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Peter Kenneth Ndege, MD Consulting Physician Kenyatta National Hospital

Peter Kenneth Ndege, MD Consulting Physician Kenyatta National Hospital Honorary Lecturer University of Nairobi School of Medicine Founder and Executive Director, Center for Addiction Studies in Africa Email: ndegepk2566@gmail.com Tel: +254 722 642 744.

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Peter Kenneth Ndege, MD Consulting Physician Kenyatta National Hospital

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  1. Peter Kenneth Ndege, MD Consulting Physician Kenyatta National Hospital Honorary Lecturer University of Nairobi School of Medicine Founder and Executive Director, Center for Addiction Studies in Africa Email: ndegepk2566@gmail.com Tel: +254 722 642 744 Medical Comorbidities

  2. Medical Co-Morbidities in the Substance Using Patient

  3. GOALS • Understand that alcohol and drug use can become disorders, that are chronic medical conditions • Understand the epidemiology and harm associated with alcohol and other drug use • Understand the complex relationship between alcohol and other drug use with other disease processes Medical Comorbidities

  4. OUTLINE • Discuss the harm and other diseases associated with the use of the “big three” substances: • Alcohol • Opioids • Cocaine • Discuss (briefly!) the harm and other diseases associated with the use of “non-big-three” substances • Discuss the complexity of defining and clinically dealing with co-morbidities • Summarize and further discussion Medical Comorbidities

  5. BACKGROUND • Alcohol and other drug use patients who present for treatment often have other medical problems • These medical conditions are consequences • of both their current and their past high risk behaviors • Injection or route of drug use • direct toxic effects of illicit drugs or caustic agents • Clinicians should screen for and treat (or refer for treatment) common comorbid medical conditions Medical Comorbidities

  6. BACKGROUND • Treating alcohol and other drug use in an office based settings provides a unique opportunity to integrate the delivery of substance abuse treatment with screening and management, increasing effectiveness and patient compliance • Clinicians should know the common comorbid medical conditions found in alcohol and other drug use patients and promote preventive health care for these patients Medical Comorbidities

  7. Medical Comorbidities

  8. ALCOHOL USE and DISORDERS:HARM and MEDICAL CO-MORBIDITIES

  9. Medical Harm of Hazardous Drinking • Hazardous drinking is associated with an increased risk for: • All-cause mortality • Hypertension • Cardiomyopathy • Diabetes • Trauma • Stroke • More serious alcohol disorders • Cancers • particularly upper GI and breast cancers Medical Comorbidities Figured from Babor et al (World Health Organization), AUDIT Guidelines for Use in Primary Care, 2001

  10. Brief Primer of Physical Exam Features for Alcohol Use • Tachycardias • Tremor • Hypertension • Hepatosplenomegaly and a tender liver edge • Peripheral neuropathy • Spider angiomata • Conjunctival injection • Unexplained trauma Medical Comorbidities

  11. Some Associations with Hazardous Drinking • Injuries • Infections • Gastritis and duodenitis • Hematologic effects • Early hepatic injury • Cardiac effects Medical Comorbidities

  12. Injuries • Due to • Fights and homicide attempts • Auto accidents • 50% of injuries involve some alcohol consumption • Drowning and other accidents • Suicide attempts • Patient neglects injuries until the next day • Injuries not painful until the following day Medical Comorbidities

  13. Infections • Heavy drinkers are more susceptible to pneumonia and other infections • Pneumococcal infections • Pseudomonas infections • Gram-negative infections • Heavy drinkers have impaired immunity • Increased sequestration of neutrophils • Decreased fixed macrophage phagocytic capacity • Decreased white blood cell production • Decreased cell mediated immunity Medical Comorbidities

  14. Gastritis and Duodenitis • Most commonly observed effects • Epigastric pain • Morning nausea and vomiting • Melena • Gastric Esophageal Reflux Disease (GERD) • Eventually • Consequences of liver disease including varices and portal hypertension Medical Comorbidities

