent study of 70,000 women, a drink a day
increased their risk by 10 percent, and more than
three daily drinks by 30 percent (Lew)
• Women's Health Study, daily alcohol intake again
was shown to modestly increase risk (Zhang)
– The relative risk for each 10 gram increase in daily alcohol
intake was 1.11 (95% CI 1.03-1.20) for ER and PR+ cancer
Medical Comorbidities
Smith-Warner SA, JAMA 1998; Lew: Ameri. Assoc. for Cancer Research 2008; Zhang SM, Am J Epidemiol. 2007
Societal Costs of Alcohol Dependence
Total Cost: $184.6 Billion
$24,093
(13%)
$10,085
(5%)
$7,466*
(4%)
$15,963
(9%)
$2,909
(2%)
$1,253
(1%)
$36,499
(20%)
Specialty alcohol services
Medical consequences (except FAS)
Medical consequences of FAS
Lost future earnings due to
premature deaths
Lost earnings due to
alcohol-related illness
Lost earnings due to FAS
Lost earnings due to crime/victims
Crashes, fires, criminal justice, etc
$86,368
(47%)
Medical Comorbidities
Harwood H, NIH Publication No. 98-4327 1998
Medical Comorbidities
OPIOID USE and DISORDERS:
HARM and
MEDICAL CO-MORBIDITIES
Balloons, Bags, and Pills
Medical Comorbidities
New Prescription Drug Users
Past Year Initiation of Non-Medical Use of Prescription-type Psycho-pharmaceutics
Age 12 or Older: In Thousands from 1965 to 2005
3000
New Users (x 1000)
2500
2000
1500
1000
500
0
6 5 96 7 96 9 97 1 97 3 97 5 97 7 97 9 98 1 98 3 98 5 98 7 98 9 99 1 99 3 99 5 99 7 99 9 00 1 00 3 00 5
19
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
2
2
Analgesics
Tranquilizers
Stimulants
Sedatives
Medical Comorbidities
NSDUH, SAMHSA, 2005
Opioid Withdrawal
•
•
•
•
•
•
•
•
•
•
•
•
Severe flu-like symptoms including shaking chills
Anxiety
Hyperactivity
Drooling
Lacrimation/Tearing
Rhinorrhea/Runny nose
Anorexia
Nausea
Vomiting
Diarrhea
Myalgias
Muscle spasms
Medical Comorbidities
Street Stuff
• Sold in “stamp bags” and “balloons”
• A opioid user will maintain a steady supply of
opioids - not a binge addiction
• Combination of abuse is important
– Can be combined with a stimulant (ala speedball)
– Rarely with a depressant
Medical Comorbidities
Changing Route of Heroin Administration
Injection
Inhalation
Smoking
Oral
Other
100%
80%
60%
40%
20%
0%
1992 1993 1994 1995 1996 1997 1998 1999 2000
Medical Comorbidities
Treatment Episode Data System, 1992-2000
Hepatitis B
• DEFINITION
– Hepatitis B (HBV) is a blood borne viral pathogen
• EPIDEMIOLOGY
–
–
–
–
Estimated 1.25 million chronically infected in U.S.
Approximately 300,000 new cases per year
Transmission by blood borne, sexual, or perinatal
Approximately 50% of active injection drug users
have serological evidence of prior exposure to
HBV
Medical Comorbidities
Hepatitis B – Clinical Course
• Early and mild viral hepatitis manifests with
symptoms of hepatic inflammation and damage with
elevated serum transaminases (> 10-20x normal)
• Chronic viral hepatitis manifests as chronic liver
disease with portal hypertension and poor hepatic
synthetic function
• Likelihood of developing chronic infection is related to
age:
– 80 to 90% of infants infected develop chronic disease
– only 2 -10% of infected adults progress to chronic disease
Medical Comorbidities
Acute Hepatitis B Infection with
Recovery
Symptoms
HBeAg
anti-HBe
Total anti-HBc
Titer
0
4
anti-HBs
IgM anti-HBc
HBsAg
8
12 16 20 24 28 32 36
Medicalafter
Comorbidities
Weeks
Exposure
52
100
Progression to Chronic Hepatitis B
Infection
Acute
(6 months)
Chronic
(Years)
HBeAg
anti-HBe
HBsAg
Titer
Total antiHBc
IgM anti-HBc
0 4 8 12 16 20 24 28
32 36
52
Medical
Comorbidities
Weeks after Exposure
Years
Hepatitis C - Epidemiology
• Hepatitis C (HCV) is the most common
bloodborne infection in the U.S.
