back to basics: substance use/abuse/withdrawal melanie willows b.sc. c.c.f.p. c.a.s.a.m. c.c.s.a.m....

of 73 /73
Back to Basics: Substance Use/Abuse/Withdrawal Melanie Willows B.Sc. C.C.F.P. C.A.S.A.M. C.C.S.A.M. Clinical Director Substance Use and Concurrent Disorders Program The Royal Assistant Professor University of Ottawa

Author: kristin-higgins

Post on 17-Dec-2015

212 views

Category:

Documents


0 download

Embed Size (px)

TRANSCRIPT

  • Slide 1
  • Back to Basics: Substance Use/Abuse/Withdrawal Melanie Willows B.Sc. C.C.F.P. C.A.S.A.M. C.C.S.A.M. Clinical Director Substance Use and Concurrent Disorders Program The Royal Assistant Professor University of Ottawa
  • Slide 2
  • LMCC Objectives Key Objectives Given a patient with an addiction or a substance abuse problem, be able to identify the issue, potential consequences and the need to provide immediate and continuing support and intervention. Given a patient with suspected substance withdrawal, the candidate will diagnose the cause, severity and complications, and will initiate an appropriate management plan.
  • Slide 3
  • LMCC Objectives Objectives List and interpret critical investigations including history, physical exam, drug and alcohol screening, risk of withdrawal, critical laboratory investigations Determine an effective initial management plan which may include brief intervention, supportive measures, safe environment, pharmacological interventions, or referral to specialized services
  • Slide 4
  • Addiction Addiction may be to substances or may be a process (behavioral) addiction. Depressants: Alcohol, Opioids, Benzodiazepines Stimulants: Cocaine, Amphetamines Hallucinogens: Marijuana Process (behavioural): Gambling Sex, Food, Internet (not in the DSM IV)
  • Slide 5
  • Addiction Reward pathway involves the nucleus accumbens, ventral tegmental area (VTA) and the prefrontal cortex Drugs of abuse act on the reward centre resulting in dopamine flooding....brain either produces less dopamine or downregulates dopamine receptors...net result is lower baseline dopamine...need to take more drug to increase dopamine
  • Slide 6
  • Causal Factors/Risk Factors Individual: Genetics, Mental Health Exposure to drug or experience (gambling) Environmental: trauma, poverty, peers
  • Slide 7
  • Case Mary is a 43 year old woman. Her mother and father both had alcohol problems. Her home life was filled with fighting and chaos. She was sexually abused by her uncle and grandfather. Mary started using drugs and alcohol when she was 13. She was diagnosed with schizophrenia at the age of 25.
  • Slide 8
  • Taking a History What is the purpose of taking a drug and alcohol history? Answer: To make a Diagnosis Medical and psychosocial history will influence management
  • Slide 9
  • DSM IV Criteria for Substance Dependence 3 or more occurring over 12 months tolerance withdrawal larger amounts or longer period of time unsuccessful efforts to cut down or control time spent obtaining, using, recovering activities given up or reduced continued use despite problems
  • Slide 10
  • DSM IV Criteria for Substance Abuse A. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following occurring within a 12 month period: 1. recurrent substance use resulting in a failure to fulfill major obligations at work, school, or home 2. recurrent substance use in situations in which it is physically hazardous 3. recurrent substance-related legal problems 4. continued use despite persistent or recurrent social or interpersonal problems caused by or exacerbated by effects of a substance B. The symptoms have never met the criteria for substance dependence for this class of substance.
  • Slide 11
  • Taking a Drug and Alcohol History History of Substance Use Past substance abuse treatment history: type of program, ?completed, attendance at AA or NA. Substances used: alcohol, marijuana, cocaine, heroin, tobacco, prescription/OTC drugs (opiates, benzodiazepines, gravol), ecstasy, crystal meth For each substance used: first use, current use, pattern of use, route, and last use
  • Slide 12
  • Quantifying Alcohol and Drug Use Alcohol One standard drink= 13.6 grams of alcohol 5 oz/142ml wine (12% alcohol) 1.5 oz/43ml hard liquor (40% alcohol) 12 oz/341 ml beer (5% alcohol) Hard Liquor: 1 bottle -13 oz. Mickey = 8 standard drinks -26 oz./750 ml = 17 standard drinks -40 oz./1.14L = 27 standard drinks Wine: 1 Bottle -26 oz./750ml = 5 standard drinks Beer: ask what size? 500ml, 710ml (=2 standard drinks)
  • Slide 13
  • One Standard Drink (equivalent to 13.6 grams of alcohol) 341 ml (12 oz.) bottle of 5% alcohol beer, cider or cooler 142 ml (5 oz.) glass of 12% alcohol wine 43 ml (1.5 oz.) serving of 40% distilled