  15. Hematologic Effects • Macrocytosis • Due to direct cytotoxic effects • Due to vitamin deficencies • Decreased platelets (may be down to 30,000 to 50,000) • Anemia usually due to • Bleeding from gastrointestinal tract • Folic acid deficiency • Also remember other vitamin deficiencies Medical Comorbidities

  16. Hepatic Effects • Alcoholic hepatitis in 10% to 15% of alcoholics • Increased liver enzymes and bilirubin • Enlarged tender liver • 80% can progress to cirrhosis • 20% result in liver failure • Cirrhosis • 40% have a 5-year survival if they continue to drink • 77% have a 5-year survival if they stop drinking • Liver cancer (also esophageal, laryngeal, and nasopharyngeal cancers) Medical Comorbidities

  17. Early Hepatic Markers • Increased gamma-glutamyl transpeptidase (GGT) up to 3 times normal in 20% to 30% of heavy drinkers • Liver enzymes • AST/SGOT > ALT/SGPT • Production Problems • Coagulopathies in end stage alcoholic liver disease • Don’t forget the pancreas! • Acute and chronic pancreatitis • Complications: • Diabetes, Steatorrhea, Pseudocyst Medical Comorbidities

  18. Cardiac Effects • Increased blood pressure • From withdrawal • Without withdrawal • Increased ischemic heart disease • Cardiomyopathy • Arrhythmias • Especially tachyarrhythmias • Atrial flutter • Atrial fibrillation – “Holiday Heart” • Paroxysmal Atrial Tachycardia Medical Comorbidities

  19. Nervous System Effects • Headaches • Sleep disorders • Wernicke syndrome • Korsakoff psychosis • Organic brain disease • Cognitive • Memory • Peripheral neuropathy Medical Comorbidities

  20. Nervous System Effects C– Confusion O– Ophthalmalplegia A– Ataxia T – Early Thiamine Deficiency (Wernicke’s) R – Retrograde Amnesia A– Anterograde Amnesia C – Confabulation and meager Conversation K – Korsakoff Syndrome (Also lack of INsight and Greater apathy) Medical Comorbidities

  21. Fetal Alcohol Spectrum • Growth retardation • Head circumference, height, and weight less than tenth percentile • Facial malformation • Palpebral fissure • Philtrum • Thin upper lip • Neurodevelopmental delay • Intelligence • Boundaries • Memory • Aggression • Motor skills • Right/wrong Medical Comorbidities

  22. Fetal Alcohol Spectrum • Defects occur before most women know they are pregnant • No known safe level of drinking for pregnant women • Binging may be worse than daily drinking • The higher the blood level of alcohol, the greater the chance of damage Medical Comorbidities

  23. Associations with Other Diseases • There exist many diseases that co-exist with alcohol use disorders that may complicate the treatment of either disorder • HIV • Major Depressive Disorder • Hepatitis • Cirrhosis • (Social morbidities – homelessness) • Emerging research is examining treatment modalities for co-morbid conditions Medical Comorbidities

  24. Alcohol Use of the Elderly • Of the 80% of elderly persons who have ever consumed alcohol, two-thirds continue to drink, often at hazardous levels of consumption • Of the elderly: • 15% drink alcohol at levels considered hazardous • 5% have diagnosis of abuse or dependence • many more drink sporadically in binge episodes • The problem drinking elderly consist of : • 30% of the hospitalized elderly • 10% of the elderly primary care • 50% of the mentally ill elderly Medical Comorbidities

  25. Alcohol Use of the Elderly • With mild alcohol consumption, compared to the non-elderly, the elderly are at increased risk for: • greater numbers of harmful medication interactions • increased falls • more cognitive deficits • greater sleep impairments • increased sexual dysfunction • greater numbers of hip fractures • more psychiatric problems compared to younger populations Medical Comorbidities

