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Back to Basics: Substance Use/Abuse/Withdrawal Melanie Willows BSc CCFP CCSAM Diplomate ABAM Clinical Director Substance Use and Concurrent Disorders Program The Royal Assistant Professor University of Ottawa April 7, 2016 LMCC Key Objectives • Given a patient with a substance-related or addictive disorder or suspected substance withdrawal, the candidate will be able to identify the issue, potential consequences and the need to provide immediate and continuing support and intervention. LMCC Enabling Objectives Given a patient with a substance-related or addictive disorder, the candidate will • List and interpret critical clinical findings, including those derived from: – a history and/or a collateral history relevant to the presenting problem and pertinent to previous, possible addictive behavior (including relevant screening tools); – a physical examination aimed at determining the duration and severity of any problems with substance abuse or addiction and potential withdrawal and co-morbidities, if necessary; • List and interpret critical investigations, including – laboratory or diagnostic imaging (e.g., drug screening, liver function studies); • Construct an effective initial management plan, including – acting on opportunities for brief intervention with regards to behavioral modification and appropriate pharmacological intervention (e.g., nicotine replacement therapy); – determining whether the patient or family members require specialized services such as addiction treatment. The patient may also require individual, family, community, psychological or other medical services. LMCC Enabling Objectives • Given a patient with suspected substance withdrawal, the candidate will • • • • • • list and interpret critical clinical findings, including those derived from: a thorough medical, family and social history (see also Substance-Related and Addictive Disorders ) ; collateral history, if indicated; a physical examination with particular attention to mental status examination and autonomic instability; list and interpret critical investigations, including drug screening; use of appropriate screening tools (e.g., MMSE, CAGE, withdrawal assessment tools); laboratory or other investigative tests to screen for organ damage and other complications as appropriate (e.g., liver function tests, chest radiography); construct an effective management plan, including supportive measures if required acutely (e.g., airway, fluid resuscitation, pain management); a safe environment (e.g.: hospitalization, recovery centers); appropriate pharmacological intervention (e.g., thiamine, long-acting benzodiazepines, sedation); referral for specialized care (e.g., addiction programs, family counseling, mental health services), if necessary. Question 1 • 35 year old woman has been diagnosed with an alcohol use disorder. The primary neurotransmitter that will flood her brain reward centre is: A) serotonin B) norepinephrine C) dopamine D) GABBA E) glutamate Question 2 27 year old man’s father has an alcohol use disorder. The patient has major depression and has many peers who use substances. He started drinking at the age of 14. Contribution of genetic risk to total risk of developing an alcohol use disorder is estimated to be: A)10% B) 20% C) 35% D) 50% E) 75% Question 3 • Mary is a 43 year old woman. Her mother and father both had alcohol problems. Her home life was filled with fighting and chaos. She was sexually abused by her uncle and grandfather. Mary started using drugs and alcohol when she was 13. Mary was diagnosed with a mental health disorder in her early 20’s. Which of the following mental health disorders is associated with the highest risk of lifetime substance use disorder: A) Social Anxiety Disorder B) Bulimia Nervosa C) Attention Deficit Hyperactivity Disorder D) Schizophrenia E) Major Depression Question 4 • An example of a process addiction that can be found in the DSM 5 is: A) Alcohol Use Disorder B) Compulsive Shopping Disorder C) Gambling Disorder D) Internet Use Disorder E) Sex Addiction Disorder Question 5 • 54 year old man with a 30 year history of daily drinking stops drinking for 6 months. Despite taking naltrexone, he still experiences cravings to drink three times per week. What is his diagnosis? A) Alcohol Use Disorder B) Alcohol Use Disorder in Early Remission C) Alcohol Use Disorder in Sustained Remission D) Alcohol Use Disorder in Early Remission in a Controlled Environment E) Alcohol Use Disorder in Sustained Remission on Maintenance Therapy Question 6 • 52 year old male presents with a history of drinking one mickey (13oz/375ml) of vodka and one 750ml bottle of wine daily. How many standard drinks is he consuming per day? A) 8 B) 10 C) 13 D) 16 E) 26 Question 7 • 72 year