Providing primary care to patients with alcohol and drug addiction

1. Providing primary care topatients with alcohol and drugaddiction Ted A. Bonebrake, M.D.

2. definitions • The AMA classified alcoholism as a disease in 1956. Despite this, many physicians still view it as a “social problem” of a “moral failing”. • The distinction between addiction and problem use is particularly important. • The problem drinker or drug user may have undiagnosed medical or social problems but not yet have experienced a major loss of control.

3. definitions • In full-blown addiction, patients continue using alcohol or drugs despite negative consequences, have a compulsion to continue using alcohol or drugs, and are in denial about the effects on themselves and others. • A practical approach for the family physician is to define addiction as the continued use of mood-altering chemicals despite an identified medical or social contraindication. • This definition is helpful because physicians do not have to consider the amounts of substances being used or the duration of use.

4. Definitions • Primary • Progressive • Chronic • Fatal

5. Definitions: DSM iv • ALCOHOL ABUSE • (A) A maladaptive pattern of drinking, leading to clinically significant impairment or distress, as manifested by at least one of the following occurring within a 12-month period: • Recurrent use of alcohol resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to alcohol use; alcohol-related absences, suspensions, or expulsions from school; neglect of children or household) • Recurrent alcohol use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by alcohol use) • Recurrent alcohol-related legal problems (e.g., arrests for alcohol-related disorderly conduct) • Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol (e.g., arguments with spouse about consequences of intoxication). • (B) Never met criteria for alcohol dependence.

6. Definitions: DSM IV • ALCOHOL DEPENDENCE • (A) A maladaptive pattern of drinking, 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: • Need for markedly increased amounts of alcohol to achieve intoxication or desired effect; or markedly diminished effect with continued use of the same amount of alcohol • The characteristic withdrawal syndrome for alcohol; or drinking (or using a closely related substance) to relieve or avoid withdrawal symptoms • Drinking in larger amounts or over a longer period than intended. • Persistent desire or one or more unsuccessful efforts to cut down or control drinking • Important social, occupational, or recreational activities given up or reduced because of drinking • A great deal of time spent in activities necessary to obtain, to use, or to recover from the effects of drinking • Continued drinking despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to be caused or exacerbated by drinking. • (B) No duration criterion separately specified, but several dependence criteria must occur repeatedly as specified by duration qualifiers associated with criteria (e.g., “persistent,” “continued”).

7. Definitions: Dsm iv DRUG DEPENDENCE (1) Tolerance, as defined by either of the following: A need for markedly increased amounts of the substance to achieve intoxication or desired effect. Markedly diminished effect with continued use of the same amount of the substance. (2) Withdrawal, as manifested by either of the following: The characteristic withdrawal syndrome for the substance (refer to Criteria A or B of the criteria sets for Withdrawal from specific substances). The same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms. (3) The substance is often taken in larger amounts or over a longer period than was intended. (4) There is a persistent desire or unsuccessful efforts to cut down or control substance use. (5) A great deal of time is spent in activities necessary to obtain the substance (such as visiting multiple doctors or driving long distances), use the substance or recover from its effects. (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.

8. Definitions: personal effects of addiction • Addiction is a disease that affects the patient physically, mentally and emotionally (spiritually) • Loss of job, possessions, family, friends • Medical problems • Incarceration • Lack of honesty, compromised morals • Denial, rationalizing, minimizing • Selfishness, self-centeredness, intolerance of others • Isolation, resentment, lack of responsibility

9. epidemiology • Substance abuse, defined as the problematic use of alcohol, tobacco, or illicit drugs, has been called the nation's number one health problem. • The costs to society are enormous; the National Institute on Alcohol Abuse and Alcoholism estimates that alcohol and drug abuse are associated with 100,000 deaths per year and cost society $100 billion per year. • It is thought that approximately 10 percent of American adults have a problem with drugs or alcohol

10. epidemiology • An estimated 20 percent of patients seen by family physicians have substance-abuse problems, excluding tobacco use. • At least half of your patients are impacted by addiction in some way. • Patients who abuse alcohol and drugs are much more likely to develop medical problems than the general population.

11. National survey on drug use and health • The National Survey on Drug Use and Health (NSDUH) is an annual survey sponsored by the Substance Abuse and Mental Health Services Administration (SAMHSA). • The survey is the primary source of information on the use of illicit drugs, alcohol, and tobacco in the civilian, noninstitutionalized population of the United States aged 12 years old or older. • Approximately 67,500 persons are interviewed each year. • Unless otherwise noted, all comparisons that are described using terms such as "increased," "decreased," or "more than" are statistically significant at the .05 level.