  • Slide 14
  • Quantifying Alcohol and Drug Use Marijuana Measured in grams, 1 ounze equals 28 grams How many grams? Pattern of use. Cocaine Powder(snort or IV) or crack/freebase/rock form (smoke) 8 ball equals 3.5 grams; speedball is cocaine and heroin
  • Slide 15
  • Quantifying Alcohol and Drug Use Benzodiazepines Total amount used per day, how many years taking (assessing for risk of withdrawal) Source of medication Opioids Which opioid? Oxy, Dilaudid (hydromorph), Fentanyl, morphine, codeine, heroin How much? What route? (IV, smoked, snorted, chewed, swallowed) How often?
  • Slide 16
  • Taking an Alcohol and Drug History Ask about blackouts, loss of control of use. Withdrawal symptoms when stopping use: Alcohol (shakes, seizures, DTs, hallucinations); Opioids ( nausea, vomiting, abdominal cramps, diarrhea, chills/hot flashes, myalgias/arthralgias, pilo-erection) Tolerance Consequences of Using: health problems (physical, mental), work or school problems, legal problems, involvement with CAS, effect on family/friends/children, financial problems.
  • Slide 17
  • Case 2 Lisa started smoking marijuana and drinking alcohol when she was 13. She started using cocaine when she was 15. She currently smokes 2 grams of marijuana a day. Smokes crack cocaine 2-3 times per week usually a 40 piece. She drinks 6 tall beers (710ml) per day. Four years ago she was prescribed oxycodone for injuries she sustained when she was beaten up by a boyfriend. Within one month she was snorting 160mg daily and has now switched to smoking a 50ug fentanyl patch per day.
  • Slide 18
  • Taking a Drug and Alcohol History Family History family history of alcohol or drug problems in blood relatives (biggest risk factor for development of addiction) Social History marital status, current relationship, children living arrangements, use of alcohol/drugs in the home education level, current employment/disability family of origin: marital status of parents, relationship with parents and siblings, abusive environment Legal History past or current legal charges or convictions (DUI, assault, theft, possession, trafficking etc.)
  • Slide 19
  • Taking a Drug and Alcohol History Past Psychiatric History inpatient admissions, outpatient counseling, suicide attempts any diagnosis ever given: trauma, anxiety, depression medications prescribed in past and present Medical History all medical problems and surgeries HIV and Hepatitis C accidents related to substance use Medications list of all current medications and dosing ask about use/abuse of over the counter medication
  • Slide 20
  • Case 2 Lisa is Hepatitis C positive. She lives in subsidized housing. She frequently uses with her next door neighbour who is addicted to crack cocaine. She has no family in town. She has two children who were taken from her care 15 years ago because of her drug use and mental health instability.
  • Slide 21
  • Screening Questionnaires CAGE CRAFFT (adolescents) AUDIT (Alcohol Use Disorders Identification Test) DAST (The Drug Abuse Screening Test)
  • Slide 22
  • CAGE Questionnaire (Screening Questionnaire for Alcohol Disorders) Have you ever felt you should CUT DOWN on your drinking? Have people ANNOYED you by criticizing your drinking? Have you ever felt bad or GUILTY about your drinking? Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (EYE-OPENER) Score of 2 or more indicates a problem Sensitivity 75-85%
  • Slide 23
  • How do addiction issues present? Sometimes patients do not initially disclose that they have a substance problem It is sometimes only by reviewing their clinical presentation that we start to suspect they may have a substance problem
  • Slide 24
  • Potential Clinical Presentation of Alcohol and Drug Problems Cardiovascular: hypertension, cardiomyopathy GI: fatty liver, hepatitis, cirrhosis, gastritis, pancreatitis, dyspepsia, recurrent diarrhea Neurological: ataxia, tremor, peripheral neuropathy, cerebellar disease, dementia, Wernicke-Korsakoffs syndrome Infections (injection drug use): cellulitis, abscess, Hepatitis C, endocarditis
  • Slide 25
  • Potential Clinical Presentation of Alcohol and Drug Problems Trauma: accidents, violence, suicide Psychiatric: fatigue, insomnia, depression, anxiety, psychosis Behavioural: missed appointments, non-compliance, drug-seeking Social: deterioration in social functioning, spousal abuse, violence, legal problems Other: weight loss, loss of libido
  • Slide 26