old woman is drinking 1.5L of wine daily. How many standard drinks is she consuming per day? A) 5 B) 8 C) 10 D) 15 E) 16 Question 8 • 28 year old woman is taking 6mg of clonazepam daily. Which of the following substances would have cross-tolerance with clonazepam? A) Alcohol B) Amphetamines C) Cocaine D) Marijuana E) Opioids Question 9 • A 45 year old married man presents to your office for a physical exam. As part of the exam you screen for an alcohol use disorder. Which screening tool are you most likely to use: A) AUDIT B) CAGE C) CIWA D) DAST E) COWS Question 10 • 35 year old woman is drinking 26 oz. of vodka on a daily basis. She would like to stop drinking. You review her risk factors for an alcohol withdrawal seizure. You are most concerned about: A) the amount she is drinking B) how long she has been drinking C) previous history of tremor D) previous history of alcohol withdrawal seizure E) family history of alcohol withdrawal seizure Question 11 • 18 year old man presents with fever, chills, dilated pupils, nausea, vomiting, diarrhea, and tremor. You assess the severity of his withdrawal symptoms using the following scale: A) AUDIT B) CAGE C) CIWA D) DAST E) COWS Question 12 • 29 year old woman presents with diaphoresis, tremor, headache, visual hallucinations, and tachycardia. You decided to assess the severity of her withdrawal symptoms with the following scale: A) AUDIT B) CAGE C) CIWA D) DAST E) COWS Question 13 • 54 year old man presents with hypertension, insomnia, gastroesophageal reflux, and elevated triglycerides. You suspect he may have a substance use disorder. What is the most likely substance: A) Alcohol B) Benzodiazepines C) Cocaine D) Marijuana E) Opioids Question 14 • 64 year old woman presents jaundiced with ascites. What laboratory bloodwork will confirm your suspected diagnosis. A) MCV, GGT B) AST, ALT C) Bilirubin, Albumin D) Hepatitis B, Hepatitis C E) Amylase, CBC Question 15 • 56 year old woman with a known alcohol use disorder presents with opthalmoplegia, confusion and ataxia. This could have been prevented by administering: A) Diazepam B) Thiamine C) Vitamin B12 D) IV Glucose E) Naltrexone Question 16 • 49 year old woman presents to the emergency room in alcohol withdrawal. She has a history of two previous withdrawal seizures. Which two medications are you most likely to give her: • A) Divalproex, Thiamine • B) Divalproex, Diazepam • C) Divalproex, Lorazepam • D) Diazepam, Thiamine • E) Lorazepam, Thiamine Question 17 • 22 year old man reports drinking alcohol 2 days ago, using heroin 1 week ago and using cocaine, amphetamines and marijuana 2 weeks ago. He agrees to provide a urine screen to drug testing. The substance you are most likely to find in the urine drug screen is: A) Alcohol B) Amphetamines C) Cocaine D) Heroin E) Marijuana Question 18 • 39 year old woman is drinking 26 oz. of hard liquor daily, smoking 3 grams of marijuana daily, smoking half a gram of crack cocaine daily, injecting 24 mg of hydromorphone daily and taking 0.5 mg of clonazepam at bedtime. Withdrawal from the following substance is most likely be life-threatening: A) Alcohol B) Clonazepam C) Crack Cocaine D) Hydromorphone E) Marijuana Question 19 • 37 year old woman presents to your office for an annual exam. You review her current use of alcohol, drugs and nicotine. You provide her with information about recommended low risk drinking for her age and sex. • A) max 8 drinks per week, max 1 most days • B) max 10 drinks per week, max 2 most days • C) max 10 drinks per week, max 3 most days • D) max 14 drinks per week, max 2 most days • E) max 14 drinks per week, max 3 most days Question 20 • The Stages of Change are: • A) precontemplation, engagement, contemplation, action, maintenance • B) engagement, contemplation, preparation, action, maintenance • C)precontemplation, contemplation, preparation, action, maintenance • D) precontemplation, preparation, contemplation, action. maintenance • E) engagement, precontemplation, contemplation, action, maintenance Question 20 • 24 year old man with schizophrenia is brought into your office by his parents. They are concerned about his use of marijuana. When his parents are out of the room, he admits to smoking 2 grams of marijuana per day. He does not really want to stop smoking. He has not completed high school and is not working. He suffers from mild paranoia and is somewhat compliant with his medications. What stage of change is this patient in? • A) Action • B) Contemplation • C) Engagement • D) Precontemplation • E) Preparation Question 21 • 19 year old man presents with pinpoint pupils, loss of consciousness, decreased respiration and heart rate. You identify that he has taken an accidental drug overdose. You chose to administer the following medication: • A) Thiamine • B) Flumazenil • C) Naltrexone • D) Naloxone • E) Charcoal REVIEW INFORMATION SUMMARY Causal Factors/Risk Factors • Individual: Genetics, Mental Health • Exposure to drug or experience (gambling) • Environmental: trauma, poverty, peers Addiction • Addiction may be to substances or may be a process (behavioral) addiction. – Depressants: Alcohol, Opioids, Benzodiazepines – Stimulants: Cocaine, Amphetamines – Hallucinogens: Marijuana – Process (behavioural): Gambling • Sex, Food, Internet (not in the DSM IV or 5) Addiction • Reward pathway involves the nucleus accumbens, ventral tegmental area (VTA) and the prefrontal cortex • Drugs of abuse act on the reward centre resulting in dopamine flooding ....brain either produces less dopamine or downregulates dopamine receptors...net result is lower baseline dopamine...need to take more drug to increase dopamine Taking a History • What is the purpose of taking a drug and alcohol history? • Answer: – To make a Diagnosis – Medical and psychosocial history will influence management DSM IV Criteria for Substance Dependence • 3 or more occurring over 12 months – tolerance – withdrawal – larger amounts or longer period of time – unsuccessful efforts to cut down or control – time spent obtaining, using, recovering – activities given up or reduced – continued use despite problems DSM IV Criteria for Substance Abuse • A. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following occurring within a 12 month period: 1. recurrent substance use resulting in a failure to fulfill major obligations at work, school, or home 2. recurrent substance use in situations in which it is physically hazardous 3. recurrent substance-related legal problems 4. continued use despite persistent or recurrent social or interpersonal problems caused by or exacerbated by effects of a substance B. The symptoms have never met the criteria for substance dependence for this class of substance. DSM 5 Template for Criteria for Substance Use Disorder • Criterion A criteria fit within the overall groupings of: – – – – Impaired Control (criteria 1-4) Social Impairment (criteria 5-7) Risky Use (criteria 8-9) Pharmacological (criteria 10-11) DSM 5 Criteria for Substance Use Disorder A. A problematic pattern of substance use leading to clinically significant impairment or distress, as manifested by at least two of the following, occurring within a 12 month period. • 1. Substance is often taken in larger amounts or over a longer period than was intended • 2. There is a persistent desire or unsuccessful effort to cut down or control substance use • 3. A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects • 4. Craving or a strong desire or urge to use the substance Impaired Control criteria (1-4) DSM 5 Criteria for Substance Use Disorder • 5. Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to alcohol use; substance-related absences, suspensions, or expulsions from school; neglect of children or household) • 6. Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance • 7. Important social, occupational, or recreational activities are given up or reduced because of the substance use Social Impairment Criteria (5-7) DSM 5 Criteria for Substance Use Disorder 8. Recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use 9. Substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance Risky Use Criteria (8-9) DSM 5 Criteria for Substance Use Disorder 10. Tolerance, as defined by either of the following: a. A need for markedly increased amounts of substance to achieve intoxication or desired effect b. A markedly diminished effect with continued use of the same amount of the substance 11. Withdrawal, as manifested by either of the following: a. The characteristic withdrawal syndrome for the substance b. The same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms Pharmacological Criteria (10-11) Taking a Drug and Alcohol History History of Substance Use • Past substance abuse treatment history: type of program, ?completed, attendance at AA or NA. • Substances used: alcohol, marijuana, cocaine, heroin, tobacco, prescription/OTC drugs (opioids, benzodiazepines, dimenhydrinate), ecstasy, crystal meth • For each substance used: first use, current use, pattern of use, route, and last use DSM 5 Criteria for Substance Use Disorder • • • Early Remission. This specifier is used if, for at least 3 months, but for less than 12 months, the individual does not meet any of the criteria 1-10 for a Substance Use Disorder (i.e. none of the criteria except for Criterion 4, “Craving or a strong desire or urge to use a specific substance”). Sustained Remission. This specifier is used if none of the criteria 1-10 for a Substance Use Disorder have been met at any time during a period of 12 months or longer (i.e. none of the criteria met except for Criterion 