– 1.8% of the U.S. population are infected
– Of the 3.9 million people in the U.S. who are infected,
2.7 million are chronically infected
• At least 30,000 new infections (cases) annually
• Morbidity and mortality
– Chronic liver disease – HCV-related: 40% - 60%
– Deaths HCV chronic disease/year: 8,000-10,000
– Most common reason for (~40%) liver transplants
Medical Comorbidities
Hepatitis C - Epidemiology
• In some series, greater than 90% of injection
drug users have antibodies to HCV
• HCV is more prevalent and more infectious
than HIV
– with 170,000,000 infected with HCV worldwide
– In injection drug users, infection results from
contact with contaminated needles, syringes,
paraphernalia
– Blood and blood products are more infectious than
saliva, vaginal secretions, or semen
Medical Comorbidities
Hepatitis C: Acute Infection with
Recovery
antiHCV
Symptoms +/-
Titer
HCV RNA
ALT
Normal
0
1
2
3
4
Months
5
6
1
Medical Comorbidities
Time after Exposure
2
3
Years
4
Hepatitis C: Progression to Chronic
Infection
antiHCV
Symptoms +/-
Titer
HCV RNA
ALT
Normal
0
1
2
3
4
Months
5
6
1
Medical
Comorbidities
Time after
Exposure
2
3
Years
4
CHRONIC Hepatitis C: Clinical Course
• Symptoms: 50% of patients report chronic
fatigue and abdominal discomfort
• Serum transaminases:
– Persistently elevated
– intermittently elevated
– normal
- 43%
- 42%
- 15%
• Risk factors for disease progression:
– alcohol use, hepatitis B virus, HIV (modifiable
risks)
– < 40 years old when infected, male sex
Medical Comorbidities
30 Year Progression of
Chronic Hepatitis C
Acute hepatitis C
>85% (10 years)
Chronic hepatitis C
20% - >50% (20 years)
Cirrhosis
< 20%
< 20%
Hepatic failure HCC (30 years)
Medical Comorbidities
Hepatitis C: HIV Co-infection
• 30% of HIV positive patients in the U.S. are
co-infected with HCV
• In HIV infected injecting drug users, the
prevalence of HCV is 50 to 90%
• HIV has a significant effect on progression of
liver disease in HCV-infected patients
• Must balance hepatotoxicity of HIV therapy
with need to treat HIV in HCV-infected
patients, while HIV therapy can worsen the
symptoms of HCV
Medical Comorbidities
Hepatitis C: Treatment in Drug Users
• Standard recommendation: >/=6 months
“clean”
• Arguments for not treating: poor adherence,
side effects, re-infection, non-urgent
treatment – but data supporting these
arguments are lacking, some drug users may
do well
• Treatment should be based on individual riskbenefit assessments
– Edlin BR et al. NEJM 345:211-214, 2001
Medical Comorbidities
Hepatitis C: Treatment in Drug Users
• The 2002 NIH Consensus Guideline on the
Treatment of HCV is available at
– Active injecting drug use should not exclude
patients from HCV treatment
– HCV treatment of active injecting drug users
should be considered on a case-by-case basis
– Web site: http://www.guideline.gov
Medical Comorbidities
HIV/AIDS: Epidemiology
• Approximately 1.1 million cases in the US
• 0.7 - 34% (median 15%) seroprevalence
entering substance abuse treatment
• IV Drug Use (IVDU) associations
– From 1993-1999 IVDU persons living with AIDS
jumped from 48,244 to 88,540
– 15-20% long-term IVDUs infected (43% of women
AIDS)
– 25% of the approximately 40,000 new HIV
infections/year through IVDU
Medical Comorbidities
HIV/AIDS: Treatment in Drug Users
• High risk for non-receipt of antiretrovirals:
– 2-3 times as likely not to be on antiretroviral
treatment if not in SA treatment
• High risk for non-adherence:
– 1998 CDC guidelines recommend delaying
HAART until active opioid use has been
addressed
Medical Comorbidities
Tuberculosis: Epidemiology
• Worldwide, approximately 2 billion people
(1/3 of world population) are infected with M.