12. Epidemiology - alcohol • Slightly more than half (52.1 percent) of Americans aged 12 or older reported being current drinkers of alcohol. • In 2012, nearly one quarter (23.0 percent) of persons aged 12 or older were binge alcohol users in the past 30 days. This translates to about 59.7 million people • In 2012, heavy drinking was reported by 6.5 percent of the population aged 12 or older, or 17.0 million people.. Heavy drinking is defined as binge drinking on at least 5 days in the past 30 days.

13. Epidemiology - alcohol • Among young adults aged 18 to 25 in 2012, the rate of binge drinking was 39.5 percent, and the rate of heavy drinking was 12.7 percent. • The rate of current alcohol use among youths aged 12 to 17 was 12.9 percent in 2012. Youth binge and heavy drinking rates in 2012 were 7.2 and 1.3 percent, respectively • In 2012, an estimated 11.2 percent of persons aged 12 or older drove under the influence of alcohol at least once in the past year. • Among persons aged 18 to 25, the rate of driving under the influence of alcohol decreased steadily between 2002 and 2011 (from 26.6 to 18.6 percent).

14. Epidemiology - drugs • In 2012, an estimated 23.9 million Americans aged 12 or older were current (past month) illicit drug users. • This represents 9.2 percent of the population aged 12 or older. • Illicit drugs include marijuana/hashish, cocaine (including crack), heroin, hallucinogens, inhalants, or prescription-type psychotherapeutics (pain relievers, tranquilizers, stimulants, and sedatives) used non-medically. • The rate of current illicit drug use among persons aged 12 or older increased from 8.1 percent in 2008 to 9.2 percent in 2012.

15. Percentage of Americans using any illicit drug in the past month

16. Epidemiology - drugs • Marijuana was the most commonly used illicit drug. • In 2012, there were 18.9 million past month users. • Between 2007 and 2012, the rate of current use increased from 5.8 to 7.3 percent, and the number of users increased from 14.5 million to 18.9 million. • Daily or almost daily use of marijuana (used on 20 or more days in the past month) increased from 5.1 million persons in 2007 to 7.6 million persons in 2012.

17. Past month marijuana use in youth

18. Epidemiology - drugs • In 2012, there were 1.6 million current cocaine users aged 12 or older, comprising 0.6 percent of the population. • The number of past year heroin users increased between 2007 (373,000) and 2012 (669,000). • An estimated 1.1 million persons aged 12 or older in 2012 (0.4 percent) used hallucinogens in the past month. • The percentage of persons aged 12 or older who used prescription-type psychotherapeutic drugs nonmedically in the past month in 2012 (2.6 percent) was similar to the percentage in 2011 (2.4 percent) and all years from 2002 through 2010.

19. epidemiology • In the past year, prescription painkillers, like Vicodin, OxyContin, Percocet have become America’s second most prevalent illegal drug problem after marijuana.  • There are three classes of prescription drugs that are most commonly abused: • opioids such as codeine, oxycodone, and morphine; • central nervous system (CNS) depressants such as barbiturates and benzodiazepines; • stimulants such as dextroamphetamine and methylphenidate.

20. Past month non-medical use of opioids in youth

21. Epidemiology – first time drug use • In 2010, an estimated 3.0 million persons aged 12 or older used an illicit drug for the first time within the past 12 months. • A majority of these past year illicit drug initiates reported that their first drug was marijuana (61.8 percent). • About one quarter initiated with psychotherapeutics (26.2 percent, including 17.3 percent with pain relievers, 4.6 percent with tranquilizers, 2.5 percent with stimulants, and 1.9 percent with sedatives). • A sizable proportion reported inhalants (9.0 percent) as their first illicit drug, and a small proportion used hallucinogens as their first drug (3.0 percent).

22. Are we adequately treating the disease? • In 2012, 23.1 million persons aged 12 or older needed treatment for an illicit drug or alcohol use problem (8.9 percent of persons aged 12 or older). • In 2012, 2.5 million persons (10.8 percent of those who needed treatment) received treatment at a specialty facility. • In 2012, 20.6 million persons (7.9 percent of the population aged 12 or older) needed treatment for an illicit drug or alcohol use problem but did not receive treatment at a specialty facility in the past year

23. Are we adequately treating the disease? • 2.5 million persons aged 12 or older who received specialty substance use treatment in 2012. • 859,000 received treatment for alcohol use only. • 899,000 received treatment for illicit drug use only. • 633,000 received treatment for both alcohol and illicit drug use.

