substance use disorders pre-clerkship lecture katherine allen, pgy4 psychiatry april 4, 2014 special...

Substance Use Disorders

Pre-Clerkship LectureKatherine Allen, PGY4 psychiatry

April 4, 2014

Special Thanks to Melanie Willows, Clinical Director SUCD Program Royal Ottawa Hospital

Objectives

• Epidemiology of Substance Use Disorders (SUD)

• DSM-5 Definition of SUD• What causes addiction?• Substance Use and Concurrent Disorders

(SUCD) assessment – History, Physical Exam, Investigations

• Management of Substance Use Disorders

Canadian Alcohol and Drug Use Monitoring Survey 2011 (CADUMS)

Pattern of Drinking Percent Reporting

Exceed chronic guideline (>10 drinks per week or more than 2 drinks per occasion for women or >15 drinks per week or more than 3 drinks per occasion for men

10.1%

Exceed acute guideline : 3 or more per occasion for women or 4 or more per occasion for men

14.1%

Past year any consumption of alcohol 78%

Epidemiology of Alcohol Use Disorders

• Twelve month prevalence is highest among individuals 18-29 years old (16.2%) and lowest among individuals age 65 and older (1.5%)

• Twelve month prevalence among adults age 18 years and older in the United States estimated to be 8.5%

• Rates of alcohol use disorders is greater among adult men (12.4%) than adult women (4.9%)

Epidemiology 2013 Ontario Student Drug & Health Use Study (OSDUHS) CAMH

• Data from 10272 students from 198 schools grades 7-12• Use in the past year

– Alcohol 49.5%– Cannabis 23%– Opioid pain relievers 12.4%

• 19.8% of students reported binge drinking at least once during the month preceding the survey

• Approximately 3% of students (25 800) use cannabis daily

Table 1. Past Year Drug Use (%) for the Total Sample, and by Sex and Grade, 2013 OSDUHS (CAMH)

Total Male Female G7 G8 G9 G10 G11 G12

Alcohol 49.5 49.8 49.1 9.9 24.6 37.1 53.5 67.9 74.4

Cannabis 23.0 25.3 20.6 1.7 7.0 14.6 24.5 33.5 39.2

Binge Drinking

19.8 21.3 18.3 3.7 8.5 18.1 29.5 39.2

Opioid Pain Relievers (NM)

12.4 12.8 12.0 8.8 8.9 11.8 13.0 12.1 16.1

Cigarettes 8.5 9.6 7.3 3.3 9.1 12.9 15.4

DSM 5 Criteria for SUD

• Criterion A criteria fit within the overall groupings of:– Impaired Control (criteria 1-4)– Social Impairment (criteria 5-7)– Risky Use (criteria 8-9)– Pharmacological (criteria 10-11)


A. A problematic pattern of substance use leading to clinically significant impairment or distress, as manifested by at least two of the following 11 criteria, occurring within a 12 month period.

• 1. Substance is often taken in larger amounts or over a longer period than was intended

• 2. There is a persistent desire or unsuccessful effort to cut down or control substance use

• 3. A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects

• 4. Craving or a strong desire or urge to use the substance

Impaired Control criteria (1-4)


• 5. Recurrent substance use 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; substance-related absences, suspensions, or expulsions from school; neglect of children or household)

• 6. Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance

• 7. Important social, occupational, or recreational activities are given up or reduced because of the substance use

Social Impairment Criteria (5-7)


8. Recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use

9. 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

Risky Use Criteria (8-9)


10. Tolerance, as defined by either of the following:a. A need for markedly increased amounts of substance to achieve intoxication or desired effectb. A markedly diminished effect with continued use of the same amount of the substance

11. Withdrawal, as manifested by either of the following:a. The characteristic withdrawal syndrome for the substanceb. The same (or a closely related) substance is taken to relieve or avoid

withdrawal symptoms

Pharmacological Criteria (10-11)


• Early Remission. This specifier is used if, for at least 3 months, but for less than 12 months, the individual does not meet any of the criteria for a Substance Use Disorder (with the exception of Criterion 4, “Craving or a strong desire or urge to use a specific substance”).

• Sustained Remission. This specifier is used if none of the criteria for a Substance Use Disorder have been met at any time during a period of 12 months or longer (with the exception of Criterion 4, “Craving or a strong desire or urge to use a specific substance”).

• Severity Scale: Specify Current Severity

– Mild: presence of 2-3 symptoms– Moderate: presence of 4-5 symptoms– Severe: presence of 6 or more symptoms


• Specifiers of remission– In a controlled environment (e.g. substance free

jails, therapeutic communities, locked hospital wards)

– On maintenance therapy (for opioid use disorders, if individual is prescribed agonist medication such as methadone or buprenorphine and none of the criteria for opioid use disorder have been met (except tolerance to, or withdrawal from, the agonist)

Physical Dependence• Physical dependence is a state of adaptation that is

manifested by a drug class-specific withdrawal syndrome that can be produced by abrupt cessation, rapid dose reduction, decreasing blood level of the drug and/or administration of an antagonist.