tuberculosis
• Since the HIV pandemic began in the U.S. in
the mid-1980s, there has been increased
concern about TB since it is more common in
this population
• Tuberculosis is also more common in alcohol
users and injection drug users in general and
in patients with alcohol use disorders
Medical Comorbidities
Opioid Dependence is Costly
• Medical Costs
• Mental illness
• An environmental and disease stressor
• Co-morbid interactions
• Trauma and infections
• Hepatitis and HIV
• Medical Cost
• $20 billion per year total costs
• $1.2 billion per year health care costs
Medical Comorbidities
How Do They Get Hooked?
Medical Comorbidities
COCAINE USE and DISORDERS:
HARM and
MEDICAL CO-MORBIDITIES
Cocaine
• Cocaine is a product of the alkaloid extract
from leaves of the Erthroxylon plant originally
grown in the Andes Mountains of western
South America
• Evidence of use in 500 AD - coca leaves in
tombs in Bolivia and Peru
• Cocaine was used by Sigmund Freud
• William Halsted used cocaine for anesthesia
in 1884
• Today, cocaine is still used (sparingly) as a
local anesthetic in the upper respiratory tract
in concentrations of 4%
Medical Comorbidities
Cocaine
• As many as 20 million people in the United States
have used cocaine at least once in their lifetime
• In New York City, cocaine use is extremely prevalent
and in one survey 26% of people sustaining fatal
injuries had evidence of cocaine metabolites in their
urine or blood
• Of pregnant women, an estimated 11% are
substance abusers and cocaine is the most
commonly abused drug other than alcohol
• Cocaine has increasingly been associated with
criminal behavior
Medical Comorbidities
Street Stuff
• Cocaine exists in many forms
– Powder
– Freebase
– Rock (crack)
• Crack is convenient
– The soft mass that develops becomes hard when
dry
– The crack can then be smoked (potent!)
– Usually it is smoked in a glass pipe or regular pipe
or by mixing it with tobacco or marijuana
– Crack is thought to be termed by the sound of
cocaine crystals ‘popping” when smoked
Medical Comorbidities
Cocaine Intoxication
• Clinically significant maladaptive behavioral or
psychological changes that developed during, or
shortly after, use of cocaine.
• Two (or more) of the following developing during or
shortly after cocaine use:
–
–
–
–
–
–
–
–
Tachycardia or bradycardia
Pupillary dilation
Elevated or lowered blood pressure
Perspiration or chills
Nausea or vomiting
Evidence of weight loss
Psychomotor agitation or retardation
Muscular weakness, respiratory depression, chest pain, or
cardiac arrhythmias
– Confusion, seizures, dyskinesias, dystonias, or coma
Medical Comorbidities
Morbidity and Co-morbidity of Cocaine
• Can be deadly in intoxication
– Mainly due to adrenergic stimulus
~ Think that you are injecting epinephrine into the blood
– Morbidity can occur secondary to social
consequences as well as direct effects
• Long term
–
–
–
–
Cardiac - cardiomyopathy, hypertension, arrythmias
Pulmonary – if smoked
Renal – rhabdomyolysis and “tea colored urine”
Cerebral – TIAs and strokes
Medical Comorbidities
Cocaine Physical Exam
•
•
•
•
Track marks (injection use)
Burnt lips/face/hair
Hand findings
Look for nasal perforation or hyperemic nares
Medical Comorbidities
OTHER DRUG CO-MORBIDITIES
(briefly!)
