Substance Use Disorders

1. Substance Use Disorders

2. 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)

3. 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

4. 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

5. 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

6. 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)

7. 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

8. 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

9. 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

10. 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 single-item 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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 end-organ damage • Benzodiazepines may help manage symptoms and prevent complications

19. 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

20. What medications are available for treatment? • Alcohol • Naltrexone • Acamprosate • Disulfiram • Opioids • Methadone • Buprenorphine • Sustained-release naltrexone • Cocaine • No FDA-approved medication

21. 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

22. 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 • Preexposureprophylaxis 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

23. 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

24. 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

25. 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