24. Are we adequately treating the disease? • Among persons in 2012 who received their most recent substance use treatment at a specialty facility in the past year: • 50.2 percent reported using their "own savings or earnings" as a source of payment for their most recent specialty treatment • 41.0 percent reported using private health insurance • 30.2 percent reported using public assistance other than Medicai • 28.7 percent reported using Medicaid • 24.7 percent reported using funds from family members • 24.1 percent reported using Medicare.

25. Are we adequately treating the disease? • 20.6 million persons aged 12 or older in 2012 were classified as needing substance use treatment but not receiving treatment. • 1.1 million persons (5.4 percent) reported that they perceived a need for treatment for their illicit drug or alcohol use problem. • Of these 1.1 million persons who felt they needed treatment but did not receive treatment in 2012, 347,000 (31.3 percent) reported that they made an effort to get treatment, and 760,000 (68.7 percent) reported making no effort to get treatment.

26. history

27. history • Benjamin Rush (1745-1813, revolutionary hero, chief army medical officer, and physician of repute) published An Inquiry into the Effects of Ardent Spirits on the Human Mind and Body in 1784. • “‘Drunkenness is the result of a loss of willpower. Initially drinking is purely a matter of choice. It becomes a habit and then a necessity.’ • Rush proposed the construction of detoxification establishments, asylums and ‘sober houses’, where regular offenders would be shut up until cured.” • Magnus Huss was a Swedish physician who coined the word alcoholism and was the first to define it as a chronic, relapsing disease. His book, AlcoholismusChronicus, was published in 1849.

28. history • For centuries the fate of the alcoholic in western civilization was a grim one. • Alcoholism was considered an untreatable and hopeless condition. Alcoholics were either locked in asylums permanently, or died of their disease. • By the 1930's the medical prognosis for the alcoholic was well known and almost universally proven to be inalterable.

29. history • William Duncan Silkworth, M.D., (1873-1951) was a specialist in the treatment of alcoholism. He was Director of the Charles B. Towns Hospital for Drug and Alcohol Addictions in New York City in the 1930s. • Dr. Silkworth described alcoholism as “an obsession of the mind and an allergy of the body”.

30. history • The origins of Alcoholics Anonymous can be traced to the Oxford Group, a religious movement popular in the United States and Europe in the early 20th century. • In the early 1930s, a well-to-do Rhode Islandernamed Rowland visited the noted Swiss psychoanalyst Carl Jung for help with his alcoholism. • Jung determined that Rowland’s case was medically hopeless, and that he could only find relief through a vital spiritual experience. Jung directed him to the Oxford Group. • Members of the Oxford Group practiced a formula of self-improvement by performing self-inventory, admitting wrongs, making amends, using prayer and meditation, and carrying the message to others.

31. history • Rowland later introduced fellow Vermonter Edwin (“Ebby”) T. to the group, and the two men along with several others were finally able to keep from drinking by practicing the Oxford Group principles. • One of Ebby’s schoolmate friends from Vermont, and a drinking buddy, was Bill Wilson, a New York stockbroker. • Ebbysought out his old friend at his home at 182 Clinton Street in Brooklyn, New York, to share what he had learned.

32. history • Bill Wilson had been a golden boy on Wall Street, enjoying success and power as a stockbroker, but his promising career had been ruined by continuous and chronic alcoholism. • Now, approaching 39 years of age, he was learning that his problem was hopeless, progressive, and irreversible. • He had sought medical treatment at Towns Hospital in Manhattan, but he was still drinking. • Dr. Silkworth, who was Bill’s attending physician, had a profound influence on Wilson and encouraged him to realize that alcoholism was more than just an issue of moral weakness. He introduced Wilson to the idea that alcoholism had a pathological, disease-like basis.

33. history • Bill was, at first, unconvinced by Ebby’s story of transformation and the claims of the Oxford Group. • But in December 1934, after again landing in Towns hospital for treatment, Bill underwent a powerful spiritual experience unlike any he had ever known. • His depression and despair were lifted, and he felt free and at peace. Bill stopped drinking, and the roots of Alcoholics Anonymous were planted.

34. history • In the summer of 1935, Bill traveled to Akron, OH for a business deal. • There he met Dr. Bob Smith, a prominent surgeon and alcoholic. • Their meeting ultimately led to the founding of Alcohlics Anonymous, and publication in 1939 of a book by the same name.

