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Monitored Abstinence
Martin H. Plawecki MD, PhD
Indiana University School of Medicine
Department of Psychiatry
Alcohol Medical Scholars Program
Introduction
• Many diseases are chronic, relapsing and remitting
• Controlled, not cured
• Examples
• Type I diabetes: 30-50% relapse rate
• High blood pressure: 50-70% relapse rate
• Substance use disorders (SUDs): 40-60% relapse rate
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Goals of SUD Treatment
• Harm reduction
• Abstinence
• Abstinence monitoring has a role in both
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This Lecture Covers
• Definition/course of Substance Use Disorders (SUDs)
• Treatments, including with monitored abstinence
• Methods of monitoring abstinence
• Efficacy of monitored abstinence
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4
This Lecture Covers
• Definition/course of Substance Use Disorders (SUDs)
• Treatments, including with monitored abstinence
• Methods of monitoring abstinence
• Efficacy of monitored abstinence
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5
Substance Use Disorder
In Same Year, ≥2 of:
• Tolerance
• Withdrawal
• Use longer/more
• Unable to ↓
• Lots time use
• ↓ Activities
• Use despite probs
• Craving
• Failed roles
• Hazardous use
• Social problems
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Remission and Relapse
• Remission
• Early: no symptoms ≥ 3 months but < 1 year
• Sustained: no symptoms ≥ 1 year
• Relapse: back to problematic substance use
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Substance Use Disorder
Abstinence
Controlled
Use
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Problems
8
Post Recovery
Within 3
years
7%
>26 %
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This Lecture Covers
• Definition/course of Substance Use Disorders (SUDs)
• Treatments, including with monitored abstinence
• Methods of monitoring abstinence
• Efficacy of monitored abstinence
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Treatment
• General treatments
• 12-step programs: Alcoholics Anonymous (“AA”)
• Cognitive behavioral treatment (CBT)
• Alcohol Rx meds examples
• Naltrexone
• Acamprosate
• Opioid Rx meds examples
• Naltrexone
• Buprenorphine
• Methadone (to be discussed below)
• Many treatments include abstinence monitoring
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12 step programs (e.g., Alcoholics Anonymous)
• Goal: commonly abstinence
• Self-help recovery group
• Very common: ~50 meetings/day in Indianapolis
• Difficult to study given program nature
• AA keeps people in and accepting of intervention
• Limited-unequivocal evidence for ↑abstinence
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Cognitive Behavioral Therapy:
(The Core of Rehab Rx)
• ↓ Dysfunctional thinking
• Substitute rational thoughts
• Relapse prevention
• Anticipate triggers
• Learn to cope w/triggers
• Change behaviors
• Evidence for ↓drinking/use, ↑abstinence
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Alcohol Rx - Naltrexone
• Goal: reduce drinking
• Thought to reduce enjoyment of alcohol
• Daily and long-acting injectable forms
• Reduces drinking
• Return to heavy drinking ↓17%
• Return to any drinking ↓4% → ↑abstinence
• Drinking days ↓4%
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Alcohol Rx - Acamprosate
• Goal: reduce drinking
• Thought to reduce withdrawal
• Oral only (3x/Day)
• Reduces drinking
• Return to heavy drinking ↓1%
• Return to any drinking ↓14% → ↑abstinence
• Abstinence duration ↑11%
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Opioid Rx - Naltrexone
• Goal: commonly abstinence
• Blocks all opioid highs
• Daily and long-acting injectable (LAI) forms
• Not well accepted by patients → high drop out
• May be especially useful for docs, nurses, etc
• Daily – some evidence for ↑abstinence, ↑ Rx
• LAI - emerging Data for ↓ heroin, ↑abstinence, ↑ Rx
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Opioid Rx – Buprenorphine Maintenance
• Goal: abstinence (harm reduction)
• Long-acting opioid replaces short-acting heroin
• Daily medication
• Increases treatment acceptance - ↑50%
• Decreases heroin and morphine usage
• ↓17% vs placebo, ↓11% vs methadone
• Dose dependent effect (↑dose → ↑results)
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Methadone Maintenance
• Goal: ↓ health risk, ↓ crime, ↑ family/job
• Replacement: Methadone vs heroin
• Lasts >24hours → 1x/day dosing
• Allows work; avoids withdrawal and prevent “high”
• Cheaper & from clinic → ↓ risky bx, ↓crimes
• Highly structured and federally regulated
• Administer methadone daily, usually at clinic
• Monitor for abstinence – urine drug screens
• Requires counselling
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Court Mandated Rx
• Goal: ↓ drug use → ↓ crime
• Links highly structured Rx to legal system
• Residential and outpatient treatment
• Random urine drug screens
• Routine judicial interaction and progress monitoring
• Success → avoid jail
• Failure→
• ↑ Monitoring frequency/intensity
• ↑ Punishment up to jail
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Physician Health Programs
• Goal: ↓ patient harm
• Links highly structured Rx to medical license
• Residential and outpatient treatment
• Random urine drug screens
• +/- Random office visit
