Substance Use and Addiction

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Substance Use and Addiction

• Presentation for Physicians and Other Health Care
  Providers
• Theda Care Behavioral Health
• March 30, 2006
• Michael M. Miller, M.D., FASAM, FAPA

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ASAM
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Addiction Medicine

• The specialty of medicine devoted to diagnosis,
  treatment, prevention, education, epidemiology,
  research, and public policy advocacy regarding
  addiction and other substance-related health
  conditions

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Addiction Medicine

• Its not just for specialists
• There can never be enough specialists to address
  such prevalent/common conditions
• Every physician encounters patients or family
  members affected by substance-related conditions
• Every physician needs to know some basics about
  recognition and referral
• Addiction can be managed in primary care

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Addiction is only one of the Substance-Related
Disorders

• Addiction (Substance Dependence)
• Problem Use (Substance Abuse)
• Intoxication States
• Withdrawal States
• Substance-Induced Medical Problems
• Substance-Induced Psychiatric Problems
• Health Problems linked to Secondary Use
• Codependency and ACOA Syndromes

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Substance Use and Addiction are Public Health
Problems

• Use direct exposure to toxic effects
• Use exposure to health risks associated with
  route of administration
• Use placing oneself in contexts with health
  consequences (unwanted pregnancy, STDs,
  violence, vehicular crashes)
• Passive exposure poses health risks
• tobacco smoke vehicle passenger gang violence

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Epidemiology

• 10 of adults have a lifetime prevalence of
  addiction to alcohol/drugs, excluding nicotine
• 20 of primary care outpatients have a lifetime
  prevalence of SUD (excl. nicotine)
• 30 of hospitalized inpatients have a lifetime
  prevalence of SUD (excl. nicotine)

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Epidemiology

• Alcohol abuse dependence lifetime prevalence
  14 (males 24, females 5)
• Drug abuse dependence lifetime prevalence 6
• Combined is about 10

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Substance Dependence or Abuse among Persons Aged
12 or Older 2002 and 2003
Numbers in Millions
22.0
21.6
3.2
3.1
NHSUD
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NSDUH
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Prevalence of Alcohol Abuse Dependence by State
12yo gt
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Prevalence of Illicit Drug Abuse Dependence by
State 12yo gt
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Substances

• Self-reinforcing
• Euphoriants
• Act on Reward Center / Pathways

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Substances

• Sedatives
• Stimulants
• Opioids
• Hallucinogens
• Inhalants

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Sedatives

• Alcoholic beverages
• Barbiturates
• Benzodiazepines
• Sedative-Hypnotics
• GHB (GBL, 1,4 BD)
• Propofol

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Stimulants

• Speed
• Cocaine
• Psychostimulants
• Appetite Suppressants
• Designer Drugs (Ecstasy, et al.)
• Nicotine

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Opioids

• Natural (codeine, morphine, opium, heroin)
• Semi-synthetic
• Synthetic
• Partial Agonists
• --novel delivery systems patches, lollipops,
  nasal sprays

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Hallucinogens

• LSD
• Mescaline (Peyote)
• Psilocybin (mushrooms)
• Cannabinoids
• NMDA-antagonists
• (PCP, ketamine, dextromethorphan)

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Inhalants

• Nitrous Oxide
• Nitrates
• Hydrocarbons

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Routes of Administration

• Oral
• Nasal
• Inhaled/Smoked
• IV
• IM
• Sub-cutaneous
• Transdermal
• Sublingual

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Range of Conditions

• Use
• Misuse
• Risky Use
• Problem Use
• Addiction
• Disability
• Death

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Relationship Between Alcohol Use and Alcohol
Problems
Alcohol Use
None
Light
Moderate
Heavy
At Risk
Problem
Dependent
Low Risk
Severe
Moderate
Small
Alcohol Problems
None
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Addiction is not Abuse

• Odd words physical abuse, sexual abuse,
  substance abuse
• Substance Abuse -- overarching term
• Substance Abuse -- DSM-IV meaning

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Addiction is not Dependence

• Physical vs. Psychological Dependence
• Physiological Dependence
• Tolerance
• Withdrawal
• DSM-IV terms

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What is Addiction?

• Substance use
• Use behaviors and procurement behaviors persist
  despite problems due to use
• Return to use after periods of abstinence,
  despite previous problems
• Inability to consistently control use
• Preoccupation with use/procurement salience of
  use-related behaviors
• Cognitive changes (over-valuation, de-valuation,
  minimization/denial)
• Enhanced cue responsiveness via conditioning and
  generalization

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DSM IV Criteria for Substance Dependence Disorder

• A maladaptive pattern of substance use, leading
  to clinically significant impairment or distress,
  as manifested by three (or more) of the
  following, occurring at any time in the same
  12-month period
• 1. Tolerance, as defined by either of the
  following
• a need for markedly increased amounts of the
  substance to achieve intoxication or the desired
  effect, or
• b) markedly diminished effect with continued use
  of the same amount of the substance

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DSM IV Substance Dependence

• 2. Withdrawal
• 3. The substance is often taken in larger
  amounts or over a longer period than was intended
• 4. There is a persistent desire or there are
  unsuccessful efforts to cut down or control
  substance use
• 5. A great deal of time is spent in activities
  necessary to obtain the substance, use the
  substance, or recover from its effects

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DSM IV Substance Dependence

• 6. Important social, occupational, or
  recreational activities are given up or reduced
  because of substance use
• 7. The 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

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Pediatric Addiction Medicine

• Most kids who have a substance use disorder have
  DSM-IV substance abuse and not DSM-IV
  substance dependence.
• Still, ADDICTION IS A PEDIATRIC DISEASE most
  people who have addiction to alcohol, nicotine,
  and other drugs had an age of onset of their
  illness prior to age 18.

