Physical Complications and Co-existing Problems

1. Physical Complications and Co-existing Problems PSMX 404 2011 This self-directed learning module has been produced by Fraser Todd for FrasersCEPblog and is used on the postgraduate paper PSMX 404 Assessment of Addiction and Coexisting Disorders. It may not be altered or used in any other form without permission of Fraser Todd. fraser.todd@otago.ac.nz

2. Overview of the Module • This self directed learning module (SDL) provides a basic introduction to the physical and medical complications of substance use and mental health problems. • You may chose which sections to read by clicking on the topic below. Those indicated with a  are essential topics. • Alternatively you may simply progress through all the slides in sequential order: = Next slide = return to overview (this page) • Text or icons in blue are hyperlinks; that means that if you click on them they will take you to the relevant slides in the presentation, or when in a sans serif font to resources elsewhere on the internet. • The topics covered in this SDL module are: 1. Introduction 2. Physical health and the comprehensive assessment  3. Physical complications by drug  4. Mental health problems secondary to medical illness 5. Prenatal Drug Effects  6. Understanding laboratory tests  7. Some Specific Conditions  ( = essential reading for PSMX 404) = Previous slide

3. 1. Introduction The physical or medical complications of CEP are as important as the mental health and addiction issues that occur, and cause significant reductions quality of life and life span. Fortunately most patients have access to doctors, especially general practitioners who are able to assist with this area of care. Regardless, many patients do not consult their GP’s regularly and it is important of a competent CEP clinician to have an awareness of the symptoms and course of intervention of the major physical complications of CEP. Among the wide range of physical complications of substance use and CEP, there are several conditions that practitioners must have a reasonable knowledge of because they are serious conditions that are potentially preventable or treatable. These include: 1. Overdose 2. Wernicke-Koraskoff’s Syndrome 3.Hepatitis C 4.Liver disease due to alcohol, especially cirrhosis of the liver. For those unfamiliar with medical terminology there are online available. These include: Online dictionary of medical terms Online description of diseases and conditions

4. 2. Physical Health & the Comprehensive Assessment  • Physical health or medical problems are as important as mental health and addiction problems in determining a persons quality of life. • Fortunately, all our patients have the ability to access General Practitioners who can care for there physical health. A working relationship with the patients GP is an essential part of there health care. • Screening for physical health problems should therefore be an integral part of every comprehensive assessment.

5. As a minimum, the following areas need to be enquired about… 

6. For a more comprehensive exploration, consider the following systems or headings…

7. 3. Physical Complications by Drug  1. Opioids 2. Stimulants 3. Injecting Drug Users 4. Alcohol 5. Benzodiazepines 6. Cannabis 7. Nicotine 8. Solvents

8. Opioids  Most of the complications of opioid use are due to injecting drug use. Overdose also a significant problem. The mortality rate for opioid users is approximately 13x higher than that for peers who do not use opioids.

9. Stimulants Most complications are due to the effects on vascular system, especially from vasoconstriction and increased oxygen demand of muscle

10. Injecting Drug Users  The mortality for IVDU’s is approximately 2.3% per year. This is may be due to overdose, physical complications such as infection and particular note should be made of the injection of impurities such as chalk from crushed tablets or adulterants used to convert drugs such as morphine into home-bake. Infection is a major risk for IVDU’s, especially: • Hepatitis C (HCV), Hepatitis B (HBV) and HIV • Bacterial endocarditis • Abscesses • Cellulitis at injection site • Pulmonary (lung) infection Factors associated with infection risk: • sharing of needles and syringes (cleaning of needles and syringes is likely to reduce the risk but effectiveness in removing Hep C virus unclear) • sharing of other injecting equipment very common • being injected by another person also common practice (...inadequate emphasis on hand washing…) • failure to clean injection site • using heavily colonized sites (lots of bacteria) such as femoral vein • crushing tablets and capsules in mouth… • blowing out clots in needles, licking needles or using saliva…

11. Alcohol I Alcohol use affects most body systems. Women are more susceptible to the physical harms at lower doses of alcohol. Note that recent Australian Guidelines differ from the ALAC guidelines and suggest lower levels of use: • Australian Guidelines: • No more than two standard drinks on any day reduces harm • No more than four drinks on any one occasion reduces risk of injury • Under 15 nil, 15-17 delay onset as long as possible • Pregnant or breast feeding = nil