• Physical dependence does not necessarily mean Substance Use Disorder***

• Symptoms of tolerance and withdrawal that occur during appropriate medical treatment with prescribed medication (e.g. opioids, sedatives, stimulants) are specifically not counted when diagnosing a substance use disorder.

CLASSIFICATION OF SUBSTANCES

• DEPRESSANTS: alcohol, opioids, benzodiazepines

• STIMULANTS: cocaine, amphetamines• HALLUCINOGENS: cannabis, LSD, PCP

DSM 5 Substance Intoxication• A. Recent use of …..• B. Clinically significant problematic behavioural or

psychological changes (e.g. ….) that developed …. (time period) …

• C. List of signs and symptoms and number required

• D. Signs and symptoms are not attributable to another medical condition, not better explained by another mental disorder, including (intoxication or withdrawal) with/from another substance

DSM 5 Substance Withdrawal• A. Cessation of (or reduction in) substance use that has been

heavy and prolonged.• B. Signs and symptoms developing within …. (time period) ….

after the cessation of (or reduction in ) substance use described in Criterion A and number of criteria required

• C. Signs and symptoms in Criterion B cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

• D. Signs and symptoms not attributable to another medical condition and are not better explained by another mental disorder including intoxication or withdrawal from another substance.

DSM 5 Alcohol/Benzodiazepine Intoxication

• A. Recent use of substance (A/B)• B. Clinically significant maladaptive behavioural or psychological changes that

developed during, or shortly after use (A/B) (inappropriate sexual or aggressive behaviour, mood lability, impaired judgement)

• C. One (or more) of the following signs or symptoms developing during, or shortly after use (A/B)– 1. Slurred speech– 2. Incoordination– 3. Unsteady gait– 4. Nystagmus– 5. Impairment in cognition (e.g. attention, memory)– 6. Stupor or coma

• D. Signs or symptoms not attributable to another medical condition, mental disorder, including intoxication with another substance.

DSM 5 Alcohol/Benzodiazepine Withdrawal

• A. Cessation of (or reduction in ) substance use (A/B) that has been prolonged.• B. Two (or more) of the following developing within several hours to a few days

after cessation of (or reduction in ) A/B– 1. Autonomic hyperactivity (e.g. sweating or pulse rate greater than 100)

(A/B)– 2. Increased hand tremor (A/B)– 3. Insomnia (A/B)– 4. Nausea or vomiting (A/B)– 5. Transient visual, tactile, or auditory hallucinations or illusions (A/B)– 6. Psychomotor agitation (A/B)– 7. Anxiety (A/B)– 8. Grand mal seizures (A/B)

• C. Signs and symptoms in Criterion B cause clinically significant distress or impairment in social, occupational. Or other important areas of functioning

• D. Signs and symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication or withdrawal from another substance.

Benzodiazepine Discontinuation Symptoms

• Very frequent: anxiety, insomnia, restlessness, agitation, irritability, muscle tension

• Common but less frequent: nausea, diaphoresis, lethargy, hyperacusis, aches and pains, blurred vision, depression, nightmares, hyperreflexia, ataxia

• Uncommon: psychosis, seizures, persistent tinnitus, paranoid delusions, hallucinations

REBOUND• Rebound is usually described in relation to

benzodiazepines• It is marked by the development of symptoms

within hours to days of drug discontinuation that are qualitatively similar to the disorder for which the drug was originally prescribed. (i.e. insomnia, anxiety)

• Symptoms are transiently more intense than they were prior to drug treatment

• Symptoms are of short duration and are self-limited

Opioids

• Opioids include substances that are directly derived from the opium poppy (i.e. morphine, codeine), semisynthetic opioids (heroin), and synthetic opioids (percocet, demerol, dilaudid, oxycontin, fentanyl)

• Opioids work on mu receptors• Opioid receptors are located in the brain, spinal

cord, gastrointestinal tract, autonomic nervous system and white blood cells

DSM 5 Opioid Intoxication• A. Recent use of an opioid• B. Clinically significant problematic behavioural or psychological changes

developing during or shortly after use. (e.g. initial euphoria followed by apathy, dysphoria, pyschomotor agitation or retardation, impaired judgement)

• C. Pupillary constriction (or pupillary dilation due to anoxia from severe overdose) and one or more of the following signs or symptoms

– 1. Drowsiness or coma– 2. Slurred speech– 3. Impairment in attention or memory

• D. Signs and Symptoms not attributable to another medical condition, mental disorder including intoxication with another substance