35. Alcoholics anonymous • Alcoholics Anonymous is a recovery program that is today practiced by over 2 million people worldwide. • The 12 steps of AA are based on the principles of the Oxford Movement. • There are AA meetings in all 50 states and in 170 countries.

36. Narcotics anonymous • Narcotics Anonymous sprang from the Alcoholics Anonymous Program of the late 1940s, and was co-founded by Jimmy Kinnon in 1953. • Narcotics Anonymous (NA) describes itself as a "nonprofit fellowship or society of men and women for whom drugs had become a major problem.” • It is the second-largest 12-step organization. • Today there are more than 61,800 NA meetings in 131 countries.

37. Addressing Alchol and drug addiction in the primary care setting

38. “red flags” commonly seen in practice • Frequent absences from school or work • History of frequent trauma or accidental injuries • Depression or anxiety • Labile hypertension • Gastrointestinal symptoms, such as epigastric distress, diarrhea, or weight changes • Sexual dysfunction • Sleep disorders • Concern expressed by family or friends

39. Screening tools • CAGE Questionnaire • Cut Down • Have you ever felt that you need to “cut down” on your drinking? • Annoyed • Are you annoyed by other peoples’ comments about your drinking? • Guilty • Have you ever felt guilty about your drinking? • Eye Opener • Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover? • Two or more positive responses strongly suggests alcoholism

40. Screening tools • Michigan Alcohol Screening Test (MAST) • A 22-question quiz with yes/no answers • This test is nationally recognized by alcoholism and drug dependence professionals. • You may substitute the words “drug use” in place of “drinking”.

41. Providing primary care • Patients who suffer from addiction fall into three groups: • Patients who are in recovery (i.e. abstinent) • Patients who are seeking recovery • Patients who are actively using alcohol or drugs, despite signs and symptoms of abuse or dependence • Family physicians should approach these patients in three different ways.

42. Providing primary care for patients who are actively abusing drugs and alcohol • These patients will generally have more health problems than patients who do not have a drug or alcohol problem. • These include: • Increased risk of STD’s • Depression and anxiety • GI problems (including pancreatitis and liver disease) • Dental problems • Other infections • Neurologic problems (Wernicke’s encephalopathy, Korsikoff syndrome, neuropathy, ataxia) • Cardiomyopathy, acute MI, arrhythmias, seizures, pulmonary edema

43. Providing primary care for patients who are actively abusing drugs and alcohol • In addition to being aware of, and treating these issues as they arise, the family physician can play an important role in motivating these patients to change. • When appropriate, explain to the patient that they meet criteria for alcoholism or drug addiction. • Let the patient know that treatment is available for their illness. • Be approachable and non-judgemental.

44. Providing primary care for patients who are actively abusing drugs and alcohol • Offer assistance to the families of alcoholics and addicts: • Referral to Al-anon • Assistance with intervention, if appropriate • Treatment for depression and anxiety • Remember that a parent who is actively using drugs in the home is reportable as child abuse to DHS

45. Providing primary care for patients who are actively abusing drugs and alcohol • Avoid prescriptions for mood-altering medications if at all possible. • It may be appropriate to have a family member (or home nursing) administer these medications if they are needed. • Cross-addiction is very common. • These patients often have increased tolerance to pain medication and anesthesia drugs, especially if they use alcohol or opiates.

46. Providing primary care for patients who are seeking recovery • Evaluate drug and alcohol use to determine if detox in a medical setting is required. • Alcohol • Opiates • Benzodiazepines • Understand and watch for delirium tremens (DT’s) in alcoholics.

47. Providing primary care to patients who are seeking recovery • Ambulatory detox may be appropriate for motivated patients with mild to moderate symptoms. A family member can sometimes assist with this process. • Determine if treatment is needed • Inpatient (7-90 days) • Outpatient (Intensive or extended) • Long term care (halfway house)

48. Providing primary care for patients who are seeking recovery • Make appropriate referrals for chemical dependency evaluation. • Have the patient follow up during or immediately after treatment. • Encourage participation in AA and/or NA.

49. Providing primary care for patients who are seeking recovery • Be aware of potential problems in early recovery: • Relapse • Post-acute withdrawal (PAWS) • Disruption of sleep patterns; nutrition and weight gain • Depression and anxiety – SSRI’s • Increased sensitivity to stress; relationship/family issues

50. Post-acute withdrawal syndrome (PAWS) • Loss of concentration, decreased problem-solving ability • Memory problems • Emotional lability • Loss of physical coordination • Memory problems • Inability to cope with stress