  26. Alcohol and Breast Cancer • More than 30 epidemiologic studies have evaluated a possible association between alcohol intake and breast cancer • Alcohol consumption is associated with a linear increase in breast cancer incidence in women over the range of consumption reported by most women (Smith-Warner) • In a recent study of 70,000 women, a drink a day increased their risk by 10 percent, and more than three daily drinks by 30 percent (Lew) • Women's Health Study, daily alcohol intake again was shown to modestly increase risk (Zhang) • The relative risk for each 10 gram increase in daily alcohol intake was 1.11 (95% CI 1.03-1.20) for ER and PR+ cancer Medical Comorbidities Smith-Warner SA, JAMA 1998; Lew: Ameri. Assoc. for Cancer Research 2008; Zhang SM, Am J Epidemiol. 2007

  27. 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 of Alcohol Dependence Total Cost: $184.6 Billion $7,466* (4%) $24,093 (13%) $15,963 (9%) $10,085 (5%) $2,909 (2%) $1,253 (1%) $36,499 (20%) $86,368 (47%) Medical Comorbidities Harwood H, NIH Publication No. 98-4327 1998

  28. Medical Comorbidities

  29. OPIOID USE and DISORDERS:HARM and MEDICAL CO-MORBIDITIES

  30. Balloons, Bags, and Pills Medical Comorbidities

  31. New Prescription Drug Users Past Year Initiation of Non-Medical Use of Prescription-type Psycho-pharmaceutics Age 12 or Older: In Thousands from 1965 to 2005 Medical Comorbidities NSDUH, SAMHSA, 2005

  32. Opioid Withdrawal • Severe flu-like symptoms including shaking chills • Anxiety • Hyperactivity • Drooling • Lacrimation/Tearing • Rhinorrhea/Runny nose • Anorexia • Nausea • Vomiting • Diarrhea • Myalgias • Muscle spasms Medical Comorbidities

  33. Street Stuff • Sold in “stamp bags” and “balloons” • A opioid user will maintain a steady supply of opioids - not a binge addiction • Combination of abuse is important • Can be combined with a stimulant (ala speedball) • Rarely with a depressant Medical Comorbidities

  34. Changing Route of Heroin Administration Medical Comorbidities Treatment Episode Data System, 1992-2000

  35. Hepatitis B • DEFINITION • Hepatitis B (HBV) is a blood borne viral pathogen • EPIDEMIOLOGY • Estimated 1.25 million chronically infected in U.S. • Approximately 300,000 new cases per year • Transmission by blood borne, sexual, or perinatal • Approximately 50% of active injection drug users have serological evidence of prior exposure to HBV Medical Comorbidities

  36. Hepatitis B – Clinical Course • Early and mild viral hepatitis manifests with symptoms of hepatic inflammation and damage with elevated serum transaminases (> 10-20x normal) • Chronic viral hepatitis manifests as chronic liver disease with portal hypertension and poor hepatic synthetic function • Likelihood of developing chronic infection is related to age: • 80 to 90% of infants infected develop chronic disease • only 2 -10% of infected adults progress to chronic disease Medical Comorbidities

  37. Acute Hepatitis B Infection with Recovery Symptoms anti-HBe HBeAg Total anti-HBc Titer anti-HBs IgM anti-HBc HBsAg 0 4 8 12 16 24 28 32 52 100 20 36 Weeks after Exposure Medical Comorbidities

  38. Acute (6 months) Chronic (Years) HBeAg anti-HBe HBsAg Total anti-HBc IgM anti-HBc Years 0 4 8 16 20 24 28 36 12 32 52 Progression to Chronic Hepatitis B Infection Titer Medical Comorbidities Weeks after Exposure

  39. Hepatitis C - Epidemiology • Hepatitis C (HCV) is the most common bloodborne infection in the U.S. • 1.8% of the U.S. population are infected • Of the 3.9 million people in the U.S. who are infected, 2.7 million are chronically infected • At least 30,000 new infections (cases) annually • Morbidity and mortality • Chronic liver disease – HCV-related: 40% - 60% • Deaths HCV chronic disease/year: 8,000-10,000 • Most common reason for (~40%) liver transplants Medical Comorbidities