Methamphetamine:
Don’t be fool!!!
Faces to remember
Medical Comorbidities
Methamphetamine effects on families
Children of Methamphetamine Addicts are
filling the foster care system across the country
Medical Comorbidities
Methamphetamine effects
Disrupt sleeping patterns, suppresses appetite, and
causes irritability/aggression
Medical Comorbidities
Methamphetamine effects on the state of mind
Psychotic, Paranoia, Hallucination, and agitation
Medical Comorbidities
Methamphetamine effects on the Penal System
The Penal System is flooding with Methamphetamine
Addicts. Recovery Centers are increasing at an
alarming rate.
Medical Comorbidities
Methamphetamine effects on health
Increase pulse rate, increase blood pressure, increase
hyperthermia, stroke and death
Medical Comorbidities
Methamphetamine effects on behavior
Repetitive behavior, obsessive behavior, and
delusional thinking
Medical Comorbidities
Methamphetamine effects on health
Nervousness, anxiety, convulsions and Heart
attack
Medical Comorbidities
Methamphetamine effects on the community
Homelessness, theft, and crime
Medical Comorbidities
Methamphetamine effects on society
Sexual Transmitted Diseases to include
HIV/AIDS
Medical Comorbidities
Methamphetamine effects on dreams
loss of job, loss of ambition, and
loss
of direction
Medical Comorbidities
Methamphetamine effects on recidivism
Chronic Relapse, loss hope,
and loss
dreams
Medical Comorbidities
Medical Comorbidities
The term”narcotic”
generally refers to
opium and to painkilling drugs made of
opium. These include
heroin, morphine, and
codeine. Codeine is
legally, but not
medically, classified in
the United States, but
is an illicit narcotic
drug. Narcotics
depress the brain and
result in feelings of
pleasure, strength and
superiority, followed
by lethargy,
drowsiness, confusion,
and depression of the
heart rate.
Intravenous (IV)
drug users risk
exposure to the
AIDS virus when
they use or share
contaminated
needles. IV drug
users form the
group with the
fastest growing
number of persons
with AIDS (PWAs).
Medical Comorbidities
Inflammation of the liver is one of the
most common problems seen in heroin
addicts. It is caused by a virus which is
transmitted from one person to another
through contaminated needles. The
liver becomes swollen, and irregular
patters of light-colored inflammation
can be seen seen scattered throughout.
Hepatitis causes weakness, loss of
appetite, tenderness in the abdomen,
dark-colored
urine, and a yellowish
Medical Comorbidities
change in the color of the skin and
A dangerous
complication can occur
when blood cloths in
the veins of an addict’s
arms break off and
float through the
bloodstream to the
heart and lungs. A
well-formed blood clot
can be seen extending
almost completely
through the course of
this pulmonary artery
within the lungs. This
patient will die
because the blood
cloth has shut off the
Medical Comorbidities
blood supply to the
When germs are injected into the
bloodstream from an unsterile
needle, they may travel through the
body and lodge in the brain. In this
illustration, note the ragged,
abscessed cavity filled with pus.
Medical Comorbidities
High
fever, convulsions, coma, and
If germs enter the bloodstream
from an unclean needle, they
may spread throughout the body
and lodge in the valves of the
heart, causing a serious infection
know as bacterial edocarditis.
The warty-like growths seen on
these heart valves produce
symptoms of fever, weakness,
heart failure, and death.
Tiny showers of clots and bacteria may be released from
the growths on the infected heart valves. They may
then spread to the kidneys and spleen. The results of
these showers are seen as multiple red spots in the
kidney, and as a grayish area of dead tissue at the
Medical Comorbidities
uppermost portion of the spleen.
This usually results in
the death of a drug user.
When an addict’s veins are repeatedly punctured,
particularly by unsterile needles, blood clots and
Medical Comorbidities
scarring may occur within
the veins.