  • Case 3 John is a 53 year old man who has been drinking alcohol daily for 25 years. He is currently drinking 20 oz of hard liquor per day. He presents today with uncontrolled hypertension, complaints of insomnia, abdominal pain, diarrhea, anxiety, and depression.
  • Slide 27
  • Physical Examination in Cases of Suspected Alcohol or Drug Abuse/Dependence BP, heart rate, pupils Level of consciousness, Mental Status Exam Signs of liver disease (hepatomegaly, spider nevae, jaundice, ascites) Signs of withdrawal/intoxication Injection marks and bruising in arms, wrists, legs, ankles, neck, inguinal region Long history of alcohol use (10+ years): hypertension, cardiomyopathy, dementia, gait (cerebellar dysfunction), distal polyneuropathy
  • Slide 28
  • Case 3 John comes to see you three years later after a recent hospitalization. You barely recognize him as he walks into your office with a walker. He is jaundiced, his face is very thin and his abdomen is distended.
  • Slide 29
  • Laboratory Investigations in Cases of Suspected Alcohol or Drug Abuse or Dependency CBC (increased MCV, decreased platelets), GGT (to detect heavy alcohol consumption) AST, ALT (to detect alcoholic or viral hepatitis) Cirrhosis: INR, albumin, bilirubin Urine drug screen Hepatitis B, C, and HIV (ask permission first)
  • Slide 30
  • Case John has been diagnosed with cirrhosis and continues to drink. His MCV is elevated at 103(80- 97). His platelets are depressed at 70(145-450). GGT is 342(24 hours) synthetic opioid agonist, require methadone exemption to prescribe Buprenorphine/Naloxone (Suboxone): long acting synthetic partial opioid agonist, naloxone component present to prevent IV abuse Naloxone: opioid antagonist, used in opioid overdose kits
  • Slide 49
  • Pharmacological Interventions Nicotine NRT (patch, gum, lozenge, inhaler) Zyban (Wellbutrin, Bupropion)- not if seizure d/o Champix (Varenicycline)-monitor for psych symptoms
  • Slide 50
  • Types of Treatment Options Mutual Help Groups: Alcoholics Anonymous, Narcotics Anonymous, Women for Sobriety, SMART recovery Withdrawal Management Outpatient Treatment (once weekly, daily) Residential Treatment programs (ranging from 21 days to 9 months+) Medically Supervised Treatment programs Individual Counseling Opioid Substitution Therapy Harm Reduction approaches
  • Slide 51
  • References DSM IV Diagnostic & Statistical Manual of Mental Disorders 4 th Ed. Test Revision 2000 Substance Abuse: A Comprehensive Textbook 4 th Ed. Lewinson et al. 2005 Management of Alcohol, Tobacco, & Other Drug Problems, Edited by Bruno Brands Phd. Addiction Research Foundation 2000 Principles of Addiction Medicine 4 th ed., American Society of Addiction Medicine. 2009
  • Slide 52
  • References NIDA National Institute on Drug Abuse NIAAA National Institute on Alcohol Abuse and Alcoholism Butt, P., Beirness, D., Cesa, F., Gliksman, L., Paradis, C., & Stockwell, T. (2011). Alcohol and health in Canada: A summary of evidence and guidelines for low-risk drinking. Ottawa, ON: Canadian Centre on Substance Abuse.
  • Slide 53
  • Differentiating between substance dependence and substance abuse Criteria for substance abuse does not include tolerance, withdrawal, or a pattern of compulsive use Although not listed as a criterion item, CRAVING (a strong subjective drive to use the substance) is likely to be experienced by most individuals with substance dependence High blood levels of the substance coupled with little evidence of intoxication suggests tolerance is likely
  • Slide 54
  • Differentiating between substance dependence and substance abuse Criteria for substance abuse does not include tolerance, withdrawal, or a pattern of compulsive use Although not listed as a criterion item, CRAVING (a strong subjective drive to use the substance) is likely to be experienced by most individuals with substance dependence High blood levels of the substance coupled with little evidence of intoxication suggests tolerance is likely
  • Slide 55
  • Canadian Guidelines for Low Risk Drinking 1.Reduce your long-term health risks by drinking no more than: 10 drinks a week for women, with no more than 2 drinks a day most days 15 drinks a week for men, with no more than 3 drinks a day most days Plan non-drinking days every week to avoid developing a habit. 2. Reduce your risk of injury and harm by drinking no more than 3 drinks (for women) and 4 drinks (for men) on any single occasion.
  • Slide 56
  • Canadian Guidelines for Low Risk Drinking 3. Do not drink when you are: driving a vehicle or using machinery and tools taking medicine or other drugs that interact with alcohol doing any kind of dangerous physical activity living with mental or physical health problems living with alcohol dependence pregnant or planning to be pregnant responsible for the safety of others making important decisions
