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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.