TOBACCO
Medical Comorbidities
80
• Buerger’s Disease. Blood vessels get blocked
and this starves the body parts which may lead
to amputation of arms.
Medical Comorbidities
81
Medical Comorbidities
82
Smokeless tobacco can cause oral cancer, gum disease, increased tooth
decay and periodontal bone loss. It may also lead to an increased risk of the
upper digestive tract
Medical Comorbidities
83
Medical Comorbidities
84
Medical Comorbidities
85
Khat (Miraa)
Medical Comorbidities
86
Medical Comorbidities
87
Short-term Effects of Miraa
•
Excitation – likened to an
intense sexual orgasm and
sensation of extreme mental
and physical power.
• Palpitation, irregular
heartbeats and high blood
pressure
•
Rapid talking, Restlessness
• Increased rate of respiration
•
Lack of sleep (insomnia)
• Browning of teeth and foul
breath
•
Poor concentration
•
False feeling of well-being
• Psychological dependence
Medical Comorbidities
88
Long term effects of Miraa
•
•
Memory loss, personality
disorders, depression
Mouth, tongue and lip ulcers
which may predisposes an
individual to HIV/AIDS
•
Oral cancer
•
Nerve damage leading to
numbness
• Hallucinations
• Excessive irritability
• Chronic constipation-slow
passage of food through
the stomach and intestines
Medical Comorbidities
89
Inhalants
Medical Comorbidities
90
Medical Comorbidities
91
Inhalants: Classification
• Inhalants are breathable chemical vapors that produce psychoactive
(mind altering) effects
• A variety of products common in the home and in the workplace contain
substances that can be inhaled
• Inhalants fall into the following categories:
• Volatile Solvents
• • Industrial or household solvents, including paint thinners or removers,
degreasers, dry-cleaning fluids, gasoline, and glue
• • Art or office supply solvents, including correction fluids, felt-tip-marker
fluid, and electronic contact cleaners
Medical Comorbidities
92
Inhalants: Classification…
• Aerosols
Household aerosol propellants and associated solvents in items
such as spray paints, hair or deodorant sprays, fabric protector
sprays, aerosol computer cleaning products, and vegetable oil
sprays
•
•
Gases
Gases used in household or commercial products, including butane
lighters and propane tanks, whipping cream aerosols or dispensers
(whippets), and refrigerant gases • Medical anesthetic gases, such as
ether, chloroform, halothane, and nitrous oxide (“laughing gas”)
Medical Comorbidities
93
Inhalants: Classification…
• Nitrites
• Organic nitrites are volatiles that include cyclohexyl,
butyl, and amyl nitrites, commonly known as
“poppers.” Amyl nitrite is still used in certain
diagnostic medical procedures.
• Volatile nitrites are often sold in small brown bottles
labeled as “video head cleaner,” “room odorizer,”
“leather cleaner,” or “liquid aroma.”
Medical Comorbidities
94
Health Hazards
Harmful irreversible effects that may be caused by abuse of specific
solvents include:
 Hearing loss—toluene (spray paints, glues, dewaxers) and
trichloroethylene (dry-cleaning chemicals, correction fluids)
 Peripheral neuropathies, or limb spasms—hexane (glues, gasoline)
and nitrous oxide (whipped cream dispensers, gas cylinders)
 Central nervous system or brain damage—toluene (spray paints, glues,
dewaxers)
 Bone marrow damage—benzene (gasoline)
Medical Comorbidities
95
Health Hazards…
Serious but potentially reversible effects include:
•
Liver and kidney damage—toluene containing substances and
chlorinated hydrocarbons (correction fluids, dry-cleaning fluids)
•
Blood oxygen depletion—aliphatic nitrites (known on the street as
poppers, bold, and rush) and methylene chloride (varnish removers,
paint thinners)
Medical Comorbidities
96
ADDRESSING CO-MORBIDITIES
TREATMENTS IN PRACTICE
CROSSING THE QUALITY CHASM
• “Quality problems occur
typically not because of failure
of goodwill, knowledge, effort
or resources devoted to health
care, but because of
fundamental shortcomings in
the ways care is organized”
• Trying harder will not work:
changing systems of care will!
