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MEDICAL COMORBIDITIES OF SUBSTANCE USE DISORDERS

MEDICAL COMORBIDITIES OF SUBSTANCE USE DISORDERS. Oregon Psychiatric Association March 4, 2006. Objectives. Review epidemiology of alcohol/substance use disorders Review importance of these disorders in medicine General overview of medical complications of alcohol/substance use disorders

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MEDICAL COMORBIDITIES OF SUBSTANCE USE DISORDERS

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  1. MEDICAL COMORBIDITIES OF SUBSTANCE USE DISORDERS Oregon Psychiatric Association March 4, 2006

  2. Objectives • Review epidemiology of alcohol/substance use disorders • Review importance of these disorders in medicine • General overview of medical complications of alcohol/substance use disorders • Discuss specific complications • Methamphetamines • Alcohol • Others

  3. Epidemiology • 2/3 ever consumed alcohol • ~40% ever used illicit drugs • 20% use tobacco • Lifetime prevalence • Alcohol use disorders • Men - 15-20% • Women - 8% • Drug use disorders • Men – 8% • Women – 5%

  4. Importance • 20-40% of general hospital admissions • 20% of primary care visits • One million ER visits per year • Drug use primary problem • 50-75% of trauma visits • Up to 200,000 deaths per year • Alcohol decreases life expectancy by 15 yrs • ~40% of suicides involve drugs/alcohol

  5. Specialty Alcohol Services* Medical Consequences (except FAS†) Medical Consequences of FAS Lost Future Earnings Due toPremature Deaths Lost Earnings Due toAlcohol-Related Illness Lost Earnings Due to FAS Lost Earnings Due to Crime/Victims Crashes, Fires, Criminal Justice, etc Societal Costs – Alcohol Use Disorders 13% 4% 9% 5% 2% 1% 20% 47% Total: ~$185 Billion †FAS = fetal alcohol syndrome. Source: Harwood, H. Report prepared by the Lewin Group for the National Institute on Alcohol Abuse and Alcoholism; 2000. National Institutes of Health, NIH Publication No. 98-4327. Rockville, MD. http://www.niaaa.nih.gov

  6. Medical Consequences • Direct Effects • Toxicity of substance of abuse • Toxicity of contaminants • Indirect Effects • Infectious diseases • Trauma • Nutritional deficiencies • Consequences of intoxication/withdrawal states

  7. Case #1 • 43 yo woman c/o dyspepsia, epigastric burning and anxiety • PMH – hypertension • Meds: Atenolol 25mg qd • HPI, ROS – unremarkable • Labs in past year – all WNL

  8. Case #1 • PE: • Looks anxious • Hands are cold,clammy, slightly shaky • Wearing strong perfume • P: 102 regular • BP: 155/101 • Temp, respirations – normal • Remainder of PE only remarkable for mild tachycardia

  9. What’s Your Diagnosis? • Differential – substance use disorders • Mild intoxication – stimulants • Withdrawal – alcohol, opioids, sedative/hypnotics • Clues • GI symptoms – gastritis • Hypertension • Symptoms of alcohol withdrawal • Use of perfume, aftershave, mouthwash to cover smell of alcohol

  10. Defining the “Standard Drink” • 10-15g ethanol • 12 oz of regular beer or cooler (5% alcohol) • 5 oz of table wine (12% alcohol) • 1.5 oz of hard liquor (40% alcohol, 80 proof) • The average person metabolizes about 1 standard drink per hour 2-3 ozcordial,liqueur,or aperitif 5 ozwine 3-4 ozfortified wine 1.5 ozbrandy 1.5 ozhard liquor 8-9 ozmalt liquor 12 ozbeer orcooler 12 oz 8.5 oz 5 oz 3.5 oz 2.5 oz 1.5 oz 1.5 oz Source: National Institute on Alcohol Abuse and Alcoholism.Bethesda, Md: NIAAA; 2004. NIH Publication No. 04-3769.