12. Alcohol II 

13. Benzodiazepines • Seizures (withdrawal) – seizures in general carry a signficant risk of death  • Respiratory depression - especially with opioids, a significant cause of death from overdose  • Anterograde amnesia • Sedation and incoordination • Complications of intravenous use as mentioned above, if benzodiazepines are injected • Often benzodiazepine users are polydrug users; there is a need to consider physical complications from other drugs • Occasionally dizzyness, blurred vision, constipation, muscle weakness, motor incoordination – may impair driving

14. Cannabis  Laboratory studies suggest that there are many potential harms from cannabis use, but it remains unclear whether these actually impair physical health in humans. • There is good evidence that cannabis may be associated with: • Cognitive; short term memory, attention • Intrauterine exposure; inattention, poor problem solving and behavioural problems beginning in middle childhood • Chronic respiratory dysfunction similar to smoking • Myocardial infarction in those with heart disease and vulnerable to hear attacks • There is weak evidence or suggestions that cannabis may: lead to lung cancers similar to those caused by smoking nicotine, but occurring at a younger age • Dysfunction of immune, endocrine and reproductive systems

15. Nicotine  • Chronic airways disease • Lung cancer • Cardiac disease and myocardial infarction • Stroke • Peripheral vascular disease • Other cancers; upper respiratory, GI tract, pancreas, bladder, kidney etc • Infertility and impotence • Diabetes • Miscarriage, preterm birth, low birth weight, SIDS

16. Solvents 

17. 4. Mental Health Problems Due to Medical Illness A wide range of medical conditions may directly cause mental health problems and many others are associated with increased rates of comorbid mental health problems. It is important to be aware of these associations and to consider them when faced with certain mental health symptoms or when a particular medical condition is present. The next slide list some of the more common or important medical conditions that may present with psychiatric problems. Further reading

18. Mental Health Problems Due to Medical Illness II Many conditions can lead to delirium , the key feature of which is disorientation and confusion. There are also a wide range of medical conditions that can present as or worsen mental health disorders. Often the presentation Hypothyroidism (underactive thyroid) can often mimic major depression and be hard to detect. Thyroid function tests (TFT’s) are often routinely performed when a person presents with major depression. Hypothyroidism can also be a side effect of lithium treatment and may destabilise bipolar disorder. TFT’s are also indicated therefore in someone with bipolar disorder treated with lithium where there is a deterioration in control of mood swings or treatment is not fully effective.

19. 5. Prenatal Drug Exposure  Further Reading:

20. 6. Understanding Laboratory tests • Laboratory investigations are frequently performed on people with CEP. A basic knowledge for a case manager should include and awareness of the following: • Alcohol Biomarkers and liver function tests • Drug Testing • Cannabinoid:creatinine ratio • Hepatitis C testing • Thyroid Function Tests

21. Alcohol Biomarkers and LFT’s Alcohol biomarkers are physiological measures that can add to self-report information to indicate the presence or extent of a drinking problem, and the progress in treatment. None are diagnostic of alcohol dependence and all can be caused by other physical health problems. However, they can be useful when someone is know to be a heavy drinker, or raise suspicion if not. Liver enzymes Liver damage from many sources leads to the release of enzymes into the blood which may be measured. These include: Gamma-glutamyle transpeptidase (GGT) – levels over 50 IU is suggest of liver damage; lots of causes. When elevated in known heavy drinkers, a useful indicator of alcohol consumption. Aspartate aminotransferase (AST) - not particularly sensitive or specific Alanine aminotransferase (ALT) - not particularly sensitive or specific Red blood cell mean cell volume (MCV) Heavy drinking can increase MCV of red corpuscles. However, many other things can also do this. Carbohydrate-deficient Transferrin (CDT)After about two weeks of moderate to heavy drinking, transferrin starts to be produced that lacks carbohydrates in its structure (therefore CDT). The percentage of transferrin that is carbohydrate deficient is usually reported. Levels above 3% usually indicate heavy drinking, and remain elevated for approximately two weeks. However, many heavy drinkers do not show increased %CDT. EtG and EtS Ethyl glucoronide (EtG) and Ethyl Sulafte (EtS) are present in the urine after even small amounts of alcohol. If present they do not indicate heavy alcohol use, but may be useful to monitor abstinence.

