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Epidemiology

Epidemiology. Steven Shoptaw, Ph.D. October 7, 2004. Important Concepts in Drug Abuse and Dependence. Prevalence: The total number or percentage of cases of a disease in a population at a given time

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Epidemiology

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  1. Epidemiology Steven Shoptaw, Ph.D. October 7, 2004

  2. Important Concepts in Drug Abuse and Dependence • Prevalence: The total number or percentage of cases of a disease in a population at a given time • Incidence: The extent or rate of occurrence, especially the number of new cases of a disease in a population over a period of time.

  3. Definitional Problems • Drug abuse/dependence is a behaviorally defined “disease” or disorder • No pathogens or biological indicators of the condition

  4. Medical/Biological Understanding “Addiction is brain disease.” Alan Leshner, Ph.D.

  5. Moral/Choice Model “You can look at [scans of] brains all day. They can be lit up like Christmas trees. But unless a person behaves in a certain way, we wouldn't call them an addict.” Sally Satel, M.D.

  6. Normal Development • Teens and early adolescence marked by regular sampling of mind-altering substances, run-ins with the law, problems with parents, financial problems, and intense conflicted relationships • The vast majority, however, resolve this condition and become regular taxpayers

  7. Differential • No known medical condition • No diagnosable psychiatric condition • Axis I OR Axis II • Behaviors don’t remit despite pressure from powerful external forces (e.g., jail, spouse, employer)

  8. Natural History of Opioid Abuse 1st treatment episode Jail Dependence Diagnosis Abuse Diagnosis Apologies to Doug Anglin

  9. Natural History of Stimulant Abuse 1st treatment episode Jail Dependence Diagnosis Abuse Diagnosis Apologies to Doug Anglin

  10. Natural History of Alcohol Abuse 1st treatment episode UCLA $$ $$ Dependence Diagnosis Abuse Diagnosis Apologies to Doug Anglin

  11. Sentinels • Monitoring the Future • 30 years of cross-sectional survey of 50,000 8th, 10th and 12th graders on drug use • Online database, with tables and figures of highest relevance available at: www.monitoringthefuture.org

  12. 5+ Drinks, Last 2 Weeks www.monitoringthefuture.org, 2004

  13. Cigarettes, Past Year www.monitoringthefuture.org, 2004

  14. Cigarettes, 10+ Per Day www.monitoringthefuture.org, 2004

  15. Annual Prevalence of Illicit Drug Use Index www.monitoringthefuture.org, 2004

  16. Methamphetamine Use, Past Year www.monitoringthefuture.org, 2004

  17. Amphetamine Use, Past Year www.monitoringthefuture.org, 2004

  18. LSD Use, Past Year www.monitoringthefuture.org, 2004

  19. More Sentinels • National Household Survey on Drug Abuse (NHSDA) • Drug Abuse Warning Network (DAWN) • Drug and Alcohol Services Information System (DASIS) • Community Epidemiology Work Group (CEWG) • Clinical Literature

  20. Prevalence - NHSDA, 2000 Illicit Drug Use Percent Admitting Any Illicit Drug Use by Gender

  21. Illicit Drug Use, Past Month -1999, 2000, 2001 Percent Admitting

  22. Prevalence – NHSDA, 2000Cigarette Use by Gender Percent Admitting

  23. Cigarettes • While 45% of Americans smoked in 1960s, 23% of general population now smoke cigarettes (CDC, 2002; Giovino, 2002) • ~430,000 Americans die of smoking-related causes (Giovino, 2002) • Treatment-refractory group (George & O’Malley 2004) • Lower educational attainment, less interest in behavioral treatments that assist cessation, and medical psychiatric and substance abuse comorbidities • Increasing percentage of smokers are women

  24. Natural History of Smoking • Early smokers (started before age 15) are more likely to progress to daily smoking than those who started smoking later • Daily smokers more likely to be dependent than non-daily smokers • Quit attempts more successful for smokers who begin after age 15 Kandel et al 2004

  25. Smoking in Past Month by Ethnicity - NHSDA, 2000

  26. Substance Use by Cigarette Smoking, Past Month, 2000 Percent Admitting

  27. Phenomenology: Seriously Mentally Ill Who Smoke • Cigarette smoking associates with psychotic symptoms in bipolar disorder (Corvin et al., 2001) • Schizophrenics often heavily dependent smokers with great difficulty in cessation (Dalack et al., 1998) • Low motivation to quit; interaction between nicotine and negative affective symptoms (Ziedonis et al., 1997)

  28. Epidemiology: SMI and Smoking • 70-90% of chronic schizophrenics smoke cigarettes (Glassman, 1993; George, 1997) • In psychiatric outpatients, schizophrenics have highest smoking rates (Hughes, 1992) • Patients with bipolar disorder smoke at higher rates than general population, but lower than schizophrenics (Diwan et al., 1998)