a new HEALTH system for the 21st century (IOM, 2001)
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SIX AIMS OF QUALITY HEALTH CARE
1. Safe – avoids injuries from care
2. Effective – provides care based on scientific
knowledge and avoids services not likely to
help
3. Patient-centered – respects and responds to
patient preferences, needs, and values
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SIX AIMS
4. Timely – reduces waits and sometimes
harmful delays for those receiving and giving
care
5. Efficient – avoids waste, including waste of
equipment, supplies, ideas and energy
6. Equitable – care does not vary in quality due
to personal characteristics (gender, ethnicity,
geographic location, or socio-economic
status)
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SIX CRITICAL PATHWAYS
FOR ACHIEVING AIMS AND RULES
• New ways of delivering care
• Effective use of information technology (IT)
• Managing the clinical knowledge, skills, and
deployment of the workforce
• Effective teams and coordination of care
across patient conditions, services and
settings
• Improvements in how quality is measured
• Payment methods conducive to good quality
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END
GOD BLESS YOU
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Medical Comorbidities
MEDICAL AND SUBSTANCE-USE
CONDITIONS
• Pervasive
– More than 33 million Americans treated annually
~ 20 % of all working age adults (18-54)
~ 21 % of adolescents
~ Millions more fail to receive care
• Frequently intertwined
– 15 - 40 % co-occurrence
• Often influence general health
– frequently accompany chronic illnesses
– 20% of heart attack patients suffer from depression, tripling
risk of death
– associated with leading causes of outpatient visits; e.g.,
headache, fatigue and pain
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MENTAL, SUBSTANCE-USE, &
GENERAL HEALTH
CONCLUSION
• Improving care delivery and outcomes for any one of
mental health, substance use, and general health
disorders depends upon improving care and
outcomes for the other two.
OVERARCHING RECOMMENDATION
• Health care for general, mental, and substance-use
problems and illnesses must be delivered with an
understanding of the inherent interactions between
the mind/brain and the rest of the body.
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CH 3. PATIENT CENTERED CARE
RECOMMENDATIONS FOR CLINICIANS
• Incorporate informed, patient-centered
decision making throughout practices
• To ensure informed decision making
• Adopt recovery-oriented and illness selfmanagement practices that support patient
preferences for treatment
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CH 3. PATIENT CENTERED CARE
RECOMMENDATIONS FOR CLINICIANS
• Coercion should be avoided whenever
possible.
• When coercion is legally authorized, patientcentered care is still applicable and should be
undertaken.
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CH 5. COORDINATING CARE
RECOMMENDATIONS FOR CLINICIANS
• Implement policies and incentives to
continually increase collaboration among
providers to achieve evidence-based
screening and care of patients.
• Clinical practices should transition along a
continuum of evidence-based coordination
models:
–
–
–
–
Formal agreements
Case management
Co-location
Integrated practices
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Core Components of Comprehensive
Services
Medical
Financial
Housing &
Transportation
Core
Treatment
Intake
Assessment
Child
Care
Treatment
Plans
Group/Individual
Counseling
Abstinence
Based
Pharmacotherapy
Mental
Health
Urine
Monitoring
Case
Management
Continuing
Care
Self-Help
(AA/NA)
Family
AIDS/HIV
Risks
Vocational
Educational
Legal
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Etheridge, Hubbard, Anderson, Craddock, & Flynn, 1997 (PAB).
Substance Abuse is a Chronic Medical
Condition
• Type 1 Diabetes:
– 30% to 50% relapse each year requiring additional medical
care
– Significant societal consequences
• Hypertension and Asthma:
– 50% to 70% relapse each year requiring additional medical
care
– Significant societal consequences
• Alcohol and Other Drug Diseases.
– 40% to 60% relapse each year
– Significant societal consequences
– Few patients receive treatment!
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McLellan, JAMA, 2000