  11. Chronic Alcohol Use Cognitive disorders CVAPsychosis Head, Neck, GI cancers Neuropathies Anemias Nutritional Deficiencies Coronary Artery Disease CardiomyopathyArrhythmiasHypertension Stroke Liver Disease Cirrhosis Stomach ulcers Gastritis Pancreatitis Diabetes Duodenal ulcers Adapted from: Schuckit MA. In: Harrison’s Principles of Internal Medicine. New York: McGraw-Hill; 2001:2561-2566. .

  12. Cardiomyopathy Gastritis, other GI complications Liver disease Dementia Neuropathy Pancreatitis Anemias Diseases Associated with Chronic Alcohol Use • Head, Neck, GI cancers • Diabetes • Coronary artery disease • CVA • Nutritional deficiencies • Hypertension Sources: Schuckit MA. In: Harrison’s Principles of Internal Medicine. New York: McGraw-Hill; 2001:2561-2566. American Psychiatric Association. DSM-IV-TR. American Psychiatric Association: Washington, DC; 2000.

  13. Nutritional Consequences • Heavy drinkers – up to 50% of daily caloric intake • >25% - significant decrease in necessary nutrients • Malnutrition • Vitamin deficiencies • Impairs activation and utilization of nutrients • Maldigestion (GI complications)

  14. Specific Deficiencies • Thiamine • Wernicke-Korsakoff’s • Neuropathies • Folate • Megaloblastic anemia • Vitamin C – with high alcohol intake • Vitamin D • Decreased intake, poor absorption, insufficient sunlight • Decreased bone mass, density • Increased osteoporosis, bone fractures

  15. GI Complications • Liver • ETOH toxic to hepatocytes • AST>ALT • Accelerates liver damage in hepatitis C infection • Increases risk of acetaminophen toxicity • Range of disease • Fatty liver • Alcoholic hepatitis • Fibrosis • Cirrhosis

  16. GI Complications • Pancreatitis • Generally after 10-15 years of heavy ETOH • GI bleeding • Gastritis • Peptic ulcer disease • Esophageal varices • Duodenitis • Esophagitis

  17. Neurologic Complications • Wernicke’s encephalopathy • Delirium, ataxia, ophthalmoplegia • Thiamine deficiency • Necrosis of mammillary bodies and thalamus • 50-85%  Korsakoff’s psychosis • Few regain cognitive function

  18. Korsakoff’s Psychosis • Common pathology and etiology as Wernicke’s • Severe memory impairment • Recent and ongoing events • Confabulation, lack of insight • Other intellectual functions may be intact • Treat with thiamine

  19. Alcoholic Dementia • Prominent effects – frontal cortex, putamen • Extreme variability • Etiology • Neurotoxic • Effects on neurotransmitters • Decreased cerebral blood flow • Vitamin deficiencies

  20. Alcoholic Dementia • Impairments • Abstract thinking • Problem solving • Visual, spatial, motor abilities • New learning • Remote memory • Personal care

  21. Other Neurologic Complications • “Blackouts” – transient anterograde amnesia • ↑risk of CVA • ↑risk of cerebral trauma • Cerebellar degeneration • Metabolic encephalopathies • Peripheral neuropathies • Sensory, motor or autonomic • “Stocking-glove” distribution

  22. Other Organ Systems • Hematologic • Anemias – Fe deficiency, folate deficiency • Pancytopenia – alcohol toxic to bone marrow • Musculoskeletal • Rhabdomyolysis • Osteopenia/osteoporosis, fractures • Myopathy • Cardiovascular • Cardiomyopathy • Hypertension • Dermatologic • Facial edema, rosacea, rhinophyma • Metabolic/endocrine • Gout • Decreased testosterone • Menstrual abnormalities

  23. Marijuana • Pulmonary toxicity • COPD • Head, neck cancers • Cognitive deficits • Attention, short term memory • Information processing • Motor impairment • ↓ Immune response • ↓ Testosterone levels • Menstrual abnormalities

  24. Summary • Common disorders • Many medical complications • Patients frequently present to ERs, general medical settings • Important to assess all patients for alcohol, tobacco, other substance use • Complaints may caused/exacerbated by substance use

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