4, “Craving or a strong desire or urge to use a specific substance”). Severity Scale: Specify Current Severity – Mild: presence of 2-3 symptoms – Moderate: presence of 4-5 symptoms – Severe: presence of 6 or more symptoms DSM 5 Criteria for Substance Use Disorder • Specifiers of remission – In a controlled environment (e.g. substance free jails, therapeutic communities, locked hospital wards) – On maintenance therapy (for opioid use disorders, if individual is prescribed agonist medication such as methadone or buprenorphine and non of the criteria for opioid use disorder have been met (except tolerance to, or withdrawal from, the agonist) Quantifying Alcohol and Drug Use • Alcohol • One standard drink= 13.6 grams of alcohol – 5 oz./142ml wine (12% alcohol) – 1.5 oz./43ml hard liquor (40% alcohol) – 12 oz./341 ml beer (5% alcohol) • Hard Liquor: 1 bottle -13 oz... Mickey = 8 standard drinks -26 oz.../750 ml = 17 standard drinks -40 oz.../1.14L = 27 standard drinks • Wine: 1 Bottle -26 oz.../750ml = 5 standard drinks • Beer: ask what size? 493ml, 710ml (=2 standard drinks) One Standard Drink (equivalent to 13.6 grams of alcohol) 341 ml (12 oz...) bottle of 5% alcohol beer, cider or cooler 142 ml (5 oz...) glass of 12% alcohol wine 43 ml (1.5 oz...) serving of 40% distilled Quantifying Alcohol and Drug Use Marijuana • Measured in grams, 1 ounze equals 28 grams • How many grams? Pattern of use. Cocaine Powder(snort or IV) or crack/freebase/rock form (smoke) 8 ball equals 3.5 grams; speedball is cocaine and heroin Quantifying Alcohol and Drug Use Benzodiazepines • Total amount used per day, how many years taking (assessing for risk of withdrawal) • Source of medication Opioids Which opioid? Oxy, Dilaudid (hydromorph), Fentanyl, morphine, codeine, heroin How much? What route? (IV, smoked, snorted, chewed, swallowed) How often? Taking an Alcohol and Drug History • Ask about blackouts, loss of control of use. • Withdrawal symptoms when stopping use: Alcohol (shakes, seizures, DTs, hallucinations); Opioids (nausea, vomiting, abdominal cramps, diarrhea, chills/hot flashes, myalgias/arthralgias, pilo-erection) • Tolerance • Consequences of Using: health problems (physical, mental), work or school problems, legal problems, involvement with CAS, effect on family/friends/children, financial problems. Taking a Drug and Alcohol History Family History • family history of alcohol or drug problems in blood relatives (biggest risk factor for development of addiction) Social History • marital status, current relationship, children • living arrangements, use of alcohol/drugs in the home • education level, current employment/disability • family of origin: marital status of parents, relationship with parents and siblings, abusive environment Legal History • past or current legal charges or convictions (DUI, assault, theft, possession, trafficking etc.) Taking a Drug and Alcohol History Past Psychiatric History • inpatient admissions, outpatient counseling, suicide attempts • any diagnosis ever given: trauma, anxiety, depression • medications prescribed in past and present Medical History • all medical problems and surgeries • HIV and Hepatitis C • accidents related to substance use Medications • list of all current medications and dosing • ask about use/abuse of over the counter medication Screening Questionnaires • • • • CAGE CRAFFT (adolescents) AUDIT (Alcohol Use Disorders Identification Test) DAST (The Drug Abuse Screening Test) CAGE Questionnaire (Screening Questionnaire for Alcohol Disorders) • Have you ever felt you should CUT DOWN on your drinking? • Have people ANNOYED you by criticizing your drinking? • Have you ever felt bad or GUILTY about your drinking? • Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (EYE-OPENER) • Score of 2 or more indicates a problem • Sensitivity 75-85% How do addiction issues present? • Sometimes patients do not initially disclose that they have a substance problem • It is sometimes only by reviewing their clinical presentation that we start to suspect they may have a substance problem Potential Clinical Presentation of Alcohol and Drug Problems • Cardiovascular: hypertension, cardiomyopathy • GI: fatty liver, hepatitis, cirrhosis, gastritis, pancreatitis, dyspepsia, recurrent diarrhea • Neurological: ataxia, tremor, peripheral neuropathy, cerebellar disease, dementia, Wernicke-Korsakoff’s syndrome • Infections (injection drug use): cellulitis, abscess, Hepatitis C, endocarditis Potential Clinical Presentation of Alcohol and Drug Problems • Trauma: accidents, violence, suicide • Psychiatric: fatigue, insomnia, depression, anxiety, psychosis • Behavioural: missed appointments, non-compliance, drug-seeking • Social: deterioration in social functioning, spousal abuse, violence, legal problems • Other: weight loss, loss