DSM 5 Opioid Withdrawal• A. Presence of either of the following:

– 1. Cessation of or reduction in opioid use that has been heavy and prolonged– 2. Administration of an opioid antagonist after a period of opioid use

• B. Three or more of the following developing within minutes to several days after Criterion A– 1. Dysphoric mood– 2. Nausea or Vomiting– 3. Muscle Aches– 4. Lacrimation or rhinorrhea– 5. Pupillary dilation, piloerection, or sweating– 6. Diarrhea– 7. Yawning– 8. Fever– 9. Insomnia

• C. Signs and Symptoms in B cause clinically significant distress or impairment….• D. Signs or Symptoms..medical, mental, including intoxication or withdrawal…

How Amphetamines Work

• Amphetamines are indirect catecholamine agonists and result in the release of newly synthesized norepinephrine and dopamine

• Amphetamine also blocks the reuptake of dopamine and norepinephrine

DSM 5 Stimulant Intoxication

• A. Recent use of amphetamine-type substance, cocaine, or other stimulant

• B. Clinically significant problematic behavioural or psychological changes (e.g. euphoria or affective blunting, changes in sociability, hypervigilance, interpersonal sensitivity, anxiety, tension or anger; stereotyped behaviours, impaired judgement) that developed during or shortly after, use of a stimulant.

DSM 5 Stimulant Intoxication• C. Two or more of the following signs or symptoms, developing during, or shortly

after, stimulant use:– 1. Tachycardia or bradycardia– 2. Pupillary dilation– 3. Elevated or lowered blood pressure– 4. Perspiration or chills– 5. Nausea or vomiting– 6. Evidence of weight loss– 7. Psychomotor agitation or retardation– 8. Muscular weakness, respiratory depression, chest pain, or cardiac

arrhythmias– 9. Confusion, seizures, dyskinesias, dystonias, or coma

• D. Signs and Symptoms are not attributable to another medical condition, mental disorder, or intoxication with another substance

DSM 5 Stimulant Withdrawal• A. Cessation of (or reduction in ) prolonged amphetamine-type substance,

cocaine or other stimulant use• B. Dysphoric mood and two (or more) of the following physiological

changes, developing within hours to several days after criterion A, – 1. Fatigue– 2. Vivid, unpleasant dreams– 3. Insomnia or hypersomnia– 4. Increased appetite– 5. Psychomotor retardation, or agitation

• C. Signs and symptoms cause clinically significant distress and impairment in social, occupational, or other important areas of functioning

• D. Signs and symptoms not attributable to another medical condition, mental disorder or intoxication or withdrawal from another substance

Cannabis• THC (delta-tetrahydrocannabinol) is principal

psychoactive ingredient - amount in a sample can vary greatly

• THC is lipophilic ( “fat loving”) and therefore easily deposits in the fat stores of the body and in heavy marijuana users (>3 joints per week) can take months to a year to clear from fatty tissues including the brain

• Because of long half-life, withdrawal signs and symptoms are not as dramatic as alcohol

DSM 5 Cannabis Intoxication• A. Recent use of cannabis• B. Clinically significant problematic behaviour or psychological changes

(e.g. impaired motor co-ordination, euphoria, anxiety, sensation of slowed time, impaired judgement, social withdrawal)…

• C. Two (or more) of the following signs or symptoms developing within 2 hours of cannabis use:

– 1. Conjunctival injection– 2. Increased appetite– 3. Dry mouth– 4. Tachycardia

• D. The signs or symptoms are not attributable to another medical condition and are not better explained by another mental disorder, including intoxication with another substance

DSM 5 Cannabis Withdrawal A. Cessation of cannabis use that has been heavy and prolonged• B. 3 or more of the following signs and symptoms develop within approximately

1 week of Criterion A– 1. Irritability, anger or aggression– 2. Nervousness or anxiety– 3. Sleep difficulty (insomnia, disturbing dreams) – 4. Decreased appetite or weight loss– 5. Restlessness– 6. Depressed mood– 7. At least one of the following physical symptoms causing

significant discomfort: abdominal pain, shakiness/tremors, sweating, fever, chills, or headache

• C. Signs or symptoms cause clinically significant distress or impairment…• D. Signs or symptoms not attributable to medical condition, mental disorder, or

intoxication or withdrawal from another substance

What Causes Addiction?

Why do people use mood altering drugs?