  40. Hepatitis C - Epidemiology • In some series, greater than 90% of injection drug users have antibodies to HCV • HCV is more prevalent and more infectious than HIV • with 170,000,000 infected with HCV worldwide • In injection drug users, infection results from contact with contaminated needles, syringes, paraphernalia • Blood and blood products are more infectious than saliva, vaginal secretions, or semen Medical Comorbidities

  41. anti-HCV Symptoms +/- HCV RNA Titer ALT Normal 6 1 2 3 4 0 1 2 3 4 5 Years Months Time after Exposure Hepatitis C: Acute Infection with Recovery Medical Comorbidities

  42. Symptoms +/- HCV RNA Titer ALT Normal 6 1 2 3 4 0 1 2 3 4 5 Years Months Time after Exposure Hepatitis C: Progression to Chronic Infection anti-HCV Medical Comorbidities

  43. CHRONIC Hepatitis C: Clinical Course • Symptoms: 50% of patients report chronic fatigue and abdominal discomfort • Serum transaminases: • Persistently elevated - 43% • intermittently elevated - 42% • normal - 15% • Risk factors for disease progression: • alcohol use, hepatitis B virus, HIV (modifiable risks) • < 40 years old when infected, male sex Medical Comorbidities

  44. Acute hepatitis C >85% (10 years) Chronic hepatitis C 20% - >50% (20 years) Cirrhosis < 20% Hepatic failure < 20% HCC (30 years) 30 Year Progression of Chronic Hepatitis C Medical Comorbidities

  45. Hepatitis C: HIV Co-infection • 30% of HIV positive patients in the U.S. are co-infected with HCV • In HIV infected injecting drug users, the prevalence of HCV is 50 to 90% • HIV has a significant effect on progression of liver disease in HCV-infected patients • Must balance hepatotoxicity of HIV therapy with need to treat HIV in HCV-infected patients, while HIV therapy can worsen the symptoms of HCV Medical Comorbidities

  46. Hepatitis C: Treatment in Drug Users • Standard recommendation: >/=6 months “clean” • Arguments for not treating: poor adherence, side effects, re-infection, non-urgent treatment – but data supporting these arguments are lacking, some drug users may do well • Treatment should be based on individual risk-benefit assessments • Edlin BR et al. NEJM 345:211-214, 2001 Medical Comorbidities

  47. Hepatitis C: Treatment in Drug Users • The 2002 NIH Consensus Guideline on the Treatment of HCV is available at • Active injecting drug use should not exclude patients from HCV treatment • HCV treatment of active injecting drug users should be considered on a case-by-case basis • Web site: http://www.guideline.gov Medical Comorbidities

  48. HIV/AIDS: Epidemiology • Approximately 1.1 million cases in the US • 0.7 - 34% (median 15%) seroprevalence entering substance abuse treatment • IV Drug Use (IVDU) associations • From 1993-1999 IVDU persons living with AIDS jumped from 48,244 to 88,540 • 15-20% long-term IVDUs infected (43% of women AIDS) • 25% of the approximately 40,000 new HIV infections/year through IVDU Medical Comorbidities

  49. HIV/AIDS: Treatment in Drug Users • High risk for non-receipt of antiretrovirals: • 2-3 times as likely not to be on antiretroviral treatment if not in SA treatment • High risk for non-adherence: • 1998 CDC guidelines recommend delaying HAART until active opioid use has been addressed Medical Comorbidities

  50. Tuberculosis: Epidemiology • Worldwide, approximately 2 billion people (1/3 of world population) are infected with M. tuberculosis • Since the HIV pandemic began in the U.S. in the mid-1980s, there has been increased concern about TB since it is more common in this population • Tuberculosis is also more common in alcohol users and injection drug users in general and in patients with alcohol use disorders Medical Comorbidities

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