  • Slide 57
  • Canadian Guidelines for Low Risk Drinking 4. If you are pregnant, planning to become pregnant, or before breastfeeding, the safest choice is to drink no alcohol at all. 5. If you are a child or youth, you should delay drinking until your late teens. Talk with your parents about drinking. Alcohol can harm the way your brain and body develop. If you are drinking, plan ahead, follow local alcohol laws and stay within the limits outlined in Guideline 1.
  • Slide 58
  • Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) Patient:__________________________ Date: ________________ Time: _______________ (24 hour clock, midnight = 00:00) Pulse or heart rate, taken for one minute:_________________________ Blood pressure:______ NAUSEA AND VOMITING -- Ask "Do you feel sick to your stomach? Have you vomited?" Observation. 0 no nausea and no vomiting 1 mild nausea with no vomiting 2 3 4 intermittent nausea with dry heaves 5 6 7 constant nausea, frequent dry heaves and vomiting
  • Slide 59
  • Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) TACTILE DISTURBANCES -- Ask "Have you any itching, pins and needles sensations, any burning, any numbness, or do you feel bugs crawling on or under your skin?" Observation. 0 none 1 very mild itching, pins and needles, burning or numbness 2 mild itching, pins and needles, burning or numbness 3 moderate itching, pins and needles, burning or numbness 4 moderately severe hallucinations 5 severe hallucinations 6 extremely severe hallucinations 7 continuous hallucinations
  • Slide 60
  • Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) TREMOR -- Arms extended and fingers spread apart. Observation. 0 no tremor 1 not visible, but can be felt fingertip to fingertip 2 3 4 moderate, with patient's arms extended 5 6 7 severe, even with arms not extended
  • Slide 61
  • Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) AUDITORY DISTURBANCES -- Ask "Are you more aware of sounds around you? Are they harsh? Do they frighten you? Are you hearing anything that is disturbing to you? Are you hearing things you know are not there?" Observation. 0 not present 1 very mild harshness or ability to frighten 2 mild harshness or ability to frighten 3 moderate harshness or ability to frighten 4 moderately severe hallucinations 5 severe hallucinations 6 extremely severe hallucinations 7 continuous hallucinations
  • Slide 62
  • Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) PAROXYSMAL SWEATS -- Observation. 0 no sweat visible 1 barely perceptible sweating, palms moist 2 3 4 beads of sweat obvious on forehead 5 6 7 drenching sweats
  • Slide 63
  • Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) VISUAL DISTURBANCES - Ask "Does the light appear to be too bright? Is its color different? Does it hurt your eyes? Are you seeing anything that is disturbing to you? Are you seeing things you know are not there?" Observation. 0 not present 1 very mild sensitivity 2 mild sensitivity 3 moderate sensitivity 4 moderately severe hallucinations 5 severe hallucinations 6 extremely severe hallucinations 7 continuous hallucinations
  • Slide 64
  • Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) ANXIETY -- Ask "Do you feel nervous?" Observation. 0 no anxiety, at ease 1 mild anxious 2 3 4 moderately anxious, or guarded, so anxiety is inferred 5 6 7 equivalent to acute panic states as seen in severe delirium or acute schizophrenic reactions
  • Slide 65
  • Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) HEADACHE, FULLNESS IN HEAD -- Ask "Does your head feel different? Does it feel like there is a band around your head?" Do not rate for dizziness or lightheadedness. Otherwise, rate severity. 0 not present 1 very mild 2 mild 3 moderate 4 moderately severe 5 severe 6 very severe 7 extremely severe
  • Slide 66
  • Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) AGITATION -- Observation. 0 normal activity 1 somewhat more than normal activity 2 3 4 moderately fidgety and restless 5 6 7 paces back and forth during most of the interview, or constantly thrashes about
  • Slide 67
  • Clinical Institute Withdrawal Assessment of Alcohol Scale, Revised (CIWA-Ar) ORIENTATION AND CLOUDING OF SENSORIUM -- Ask "What day is this? Where are you? Who am I?" 0 oriented and can do serial additions 1 cannot do serial additions or is uncertain about date 2 disoriented for date by no more than 2 calendar days 3 disoriented for date by more than 2 calendar days 4 disoriented for place/or person Total CIWA-Ar Score ______ Rater's Initials ______ Maximum Possible Score 67 The CIWA-Ar is not copyrighted and may be reproduced freely. This assessment for monitoring withdrawal symptoms requires approximately 5 minutes to administer. The maximum score is 67 (see instrument). Patients scoring less than 10 do not usually need additional medication for withdrawal.