22. The Clinical Use of Alcohol Biomarkers Few of the biomarkers of alcohol use are specific enough to diagnose heavy drinking; they may be elevated for many other reasons, and may be normal in some very heavy drinkers. Screening While no physiological test is diagnostic of heavy alcohol use, many clinicians use a combination of GGT + CDT as screening tools. Elevations indicate further questioning around alcohol use levels. Enhancing motivation and documenting progress If a person has known heavy alcohol use and high levels of GGT, the levels reduce as drinking reduces. Regular measurement of GGT may provide objective confirmation of progress in reducing alcohol use which may be useful in reinforcing change in the clinical setting. Assessing for abstinence and identifying relapse In people who are abstinent from alcohol urinary EtG or EtS may be useful where available to indicate relapse. This may be particularly useful when a patients return to work is dependent on them not drinking, though in such cases a breath analysis is probably a better option. Similarly %CDT may be an indicator of heavy consumption in those aiming to drink in moderation. Further Reading

23. Drug Testing Testing for the presence of drugs in the body can be done on urine, hair or blood. Urine testing is the most common method. Urine drug tests (like other forms of testing) have a minimum level of drug below which levels will be reported as if the drug is not present. It is highly unlikely that passive cannabis use would return a positive screen for cannabis. Poppy seed contains small amounts of opium. However, to produce a positive screen for opioids, a very large amount of poppy seed would need to be consumed. Various strategies are used by clients to avoid drug detection in urinary screens. This includes the use of adulterants and the dilution of urine with water. Current testing methods detect most common forms of adulteration and can detect urine samples likely to be diluted with water. It should be noted that the cannabis metabolite measured in most urine tests is not THC, but an INACTIVE metabolite of cannabis. Thus a positive screen indicates recent exposure to cannabis but does NOT indicate intoxication. Further reading on drug testing in opioid treatment

24. Drug Testing – detection periods  * Days unless otherwise specified

25. Cannabinoid:Creatinine Ratio  Cannabinoids are cleared from the body through the kidneys and are sensitive to day to day differences in kidney function. Thus urinary levels of cannabinoids are not a good indicator of the amount of cannabis used. Nor are they a reliable indicator of whether cannabis use is decreasing or not. The cannabinoid:creatinine ratio takes into account how the kidneys are functioning and provides a better measure of changes in cannabis use. Again, the initial ratio does not indicate the amount of cannabis used, but changes from the initial baseline ratio provides a good indication as to whether cannabis use is reducing or increasing. Thus a cannabinoid:creatinine ratio is very useful in providing objective feedback to tangata whaiora trying to reduce cannabis use and can be highly motivating as a result.

26. Hepatitis C testing  The routine test for Hepatitis C is a blood test of antibodies. This looks for the presence of antibodies against Hepatitis C in the blood, and if present (positive) indicates that the person has at some point been exposed to the Hepatitis C virus. However, often the virus is no longer present or active. The initial test performed detects the presence of HCV antibodies. This simply indicates that the person has been exposed to HCV at some point. It may not be active. Abnormal liver function tests suggest ongoing active HCV infection which is damaging the liver. To confirm the presence of the virus, a PCR (polymerase chain reaction) blood test is performed. This detects the presence of the specific HCV RNA. When positive, current HCV infection is present and further treatment (e.g.interferon treatment) should be considered.

27. Thyroid Function Tests (TFT’s) Thyroid function tests measure the various thyroid related hormones in the blood and allow a diagnosis of hypothyroidism or hyperthyroidism to be made. TRH (Thyroid Releasing Hormone) stimulates the pituitary to release TSH (Thyroid Stimulating Hormone) TSH stimulates the release of thyroid hormone from the thyroid gland in the neck. T3 is the main active metabolite T4 is also active and commonly measured. It is the T4that is free i.e. not protein bound that is important. This is measured and called the Free Thyroid Index (FT4I) T3 and T4 reduce TRH secretion by negative feedback. Hypothyroidism typically is associated with low T3 and FT4I and increased TSH (due to less negative feedback of T3 and T4 Hyperthyroidism is associated with increased levels of T3 and FT4I, and low TSH (due to negative feedback of T3 and T4)

28. Thyroid Function in Bipolar Disorder Abnormal thyroid function may destabilise bipolar disorder leading to increased episodes of depressed or elevated mood. Lithium Carbonate is frequently prescribed as a mood stabiliser for bipolar disorder and may cause hypothyroidism. Regular TFT’s are therefore indicated in people on Lithium Carbonate. Subtle under-activity of the thyroid, at levels insufficient to cause other symptoms of hypothyroidism or to reduce FT4I and T3 levels below normal (subclinical hypothyroidism) may still destablise bipolar disorder. In this case, TSH will be in the upper normal range and may indicate treatment. For example, where the normal range of TSH may be below 5 mIU/L many clinicians would treat if TSH was in fact above 2.5 – 3 mIU/L