of libido Physical Examination in Cases of Suspected Alcohol or Drug Abuse/Dependence • BP, heart rate, pupils • Level of consciousness, Mental Status Exam • Signs of liver disease (hepatomegaly, spider nevae, jaundice, ascites) • Signs of withdrawal/intoxication • Injection marks and bruising in arms, wrists, legs, ankles, neck, inguinal region • Long history of alcohol use (10+ years): hypertension, cardiomyopathy, dementia, gait (cerebellar dysfunction), distal polyneuropathy Laboratory Investigations in Cases of Suspected Alcohol or Drug Abuse or Dependency • CBC (increased MCV, decreased platelets), GGT (to detect heavy alcohol consumption) • AST, ALT (to detect alcoholic or viral hepatitis) • Cirrhosis: INR, albumin, bilirubin • Urine drug screen • Hepatitis B, C, and HIV (ask permission first) Case • John has been diagnosed with cirrhosis and continues to drink. His MCV is elevated at 103(8097). His platelets are depressed at 70(145-450). GGT is 342(<60). AST is 370(<37) and ALT is 240(<46). • His INR is increased to 1.3, albumin is decreased at 24 (34-48) and her bilirubin is increased at 35(<23). Urine Drug Testing Methods • Immunoassay: Based on the principle of competitive binding. An antibody reacts to a portion of a drug or its metabolite. – Point of care testing possible – Not as specific • Gas Chromotography with mass spectroscopy (GC/MS): couples the separation potential of gas chromatography with the precise detection and identification capability of mass spectroscopy. – More expensive – Gold Standard Drug Minimum detection (hours) Maximum detection Ethanol 0 to 4 <=6-12 hours Benzodiazepines 2 to 7 Infrequent User- 3 days Chronic User- 4-6 weeks Marijuana metabolite 6 to 18 Infrequent User – up to 10 days Chronic User – 30 days or longer Cocaine metabolite 1 to 4 2 to 4 days Amphetamines 2 to 7 2 to 4 days Methamphatamine 1 to 3 2 to 4 days MDMA (Ecstasy) 1 2 to 3 days Opiates (codeine, morphine, heroin) 2 2 to 3 days Oxycodone 1 1 to 2 days Methadone 2 2 to 6 days Treatment for Substance Use or Abuse • Advise of concern and in the case of alcohol advise of low risk drinking guidelines • Motivational interviewing to determine and set goals to reduce harm • Follow up and monitoring for any progression to substance dependence (addiction) Canada’s Low-Risk Alcohol Drinking Guidelines • Women ≤ 10 drinks/week (≤ 2 drinks/day most days) • Men ≤ 15 drinks/week (≤ 3 drinks/day most days) • In one sitting: • Women, no more than 3 drinks • Men, no more than 4 drinks – Plan a few non drinking days each week to avoid developing a habit Stages of Change Maintenance: Change 6 months PreContemplation Contemplation: Change date <6 months Preparation: Change date <1 month Motivational Interviewing • Four General Principles 1. Express Empathy • Acceptance facilitates change 2. Develop Discrepancy • Between behaviour and personal goals 3. Roll with resistance • Patient primary source for solutions 4. Support self-efficacy • Patient responsible for choosing and carrying out change FRAMES brief intervention interviewing technique • Feedback: specifically address concerns about use (i.e. I am concerned about how alcohol is affecting your liver) • Responsibility: Emphasize that change is up to the patient. (Only you can decide to make your life better) • Advice: Give specific goals you have for the patient (I want you to be evaluated at a treatment center) • Menu: Offer alternatives to advice (You could alternatively go to an AA meeting) • Empathy: I know you find talking about this difficult • Self-efficacy: you deserve better – you can be better with help Treatment Decision Tree for Substance Dependence (Addiction) Want to stop? No Motivational interviewing Yes Is it safe to stop? No Medically supervised detox Inpatient or outpatient Yes Can they stop? Yes Explore addiction treatment options No Community withdrawal Or Residential Withdrawal Management level 2 Withdrawal Assessment Tools • Alcohol: CIWA (Nausea & Vomiting, Tactile Disturbances, Tremor, Auditory Disturbances, Paroxysmal Sweating, Visual Disturbances, Anxiety, Headache/Fullness in the Head, Agitation, Orientation and Clouding of Sensorium • Opioids: COWS: (Resting Heart Rate, Sweating, Restlessness, Pupil Size, Bone or Joint Aches, Nose Running or Tearing, GI upset, Tremor, Yawning, Anxiety or Irritability, Gooseflesh Skin) Treatment of Withdrawal • Alcohol • Benzodiazepines • • • • May be life-threatening May require benzodiazepines Inpatient or outpatient Vitamin B1 (Thiamine) • Requires tapering (weeks to months) Inpatient or outpatient • • Opioids • • Withdrawal not life-threatening but very distressing Likely will require supportive medications +/- opioids • Cannabis • No medications required • Amphetamines/Cocaine • • No medications required Suicide Risk Assessment