Points to Ponder….

1. Ms. Alvarez is a 45 year old Latin-American female with a history of multiple episodes of alcoholic pancreatitis. She presents to the ER complaining of epigastric abdominal pain and nausea for 2 days. The ER physician picks up her chart, rolls his eyes after recognizing her name, and mumbles to himself in disgust, “Why in the hell is she here again? What do you want me to do…why doesn’t she just stop drinking?”

2. He barges into her room, says a few words, smashes on her abdomen until she screams, and rushes out of the room. He orders a CBC, chem-14 and lipase, and starts IVF. The lipase is only mildly elevated, but she is admitted with a diagnosis of pancreatitis. She tells the hospitalist that she quit drinking 9 months ago, but he does not believe her. She is made NPO, and given IVF and morphine prn.

3. Overnight, her abdominal pain worsens, and she continues to ask for more pain medicine. Her nurse reluctantly gives her more morphine. At the nursing station, she is referred to as “the alcoholic lady in 742,” and the nurses talk about how many times they have taken care of her. When her admitting physician makes rounds the next morning, her nurse is annoyed and comments, “This one kept me up all night.”

4. He examines the patient, and notes that her abdomen is much more tender, and she now has rebound tenderness. Her temperature is 101º and her WBC is 22K. He obtains a CT of the abdomen and a surgical consult. The CT shows an inflamed gallbladder with a surrounding fluid collection. She develops obvious peritoneal signs, and she is taken to the operating room. The surgeon finds a perforated gallbladder.

5. Points to Ponder…. • All of us have admitted patients with poorly controlled diabetes mellitus. We pardon their morbid obesity, poor dietary habits, and noncompliance, and we continue to treat them with respect. So, why do we excuse noncompliant diabetics BUT we stigmatize noncompliant or relapsing patients with substance abuse disorders? • How often do we treat the medical complications but never address the underlying substance abuse disorder? If it were that simple, writing “stop drinking” on the discharge sheets would actually work.

6. Update on Substance Abuse Disorders Nilam J. Soni, MD

7. Overview • Epidemiology • Neurobiology of Addiction • Definitions • Screening for Substance Abuse • Brief Interventions and Motivational Interviewing • Alcohol • Inpatient Management • Outpatient Management • Opioids • Inpatient Management • Outpatient Management • Resources

8. Epidemiology

9. Epidemiology • In 2002, approximately 19.5 million Americans, or 8.3% of the population ages 12 or older, were current illicit drug users [ 2002 National Survey on Drug Use and Health (NSDUH), SAMHSA] • 53% of students have tried an illicit drug by the time they finish high school • In 2003, 4.5% of 12th graders used Oxycontin in the past year and 10.5% used Vicodin-making Vicodin the second-ranked drug after marijuana (University of Michigan, 2003 Monitoring the Future Study)

10. Any Illicit Drug Including Inhalants: Trends in Lifetime Use(8th, 10th, and 12th Graders) Percent Who Ever Used Source: Monitoring the Future Study, 2003, NIDA

11. Mr. and Mrs. Smith come to see you in the clinic. Mrs. Smith is very angry about her husband’s drinking, but he doesn’t feel like he has a problem. His father was an alcoholic, but Mr. Smith adamantly says, “There is no way that I am.” Mrs. Smith says, “I think that he is just weak, mentally that is, and he just needs to strengthen his will power. After all, isn’t alcoholism just a matter of will power.” How would you respond to her?

12. Neurobiology of Addiction (National Institute on Drug Abuse)

13. Advances in science have revolutionized our fundamental views of drug abuse and addiction

14. 1-2 Min 3-4 5-6 6-7 7-8 8-9 9-10 10-20 20-30 This is your brain on drugs….. YELLOW shows areas of brain stimulated by cocaine (striatum)

15. Disease Model for Drug Addiction • Genes • CYP 2A6 levels and tobacco dependence • Mu-receptor and heroin addiction • Environment • Early physical/sexual abuse • Witnessing violence • Stress • Drug availability • Dopamine and Serotonin Pathways

16. Dopamine Receptor Levels and Response to Methamphetamine Subjects with low dopamine receptor levels found methamphetamine pleasant while those with high dopamine receptor levels found methamphetamine unpleasant Thus, drugs have variable effects on the brain which determine a pleasant from an unpleasant response. 2.5 unpleasant response 0 pleasant response

17. striatum hippocampus frontal cortex substantia nigra/VTA nucleus accumbens raphe Dopamine Pathways Serotonin Pathways • Functions • mood • memory • processing • sleep • cognition • Functions • reward (motivation) • pleasure, euphoria • motor function • compulsion • perseveration