  • Slide 68
  • COWS (Clinical Opioid Withdrawal Scale) Resting Pulse Rate: _________beats/minute Measured after patient is sitting or lying for one minute 0 pulse rate 80 or below 1 pulse rate 81-100 2 pulse rate 101-120 4 pulse rate greater than 120 Sweating: over past hour not accounted for by room temperature or patient activity. 0 no report of chills or flushing 1 subjective report of chills or flushing 2 flushed or observable moistness on face 3 beads of sweat on brow or face 4 sweat streaming off face Restlessness Observation during assessment 0 able to sit still 1 reports difficulty sitting still, but is able to do so 3 frequent shifting or extraneous movements of legs/arms 5 Unable to sit still for more than a few seconds
  • Slide 69
  • COWS (Clinical Opioid Withdrawal Scale) Pupil size 0 pupils pinned or normal size for room light 1 pupils possibly larger than normal for room light 2 pupils moderately dilated 5 pupils so dilated that only the rim of the iris is visible Bone or Joint aches If patient was having pain previously, only the additional component attributed to opiates withdrawal is scored 0 not present 1 mild diffuse discomfort 2 patient reports severe diffuse aching of joints/ muscles 4 patient is rubbing joints or muscles and is unable to sit still because of discomfort Runny nose or tearing Not accounted for by cold symptoms or allergies 0 not present 1 nasal stuffiness or unusually moist eyes 2 nose running or tearing 4 nose constantly running or tears streaming down cheeks
  • Slide 70
  • COWS (Clinical Opioid Withdrawal Scale) GI Upset: over last hour 0 no GI symptoms 1 stomach cramps 2 nausea or loose stool 3 vomiting or diarrhea 5 Multiple episodes of diarrhea or vomiting Tremor observation of outstretched hands 0 No tremor 1 tremor can be felt, but not observed 2 slight tremor observable 4 gross tremor or muscle twitching Yawning Observation during assessment 0 no yawning 1 yawning once or twice during assessment 2 yawning three or more times during assessment 4 yawning several times/minute
  • Slide 71
  • COWS (Clinical Opioid Withdrawal Scale) Anxiety or Irritability 0 none 1 patient reports increasing irritability or anxiousness 2 patient obviously irritable anxious 4 patient so irritable or anxious that participation in the assessment is difficult Gooseflesh skin 0 skin is smooth 3 piloerrection of skin can be felt or hairs standing up on arms 5 prominent piloerrection Total Score ________ The total score is the sum of all 11 items Initials of person completing Assessment: ______________ Score: 5-12 = mild; 13-24 = moderate; 25-36 = moderately severe; more than 36 = severe withdrawal
  • Slide 72
  • Pathological Gambling Persistent and recurrent maladaptive gambling behaviour as indicated by five (or more) of the following: 1. is preoccupied with gambling (e.g. preoccupied with reliving past gambling experiences, handicapping or planning the next venture, or thinking of ways to get money with which to gamble) 2. Needs to gamble with increasing amounts of money in order to achieve the desired excitement. 3. Has repeated unsuccessful efforts to control, cut back or stop gambling 4. is restless or irritable when attempting to cut down or stop gambling 5. gambles as a way of escaping from problems or of relieving a dysphoric mood (e.g. feelings of helplessness, guilt, anxiety, depression) 6. after losing money gambling, often returns another day to get even (chasing ones losses) 7. Lies to family members, therapist or others to conceal the extent of involvement with gambling 8.Has committed illegal acts such as forgery, fraud, theft or embezzlement to finance gambling 9. Has jeopardized or lost a significant relationship, job, or educational or career opportunity because of gambling 10 relies on others to provide money to relieve a desperate financial situation caused by gambling B. The gambling behaviour is not better accounted for by a Manic Episode.
  • Slide 73
  • Drug Testing - Opioids Immunoassay: detects morphine, does not differentiate between opioids and has poor sensitivity for oxycodone and meperidine; 3-4 day detection period Chromotography required to identify specific opioids, but only 1-2 day detection period Heroin: metabolite 6-monoacetylmorphine detected by chromatography for