Pharmacological Interventions • Alcohol – Thiamine (B1) 100mg IM then po to prevent WernickeKorsakoff – Diazepam, Chlorodiazepoxide: long acting for management of withdrawal and prevention of seizures, DT’s – Lorazepam: short acting, used if respiratory or hepatic compromised Pharmacological Interventions • Antabuse (Disulfiram): • binds irreversibly to aldehyde dehydrogenase • Daily dose of 250mg to 500mg • Must not drink alcohol within 7 days of taking • Common effects with drinking include: flushed face, vomiting, headache, chest pain, palpitations. • Serious effects include: seizures, hypotension, vagally induced dysrhythmias. • Contra-indications: unstable angina, recent MI, schizophrenia and other psychotic states, pregnancy, severe cirrhosis of the liver • Liver enzymes monitored at quarterly intervals, monitored for visual changes and symptoms of peripheral neuropathy Pharmacological Interventions • Naltrexone (Revia) – Competitive opioid antagonist – Usual dose 50mg po daily • Indications: – alcohol dependence (reduce craving and intensity and frequency of alcohol binges) and for – Opioid dependence(for those who wish to remain abstinent from all opioids) • Side effects: nausea, GI symptoms, headache, dizziness, lightheadedness, weakness • Contra-indications: acute hepatitis, liver failure, opioids should be discontinued 10 days prior to starting naltrexone, naltrexone should be discontinued 3 days prior to elective surgery • Monitor ALT, AST and bilirubin Pharmacological Interventions • Campral (Acamprosate): – amino acid derivative that increases GABA and has complex effects on excitatory amino acid (i.e. Glutamate) neurotransmission – Positive and negative studies – Dosing 2 333mg tablets TID – Side effects: GI (diarrhea, bloating), pruritis – Excreted unmetabolized through the kidney’s, must evaluate renal function prior to initiations Pharmacological Interventions • Opioids – Dimenhydrinate (vomiting, nausea), Immodium (diarrhea), ibuprofen (aches and pain), meds for insomnia – Clonidine: Alpha 2 Adrenergic agonist • 0.05-0.2mg po TID prn • Most effective in suppressing autonomic signs and symptoms of opioid withdrawal • warn of sedation and orthostatic hypotension • BP must be greater than 90/60 to take Pharmacological Interventions • Opioids – Methadone: long-acting (>24 hours) synthetic opioid agonist, require methadone exemption to prescribe – Buprenorphine/Naloxone (Suboxone): long acting synthetic partial opioid agonist, naloxone component present to prevent IV abuse – Naloxone: opioid antagonist, used in opioid overdose kits Pharmacological Interventions • Nicotine – NRT (patch, gum, lozenge, inhaler) – Zyban (Wellbutrin, Bupropion)- not if seizure d/o – Champix (Varenicycline)-monitor for psych symptoms Types of Treatment Options • Mutual Help Groups: Alcoholics Anonymous, Narcotics Anonymous, Women for Sobriety, SMART recovery • Withdrawal Management • Outpatient Treatment (once weekly, daily) • Residential Treatment programs (ranging from 21 days to 9 months+) • Medically Supervised Treatment programs • Individual Counseling • Opioid Substitution Therapy • Harm Reduction approaches References • DSM 5 Diagnostic & Statistical Manual of Mental Disorders 5th Ed. Test Revision 2013 • DSM IV Diagnostic & Statistical Manual of Mental Disorders 4th Ed. Test Revision 2000 • Substance Abuse: A Comprehensive Textbook 4th Ed. Lewinson et al. 2005 • Management of Alcohol, Tobacco, & Other Drug Problems, Edited by Bruno Brands Phd. Addiction Research Foundation 2000 • Principles of Addiction Medicine 4th ed. , American Society of Addiction Medicine. 2009 References • NIDA National Institute on Drug Abuse • NIAAA National Institute on Alcohol Abuse and Alcoholism • Butt, P., Beirness, D., Cesa, F., Gliksman, L., Paradis, C., & Stockwell, T. (2011). Alcohol and health in Canada: A summary of evidence and guidelines for low-risk drinking. Ottawa, ON: Canadian Centre on Substance Abuse. Gambling Disorder • Persistent and recurrent problematic gambling behavior leading to clinically significant impairment or distress, as indicated by the individual exhibiting four (or more) of the following in a 12-month period: – – – – – – – – – • Needs to gamble with increasing amounts of money in order to achieve the desired excitement. Is restless or irritable when attempting to cut down or stop gambling. Has made repeated unsuccessful efforts to control, cut back, or stop gambling. Is often preoccupied with gambling (e.g., having persistent thoughts of reliving past gambling experiences, handicapping or planning the next venture, thinking of ways to get money with which to gamble). Often gambles when feeling distressed (e.g., helpless, guilty, anxious, depressed). After losing money gambling, often returns another day to get even (“chasing” one’s losses). Lies to conceal the extent of involvement with gambling. Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling. Relies on others to provide money to relieve desperate financial situations caused by gambling. The gambling behavior is not better explained by a manic episode. Differentiating between substance dependence and substance abuse Criteria for substance abuse does not include tolerance, withdrawal, or a pattern of compulsive use Although not listed as a criterion item, CRAVING (a strong subjective drive to use the substance) is likely to be experienced by most individuals with substance dependence High blood levels of the substance coupled with little evidence of intoxication suggests tolerance is likely Differentiating between substance dependence and substance abuse Criteria for substance abuse does not include tolerance, withdrawal, or a pattern of compulsive use Although not listed as a criterion item, CRAVING (a strong subjective drive to use the substance) is likely to be experienced by most individuals with substance dependence High blood levels of the substance coupled with little evidence of intoxication suggests tolerance is likely Canadian Guidelines for Low Risk Drinking 1.Reduce your long-term health risks by drinking no more than: 10 drinks a week for women, with no more than 2 drinks a day most days 15 drinks a week for men, with no more than 3 drinks a day most days Plan non-drinking days every week to avoid developing a habit. 2. Reduce your risk of injury and harm by drinking no more than 3 drinks (for women) and 4 drinks (for men) on any single occasion. Canadian Guidelines for Low Risk Drinking 3. Do not drink when you are: • driving a vehicle or using machinery and tools • taking medicine or other drugs that interact with alcohol • doing any kind of dangerous physical activity • living with mental or physical health problems • living with alcohol dependence • pregnant or planning to be pregnant • responsible for the safety of others • making important decisions Canadian Guidelines for Low Risk Drinking • 4. If you are pregnant, planning to become pregnant, or before breastfeeding, the safest choice is to drink no alcohol at all. • 5. If you are a child or youth, you should delay drinking until your late teens. Talk with your parents about drinking. Alcohol can harm the way your brain and body develop. If you are drinking, plan ahead, follow local alcohol laws and stay within the limits outlined in Guideline 1. Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) • • • • • • • • • • • • Patient:__________________________ Date: ________________ Time: _______________ (24 hour clock, midnight = 00:00) Pulse or heart rate, taken for one minute:_________________________ Blood pressure:______ NAUSEA AND VOMITING -- Ask "Do you feel sick to your stomach? Have you vomited?" Observation. 0 no nausea and no vomiting 1 mild nausea with no vomiting 2 3 4 intermittent nausea with dry heaves 5 6 7 constant nausea, frequent dry heaves and vomiting Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) • • • • • • • • • • • TACTILE DISTURBANCES -- Ask "Have you any itching, pins and needles sensations, any burning, any numbness, or do you feel bugs crawling on or under your skin?" Observation. 0 none 1 very mild itching, pins and needles, burning or numbness 2 mild itching, pins and needles, burning or numbness 3 moderate itching, pins and needles, burning or numbness 4 moderately severe hallucinations 5 severe hallucinations 6 extremely severe hallucinations 7 continuous hallucinations Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) • • • • • • • • • • TREMOR -- Arms extended and fingers spread apart. Observation. 0 no tremor 1 not visible, but can be felt fingertip to fingertip 2 3 4 moderate, with patient's arms extended 5 6 7 severe, even with arms not extended Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) • • • • • • • • • • • • AUDITORY DISTURBANCES -- Ask "Are you more aware of sounds around you? Are they harsh? Do they frighten you? Are you hearing anything that is disturbing to you? Are you hearing things you know are not there?" Observation. 0 not present 1 very mild harshness or ability to frighten 2 mild harshness or ability to frighten 3 moderate harshness or ability to frighten 4 moderately severe hallucinations 5 severe hallucinations 6 extremely severe hallucinations 7 continuous hallucinations Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) • • • • • • • • • PAROXYSMAL SWEATS -- Observation. 0 no sweat visible 1 barely perceptible sweating, palms moist 2 3 4 beads of sweat obvious on forehead 5 6 7 drenching sweats Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) • • • • • • • • • • • • VISUAL DISTURBANCES - Ask "Does the light appear to be too bright? Is its color different? Does it hurt your eyes? Are you seeing anything that is disturbing to you? Are you seeing things you know are not there?" Observation. 