• ≥5 Yr follow-up
• Success → practice medicine, keep job
• Failure →
• Treatment, ↑monitoring frequency/intensity
• Referral to medical licensing board
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Chronic Pain Management
• Goal: control pain, minimize substance misuse
• Adherence monitoring and risk minimization
• Explicit behavior agreements
• Estimate risk
• Use difficult-to-abuse medications
• Rx drug monitoring programs
• Urine drug screens
• Success → continue in program
• Failure → lose access to prescription opioids
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This Lecture Covers
• Definition/course of Substance Use Disorders (SUDs)
• Treatments, including with monitored abstinence
• Methods of monitoring abstinence
• Efficacy of monitored abstinence
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Monitoring Abstinence - Breath
• Advantages
• Easy, non-invasive
• Cost – reusable device
• Disadvantages
• Must be done properly
• Possibly non-specific
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Monitoring Breath Alcohol & Nicotine
• Breath alcohol concentration
• Alcohol is water soluble -> appears in the breath
• Electrochemical detection (burns alcohol)
• Deep breath is proportional to blood level
• Detects low alcohol concentration (1 drink in last hour)
• Nicotine
• Carbon monoxide (CO) from burning tobacco in breath
• Electrochemical detection (burns CO)
• Detected up to 2 days; “smoker” sensitivity < 10 hours
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Monitoring Abstinence - Urine
• Advantages
• Easy to obtain/non-invasive
• Detection via specific antibodies
• Common and inexpensive
• Disadvantages
• Positive test → expensive replication
• Replication takes weeks to get results
• Specific drugs detected for different time lengths
• Cheating
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Monitoring Abstinence - Urine
• Urine drug screen
• Specific antibody screening for substances/byproducts
• Many substances can be screened in a single test
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Times for Useful Urine Monitoring
Detection Times
• Opioids – 1-3 days
• Cocaine – 2-4 days
• Cannabinoids
• PCP – 8 days
• Single use – 3 days
• Alcohol – ¼ - ½ day
• Daily – 10-15 days
• Sedatives
• Heavy – >30 days
• Amphetamines – 2 days
• Short-acting – 3 days
• Long-acting – 30 days
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A Problem With Urine Monitoring
• Cheating
•
•
•
•
Adulterants - substances added to urine sample
Dilution - intentional fluid over-ingestion
Substitution - use of another’s, old, or synthetic urine
False attribution - claimed use of one to hide another
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Monitoring Abstinence - Blood
• Advantages
• Highly specific → confirm other tests
• Difficult to cheat, low false positives
• Direct and indirect measurements possible
• Disadvantages
• Invasive – requires a blood draw
• Expensive – includes testing and procedure fees
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Monitoring Blood Alcohol and Cannabis
• Alcohol: Blood Alcohol Concentration
• Direct detection of alcohol
• Limited to recent consumption only
• Alcohol: Carbohydrate deficient transferrin (CDT)
• Indirect marker - ↑ alcohol > 2 wks → ↑ CDT
• Timing: abstinence → ↓ CDT in 2-5 weeks
• Cannabis
• Direct detection of cannabinoids
• Acute use: peaks in minutes, ↓ <1 hr but > 0 for 1 day
• Chronic: detectable up to 30 days
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Monitoring Abstinence - Electronic
• Advantages
• Continuous monitoring
• Data can be monitored remotely
• Disadvantages
• Intrusive and highly visible
• Expensive
• Optimized for forensics
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Electronic Monitoring - Scram
• Alcohol → sweat
• Samples every 30 minutes
• Automatic alerts
• Tamper Resistant
• Cost
• Lease: $6-8/day lease
• Purchase: $1,400-1,800 + $5/day
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This Lecture Covers
• Definition/course of Substance Use Disorders (SUDs)
• Treatments, including with monitored abstinence
• Methods of monitoring abstinence
• Efficacy of monitored abstinence
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33
Efficacy of Monitored Abstinence
• Methadone clinic
• 3x ↑ Remain in Rx vs no opiate replacement
• 2/3x ↓ Positive opioid hair/urine samples
• 2 ½x ↓ Crime involvement
• Chronic Pain Management
• Urine drug testing → ↓ illicit drug usage
• ↑ Urine drug tests → ↑ prescription adherence
• ↑ Urine drug tests → ↓ non-prescribed medications
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Efficacy of Monitored Abstinence
• Court mandated Rx
• 12% ↓ Criminal relapse
• No clear effect on SUD outcomes
• Difficult to quantify
• Highly variable population
• Different Rx approaches/referral networks
• Physicians health programs
• Only ~20% w/ positive UDS at any time during 5 yrs
• 70-80% Physicians still licensed/employed at 5 yrs
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Summary
• SUDs are chronic relapsing/remitting conditions
• Interventions can include abstinence monitoring
• Monitoring - chemical and electronic forms
• Monitored abstinence → better outcomes
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Questions
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