18. COCAINE AMPHETAMINE Accumbens 1100 Accumbens 400 1000 900 DA 800 DA 300 DOPAC 700 DOPAC % of Basal Release HVA HVA 600 % of Basal Release 500 200 400 300 100 200 100 0 0 0 1 2 3 4 5 hr Time After Amphetamine Time After Cocaine MORPHINE NICOTINE 250 Accumbens 250 Dose (mg/kg) 200 Accumbens 0.5 200 Caudate 1.0 2.5 % of Basal Release 150 % of Basal Release 10 150 100 0 1 2 3 hr 100 0 1 2 3 4 5 hr 0 0 0 1 2 3 4 5hr Time After Nicotine Time After Morphine Effects of Drugs on Dopamine Release Source: Di Chiara and Imperato

19. Development of Addiction Genetic Predisposition ↓ Environmental Stress ↓ Drug Abuse (Initiation of drug use, pleasurable experiences, hazardous use) ↓ Drug Addiction (Neurochemical brain changes, uncontrollable drug use)

20. Amygdala Nature Video Cocaine Video Anterior Cingulate Prolonged drug use→ development of pathways that cause craving

21. Cocaine CravingPopulation (cocaine addicts vs. controls) x Films (cocaine, erotic) Cingulate Ant Cing SignalIntensity(AU) IFC Controls Cocaine Addicts Garavan et al A .J. Psych 2000

22. Effects of Abstinence [C-11]d-threo-methylphenidate Abstinence from methamphetamine for 24 months demonstrated somerecovery, but not complete normalization. Therefore, addicts are always at risk for relapse. Normal Control Methamphetamine Abuser (1 month detoxification) Methamphetamine Abuser (24 month abstinent) Volkow, N.D. et al., Journal of Neuroscience, 21(23), pp. 9414-9418, December 1, 2001.

23. Summary Normal (at risk) Drug Use Addiction Treatment

24. Definitions

25. Spectrum of Substance Use Substance Use Disorders heavy severe Dependent Abuse consumption Hazardous consequences Low Risk Abstinence none none

26. Drug AbuseDSM IV Criteria 1 or more adverse effects over 12 months: • Recurrent use resulting in failure to fulfill major role obligations • Recurrent use in hazardous situations • Recurrent substance-related legal problems • Continued use despite interpersonal or social problems related to use

27. Drug DependenceDSM IV Criteria 3 or more in 12 months • Tolerance • Withdrawal • Much timeobtaining, using, recovering • Activities given up or reduced • More or longer than intended • Unable to cut down or control • Use despite knowledge of health consequences (Preoccupation and compulsion addressed in 3-7)

28. What is Addiction? • Compulsive substance use without medical purpose in the face of negative consequences • A different neurobiological state; the addicted brain is different from the non-addicted brain • A condition involving activation of the brain’s mesolimbic dopamine system; a common denominator inthe acute effects of drugs of abuse Leshner AI. Science-based views of drug addiction and its treatment. JAMA. 1999;282:1314-1316.

29. Alcohol Use in Primary Care SettingAdults > 18 Hazardous Drinkers 9% Alcohol Abuse 8% Alcohol Dependent 5% Low-risk Drinkers 38% Abstainers 40% Manwell, et al, 1997

30. Case A 36 year old white male presents to your clinic for the first time. He reveals that he smoked marijuana occasionally in high school. Currently, he drinks “socially” and does not use any drugs. You investigate his drinking further. He reports drinking a 6-pack with friends on Friday night and 6-pack while watching sports on Saturday or Sunday. His drinking has never interfered with his daily activities. Are his drinking habits consistent with hazardous drinking, alcohol abuse, or alcohol dependence, OR is his drinking of no concern?

31. Screening for Substance Abuse

32. Screening for Alcohol Abuse Alcohol Use None Light Moderate Heavy Hazardous Dependent Abuse Low Risk Severe Moderate Small None Alcohol Problems

33. NIAAA Guidelines • Low risk drinking • Men: < 14 drinks/wk; < 4 drinks/occ • Women:< 7 drinks/wk; < 3 drinks/occ • No use in risky situations • Hazardous (at risk) drinking • Men: >14 drinks/wk; >4 drinks/occ • Women & over 65: • >7 drinks/wk; >3 drinks/occ National Institute on Alcohol Abuse and Alcoholism. Physicians’ Guide to Helping People with Alcohol Problems, 1995,2003

34. What is a Standard Drink? 1 can of ordinary beer or ale 12 oz. single shot of spirits, gin, whiskey, vodka, etc.. 1.5 oz. small glass of sherry 4 oz. glass of wine 5 oz. small glass of liqueur or aperitif 4 oz.