29. Increased QT interval The QT interval is the time or distance on an ECG between the Q and T waves, which represent the depolarization and repolarization of heart muscle as the ventricles contract and relax. A prolonged QT interval may result in a ventricular arrhythmia and sudden death Causes of a prolonged QT include genetic, drugs such as methadone, older antipsychotics and medical conditions such as hypothyroidism. Some SSRI’s may lead to arrhythmia in those with genetically caused prolonged QT interval It may be triggered by sudden exercise of emotional stress. Some people experience fainting (syncope) due to it, but often there is no warning prior to a fatal episode. Diagnosis is made on the basis of an ECG showing prolonged QT It can usually be effectively treated with medication (beta blockers)

30. 7. Some Specific Conditions  The following section outlines briefly some important conditions that you should be aware of at a basic level and some links for further reading. Practitioners with some medical training (nurses, doctors) would be expected to know more than the basic information included here.

31. Hepatitis C (HCV)  • Between 75-90% of IVDU’s are positive for HCV • Many are infected in first year of use • HCV is often asymptomatic • 70-80% of those infected develop chronic HCV infection. In the other cases, the infection is cleared from the body • Of those with chronic HCV, 60-70% have abnormal liver function tests, 5-10% develop cirrhosis and 3-5% develop liver failure or liver cancer • Testing for HCV and other blood born infections is essential if not done recently. Tests for HCV involve the detection of antibodies, of active viral RNA and monitoring of liver function. • HCV may be treated with a course of antiviral drugs such as interferon. • Further information including symptoms of HCV infection:

32. Wernicke-Korsakoff Syndrome  Wernicke’s Encephalopathy is a medical emergency and requires immediate medical referral for IV Thiamine followed by oral thiamine. All patients presenting for detoxification with severe alcohol dependence should be prescribed thiamine supplements preventatively . Wernicke’s Encephalopathy (WE) and Korsakoff Syndrome (KS) are both caused by vitamin B1 (thiamine) deficiency. This is most commonly caused by dietary insufficiency (Beri Beri) in undeveloped countries or by chronic heavy alcohol use in more developed countries, though there are other causes as well. The acute syndrome, WE, is due to effects on the lower brain regions and is reversible with thiamine replacement, while KS usually emerges after the acute WE symptoms subside and tends to be much less reversible. Wernicke’s Encephalopathy: The classical triad of presenting symptoms are • Confusion • Ataxia (staggering gate) • Nystagmus (side to side or up and down eye flickering) However, these are only present in a minority of cases. Korsakoff Syndrome Anterograde (learning) and retrograde (past) memory impairment which tends to be noticeable after the initial confusion of WE subsides. In severe cases, thought to be irreversible. Further reading: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001776/

33. Alcoholic Liver Disease  Alcohol related liver problems involve three disease: • Fatty liver • Alcoholic hepatitis • Liver cirrhosis Fatty Liver: Fat deposits in the liver seldom causing symptoms and is reversible with abstinence. Alcoholic Hepatitis: Acute inflammation of the liver causing high temperature, abdominal pain and jaundice. High mortality rates in the early stages so requires urgent medical referral. Corticosteroids may be helpful. Liver Cirrhosis: Liver cirrhosis is the replacement of normal liver tissue with scar tissue due to damage. It is usually irreversible and frequently fatal over a number of years. It is most often caused by chronic heavy alcohol use or Hepatitis B or C though there are many other causes It occurs in about 30% of chronic alcoholics and has a wide range of signs and symptoms, including weakness, fatigue, anorexia, jaundice, ascites, confusion,, testicular atrophy, but it is usually asymptomatic in the early stages. Diagnosis is on the basis of clinical presentation, liver function tests, radiology, liver biopsy. Treatment involves treating underlying causes, avoiding other things that damage the liver e.g. paracetamol, and liver transplant.

34. Substance-related Brain Injury Facial features of foetal alcohol syndrome (From: http://www.nsnet.org/nsfas/symptoms.html) Further Reading: Substance-related brain injury Foetal Alcohol Spectrum http://www.intellectualdisability.info/diagnosis/fetal-alcohol-spectrum-disorder-an-overview http://www.arbias.org.au/fasd-services/resources.html

35. The End Return to the first slide