  29. Substance Use, Past Year by Serious Mental Illness: 2001 Percent Admitting

  30. Past Year Substance Abuse or Dependence by SMI: 2001 Percent Diagnosed

  31. Heroin Prevalence • Across years and across cultures, prevalence of heroin abuse is fairly stable at about 1.5% of the adult population. • Social upheaval linked to increases in heroin abuse (Afghanistan, Iraq, Russia)

  32. Cocaine Epi • Cocaine abuse: 1.7 million Americans • 400,000 crack cocaine abusers (SAMHSA, 2002) • Concentrated in urban areas and in ethnic and racial groups • Primary reason for treatment admission in African Americans after alcohol in LA County

  33. Methamphetamine Epi • Methamphetamine abuse: 600,000 Americans • Additional 500,000 abuse other amphetamine type stimulants (SAMHSA, 2000) • Fast growing problem with established use in West, new problems in South and Midwest (Rawson et al., 2002) • 20% increase in treatment admissions (DASIS, 2003) • Primary reason for admission in California after alcohol • International problem in Europe, S.E. Asia, Thailand, New Zealand and Australia

  34. Meth+amphetamine, DAWN www.oas.samhsa.gov, 2004

  35. Eureka Police Department A classic example of what using methamphetamine for five years can do for your complexion. 1990 1995 The results of injecting illegal drugs into the muscle of an arm.

  36. How to recognize a drug lab • Many people may be unaware that they're living near a meth lab. Here are some things to look for: • Late night secretive activity in a rural/farm area. • Unusual, strong odors (like cat urine, ether, ammonia, acetone or other chemicals). • Residences or buildings with windows blacked out. • Renters who pay their landlords in cash. (Most drug dealers trade exclusively in cash). • Lots of traffic - people coming and going at unusual times. There may be little traffic during the day, but at night the activity increases dramatically. • Excessive trash including large amounts of items such as: antifreeze containers, lantern fuel cans, red chemically stained coffee filters, drain cleaner and cold medicine. • Unusual amounts of clear glass containers being brought into the home. • The mixing of unusual chemicals in a house, garage or barn by persons not involved in the chemical industry. • Possession of unusual chemicals, such as large quantities of MEK, Coleman Fuel, Toluene, Acetone or cold/allergy medications. www.henrycty.com/sheriff/meth.html

  37. Amphetamine Treatment, 2001 www.oas.samhsa.gov, 2004

  38. Infectious Diseases Associated with Substance Abuse • Infective Endocarditis • Gonorrhea/Syphilis/Chlamydia/other STDs • Pneumonia • Tuberculosis • Viral Hepatitis and Liver Disease • HIV

  39. Infectious Diseases Associated with Substance Abuse • Infective Endocarditis (i.e., staphylococcus aurcus) • Frequent among IDUs • 8-16% of hospital admissions for IDUs • Organism colonizes skin, also includes drug, adulterants, packaging, fluids • Occurs mostly to right side of heart • Most common symptom is chest pain, cough, fever, chills, arthralgia • Antibiotic treatment or surgery

  40. Infectious Diseases Associated with Substance Abuse • Gonorrhea/Chlamydia • Syphilis • Associates with MSM and non-injection drug use in Los Angeles County

  41. HIV Serostatus of LA County MSM Early Syphilis Cases 2002 (Provisional), n=406 Kerndt, 2003

  42. Infectious Diseases Associated with Substance Abuse • Pneumonia • Most common reason for hospitalization for IDUs (38%) • Depression of gag reflex causes aspiration • Cigarette and other types of smoking damage lung function • Malnutrition hampers healing • HIV complications

  43. Infectious Diseases Associated with Substance Abuse • Pneumonia (Cont’d) • Fever, cough, chest pain, and breathing problems for several weeks • Pneumococcal pneumonia most common in substance abusers • Chest X-Rays, sputum sample, blood cultures, arterial blood gases • IV antibiotics treatment

  44. Infectious Disease Associated with Substance Abuse • Tuberculosis – about 1,000 active cases in LAC, 2003 • Mycobacterium tuberculosis • Airborne transmission • 10% of infected individuals develop active TB • More common among debilitated and immunocompromised – substance abusers Homeless HealthCare, LA 2004

  45. Infectious Disease Associated with Substance Abuse • Hepatitis • Hep A, B, C, D… • 41-48% of IDUs have history of acute hepatitis • 2/3 have abnormal liver transaminase (AST, ALT, GGTP) • Hep A transmitted fecal-oral • Hep B transmitted through body fluids • Non A/Non B (Hep C) transmitted through injection and via sex

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