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Pediatric Addiction Medicine

• Even more so for adolescents than for adults, the
  indicators of addiction are PSYCHOSOCIAL
  DYSFUNCTION more than physiological dysfunction.
• Look for irritability/mood changes, decreased
  school performance, changes of peer groups,
  misconduct / lawbreaking, rather than tolerance /
  withdrawal or organ damage (exceptions nasal
  septum changes, tachycardia, weight loss, STDs)

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Loss of Control impairment in ability to
consistently control use
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Both Substance Use and Addiction are Public
Health Problems

• Use direct exposure to toxic effects
• Use exposure to health risks associated with
  route of administration
• Use placing oneself in contexts with health
  consequences (unwanted pregnancy, STDs,
  violence, vehicular crashes)
• Passive exposure poses health risks
• tobacco smoke vehicle passenger gang violence

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Substances

• DRUGS vs. ALCOHOL
• ILLEGAL vs. LEGAL
• HARD vs. SOFT
• STREET vs. PRESCRIPTION
• CLUB DRUGS vs. THERAPEUTIC RXs

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Drugs du Jour

• Methamphetamine
• Prescription Opioids
• Inhalants and Herbals
• Internet Drugs

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Its TOBACCO !

• The Killer Drug
• The Gateway Drug
• The Commonest Drug

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Mortality from Drug Use(direct toxic effects of
intoxication)(medical complications of chronic
use)

• Tobacco 500,000 deaths / year
• Alcohol 125,000 deaths/year
• Drugs lt 50,000 deaths / year

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What should you do?

• Ignore it
• Finesse it (later)
• Rationalize it
• Address it
• Assessment
• Detoxification (withdrawal management)
• Rehabilitation (treatment of a chronic primary
  disease, psychosocial interventions
  pharamcotherapeutic interventions)

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Addressing Nicotine Dependence

• The Five As
• Ask
• Advise
• Assess Motivation to Change
• Assist
• Arrange Follow-Up

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Ask About It

• Use
• Concerns (of self, of others)
• Physiological Dependence (need for detox)
• Medical Complications
• Criteria of Addiction (C.A.G.E.) need for
  treatment

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Advise

• I would like you to stop smoking
• You need to reduce your drinking
• We need to look for alternatives to the pills
  youre taking for your sleep disturbance, for
  your pain.

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Assess Motivational Level

• Precontemplative
• Contemplative
• Preparation
• Action
• Maintenance

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Assist the Patient

• Provide Behavioral Tools
• Provide Pharmacological Supports
• Provide Specific Referrals
• (to community-based resources)
• (to professional specialists)

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Arrange Follow-Up

• Its a CHRONIC disease
• If its addiction, it wont go away with brief
  advice only
• It must be addressed again and again over the
  course of the condition, whether its getting
  worse or better
• If you give an assignment, you must follow up or
  else the patient will know that this isnt really
  important

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Assessment

• Quantity / Frequency Questions
• Standard Drink
• 0.6 oz of 100 ethanol 13 gm.
• 12 oz of 5 beer
• 5 oz of 12 wine
• 1.5 oz of 80-proof liquor
• Qualitative Features
• (Pathological Pattern of Use)

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Assessing Quantity Backwards

• 6 pack -- 12 pack -- 18 pack -- 24 pack
• 1/2 pt -- pint ---1/5 gal (27 oz or 18 drinks)
• 4/5 quart of wine -- 1/2 gal of wine --
• 1.75 liters 57 oz ( 12 drinks of wine, 38
  drinks of 80-proof, 48 drinks of 100-proof)
• HOW MANY DO YOU BUY PER WEEK?

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Assessment Taking a History

• Age at First Use
• Age at First Regular Use
• Age of First Problem Use
• Physical symptoms from use
• Alcohol Blackouts
• First O.W.I.
• First complaints from family/friends/employer
• Period of Heaviest Use

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Assessing for Detox Needs

• Maximum Use in 24 Hours
• Tolerance noted (larger dose required to produce
  given effect)
• First withdrawal symptoms
• Worst withdrawal symptoms

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Assessing for Rehab Needs

• Days of use per month
• Longest span without use in last one, three,
  twelve months
• Days of intoxication per month
• Ability to stop or cut back as desired
• Salience of use it takes over, becomes 1
  thing of importance
• Assess denialsymptom attribution

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• BREAK