35. Screening Instruments Common in Practice • Quantity & frequency • CAGE • AUDIT-C Piccinelli ‘97, Bradley ‘98, ‘03, Reid ‘99, Knight ‘01, Isaacson ‘94, Brown ‘95 Other Screens • MAST (25 items) • S-MAST • AUDIT (10 items) • TWEAK (pregnancy) • T-ACE (pregnancy) • CRAFFT (adolescent) • POSIT (adolescent) • CAGE-AID (drugs)

36. CAGE Questions • Cut down on your drinking? • Annoyed at others’ criticism of your drinking? • Guilty about something that happened when you were drinking? • Eye-opener (drink 1st thing in the morning) Cut- off point: > 2 positive Mayfield, et al; Am J Psychiatry 131:1121-1123, 1974

37. CAGE > 2 Positive Responses • Sensitivity 77 - 94% • Specificity 76 - 96% • Positive predictive value: 55-75%, assuming 20% prevalence Limitations: • Lifetime use • More reliable for alcohol abuse and dependence • Not as sensitive for: • women • elderly • African-Americans

38. Summary of Screening

39. Summary of Screening Monitor patient progress

40. Detection Time in Urine • 1-3 days • marijuana, heroin, cocaine, codeine, morphine • 2-4 days • Amphetamine, methamphetamine, short-acting barbiturates, methadone • Up to 30 days • chronic marijuana or PCP use • long-acting benzodiazepines

41. Case A 36 year old white male present to your clinic for the first time. He reveals that he smoked marijuana occasionally in high school. Currently, he drinks “socially” and does not use any drugs. You investigate his drinking further. He reports drinking a 6-pack with friends on Friday night and a 6-pack while watching sports on Saturday or Sunday. His drinking has never interfered with his daily activities. Are his drinking habits consistent with hazardous drinking, alcohol abuse, or alcohol dependence, OR is his drinking of no concern?

42. Brief Interventions and Motivational Interviewing

43. Readiness to Change Model Precontemplation Contemplation Relapse Determination Maintenance Action

44. Motivational InterviewingMotivational interviewing is a directive, client-centered counseling style for eliciting behavior change by helping clients explore and resolve ambivalence. Stephen Rollnick, William R. Miller, 1995 Rollnick, S., & Miller, W. R. What is motivational interviewing? Behavioral and Cognitive Psychotherapy. 1995;23:325-334.

45. Motivational Interviewing Techniques • Develop discrepancy • Avoid argumentation • Role with Resistance • Express Empathy • Support Self-efficacy Miller WR, Rollnick S, Conforti K. Motivational Interviewing, Second Edition: Preparing People for Change. New York: Guilford Press; 2002.

46. Brief Intervention • 5-15 minute counseling session • Four components • State your concerns about patient’s use of alcohol/drugs • Make explicit recommendation for change in behavior • Discuss patient’s reaction • Review treatment options; negotiate plan

47. Case A 42 year old Navajo male is brought by EMS to the ER with altered mental status. He ended a 7-day alcohol binge 1 day ago. His blood alcohol level is negligible, and he is admitted for alcohol withdrawal. He is given 4mg of lorazepam IV in the ER followed by 2mg upon arrival to the floor. He receives scheduled lorazepam, 2mg IV every 6 hours. Over the next 12-16 hours, he becomes progressively more agitated. His nurse calls you, and you give him a booster of lorazepam 4mg IV.

48. Case She calls you back in 1 hr and tells you that he is still very agitated with a pulse of 140 bpm and BP of 185/100. You give him an additional 4mg of lorazepam. The nurse calls you after 30min and says that he is “out-of-control.” He is pulling fiercely at his restraints, screaming, and complaining of insects on the wall, and his BP and pulse are still elevated. You give him 4mg more of lorazepam, but he does not improve. What should you do next?

49. Management of Alcohol Abuse Inpatient and Outpatient Management

50. Alcohol Withdrawal • Onset 5-10 hrs, peak 2-3 days, resolve 4-5 days • Signs and symptoms ( ≥ 2 by DSM IV criteria) • Autonomic hyperactivity (sweating, tachycardia, ↑ BP) • Tremor • Nausea/vomiting • Anxiety • Psychomotor agitation • Anxiety • Grand mal seizures • Hallucinations (tactile, visual, auditory)