0 not present 1 very mild sensitivity 2 mild sensitivity 3 moderate sensitivity 4 moderately severe hallucinations 5 severe hallucinations 6 extremely severe hallucinations 7 continuous hallucinations Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) • • • • • • • • • • ANXIETY -- Ask "Do you feel nervous?" Observation. 0 no anxiety, at ease 1 mild anxious 2 3 4 moderately anxious, or guarded, so anxiety is inferred 5 6 7 equivalent to acute panic states as seen in severe delirium or acute schizophrenic reactions Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) • • • • • • • • • • • HEADACHE, FULLNESS IN HEAD -- Ask "Does your head feel different? Does it feel like there is a band around your head?" Do not rate for dizziness or lightheadedness. Otherwise, rate severity. 0 not present 1 very mild 2 mild 3 moderate 4 moderately severe 5 severe 6 very severe 7 extremely severe Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) • • • • • • • • • • AGITATION -- Observation. 0 normal activity 1 somewhat more than normal activity 2 3 4 moderately fidgety and restless 5 6 7 paces back and forth during most of the interview, or constantly thrashes about Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) • • • • • • • • • • ORIENTATION AND CLOUDING OF SENSORIUM -- Ask "What day is this? Where are you? Who am I?" 0 oriented and can do serial additions 1 cannot do serial additions or is uncertain about date 2 disoriented for date by no more than 2 calendar days 3 disoriented for date by more than 2 calendar days 4 disoriented for place/or person Total CIWA-Ar Score ______ Rater's Initials ______ Maximum Possible Score 67 The CIWA-Ar is not copyrighted and may be reproduced freely. This assessment for monitoring withdrawal symptoms requires approximately 5 minutes to administer. The maximum score is 67 (see instrument). Patients scoring less than 10 do not usually need additional medication for withdrawal. COWS (Clinical Opioid Withdrawal Scale) • • • • • • Resting Pulse Rate: _________beats/minute Measured after patient is sitting or lying for one minute 0 pulse rate 80 or below 1 pulse rate 81-100 2 pulse rate 101-120 4 pulse rate greater than 120 • • • • • • Sweating: over past ½ hour not accounted for by room temperature or patient activity. 0 no report of chills or flushing 1 subjective report of chills or flushing 2 flushed or observable moistness on face 3 beads of sweat on brow or face 4 sweat streaming off face • • • • • Restlessness Observation during assessment 0 able to sit still 1 reports difficulty sitting still, but is able to do so 3 frequent shifting or extraneous movements of legs/arms 5 Unable to sit still for more than a few seconds COWS (Clinical Opioid Withdrawal Scale) • • • • • Pupil size 0 pupils pinned or normal size for room light 1 pupils possibly larger than normal for room light 2 pupils moderately dilated 5 pupils so dilated that only the rim of the iris is visible • • • • • Bone or Joint aches If patient was having pain previously, only the additional component attributed to opiates withdrawal is scored 0 not present 1 mild diffuse discomfort 2 patient reports severe diffuse aching of joints/ muscles 4 patient is rubbing joints or muscles and is unable to sit still because of discomfort • • • • • Runny nose or tearing Not accounted for by cold symptoms or allergies 0 not present 1 nasal stuffiness or unusually moist eyes 2 nose running or tearing 4 nose constantly running or tears streaming down cheeks COWS (Clinical Opioid Withdrawal Scale) • • • • • • GI Upset: over last ½ hour 0 no GI symptoms 1 stomach cramps 2 nausea or loose stool 3 vomiting or diarrhea 5 Multiple episodes of diarrhea or vomiting • • • • • Tremor observation of outstretched hands 0 No tremor 1 tremor can be felt, but not observed 2 slight tremor observable 4 gross tremor or muscle twitching • • • • • Yawning Observation during assessment 0 no yawning 1 yawning once or twice during assessment 2 yawning three or more times during assessment 4 yawning several times/minute COWS (Clinical Opioid Withdrawal Scale) • • • • • Anxiety or Irritability 0 none 1 patient reports increasing irritability or anxiousness 2 patient obviously irritable anxious 4 patient so irritable or anxious that participation in the assessment is difficult • • • • Gooseflesh skin 0 skin is smooth 3 piloerrection of skin can be felt or hairs standing up on arms 5 prominent piloerrection • • • Total Score ________ The total score is the sum of all 11 items Initials of person completing Assessment: ______________ Score: 5-12 = mild; 13-24 = moderate; 25-36 = moderately severe; more than 36 = severe withdrawal •