• To feel good

– Pleasure– Relax

• To feel better

– Anxiety/Worries– Depression– Pain– Fear

• To satisfy curiosity (experimentation)• To attain a sense of “belonging” to a group

Risk Factors for Addiction Genetics 40-60%

AGENT : availability, cost, rapidity with which the agent reaches the brain, efficacy of the agent as a tranquilizer

ENVIRONMENT: low socioeconomic class, poor parental support, peer group, chaotic family

HOST: genetic predisposition, psychiatric disorders

http://z.about.com/d/alcoholism/1/0/E/v/1/cocaine06.jpg

http://blog.cityspk.com/wp-content/uploads/2008/12/alleyfix_sml.jpg

Addiction as a Disease

• Initial decision to take drugs is mostly voluntary.• Repeated administration of certain drugs causes

changes in the functioning of the brain (mesolimbic dopamine system)

• Repeated self-administration of drugs produces a change in how the brain functions, leading to loss of an individuals ability to control use of substance

NIDA

Anyone can become addicted!

VULNERABLE HOST+

RIGHT(WRONG) ENVIRONMENT +

REPEATED ADMINISTRATION OF DRUG=

ADDICTION

How do drugs work in the brain to produce pleasure?

• All drugs of abuse target the brain’s reward system by flooding the circuit with dopamine (either directly or indirectly).

• Dopamine is present in regions of the brain that regulate movement, emotion, cognition, motivation and feelings of pleasure.

• Overstimulation of the reward system produces the euphoric effects sought by people who abuse drugs and teaches them to repeat the behaviour.

NIDA

The Reward Pathway

When activated by a rewarding stimulus (e.g., food, water, sex), information travels from the VTA to the nucleus accumbens and then up to the prefrontal cortex.

What happens to your brain if you keep taking drugs?

• Brain responds to surges in dopamine by producing less dopamine or by reducing the number of receptors

• As this happens, dopamine’s impact on the reward centre can become abnormally low and the ability to experience any pleasure is reduced

• The addicted brain now needs drugs to bring dopamine function back to normal

• They must take larger amounts of the drug in order to create the dopamine high (tolerance)

NIDA

Neurotransmitters Involved in SubstanceUse

• Dopamine– All substances to some extent– Most significant for psychostimulants

• Endogenous opioid system– Opioids, alcohol, nicotine

• Serotonin– Alcohol, cocaine, ecstasy

• Gama aminobutyric acid (GABA)– Alcohol and other sedative hypnotics (benzodiazepines,

barbiturates)

Course of Addiction

• Addiction is considered a chronic (life-long) progressive disease

• Marked by remission, relapse and often premature death

• Progression from social use to abuse to dependence (may take years to decades)

• Relapse is quite common• Unlike most medical disorders, severity or

“hitting bottom” can facilitate a favourable prognosis

Relapse Rates• Are similar for drug addiction and other chronic diseases

– Drug addiction 40-60%– Type 1 diabetes 30-50%– Hypertension 50-70%– Asthma 50-70%

• McLellan et al JAMA 2000

Risk Factors for Relapse

• Cues: people, places and things• Stress: physical, psychological• Substance: primary substance or other

potentially addictive substance

Relapse

• Extended abstinence is predictive of sustained recovery.• Takes more than 1 year of abstinence before more than

half remain abstinent• If you abstain for 5 years chances are you will continue to

do so.

Denis et al. Eval Rev. 2007

How does addiction present at different life stages?

Presentation of Substance Use: Adolescents

• Often have concurrent anxiety or mood disorders

• Sometimes difficult to differentiate experimentation from a more serious problem

• May clinically present with changes in school performance, involvement in illegal activities, change in peer group, insomnia, unexplained weight loss

Substance Use Presentation in Adults

• Primary Care: hypertension, fatigue, insomnia, depression, anxiety, difficulty coping at work/school (request for sick note), weight loss, smell of alcohol on breath, non-compliance, not going for regular/annual visits

• Emergency Services: suicidal, intoxication or overdose, injuries, drug seeking (opiates, benzodiazepines, stimulants)

• Family: irritability, mood swings, isolation, secretive, money issues, relationship problems, family violence

• Work and School: missing work, change in/or poor performance, loss of job

• Legal: DUI, assault, theft, possession, trafficking, Children’s Aid Society(CAS) involvement

Presentation of Substance Use: Elderly

• Two types: those who have a lifelong pattern of drinking, those who became alcoholic in their drinking patterns for the first time late in life

• Difficult to recognize • Strong indicator is continuation of drinking

even after repeated warnings to stop for medical or cognitive reasons

Signs of an alcohol or drug problem can be mistaken for “signs of aging”

• Loss of interest in activities

• Social isolation

• Tremors

• Irregular heart rate

• Poor appetite

• Stomach complaints

• Confusion

• Depression

• Disorientation

• Unsteady gait/falls

• Recent memory loss

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

• 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.

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.)

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

Screening Questionnaires

• CAGE• CRAFFT (adolescents)• AUDIT (Alcohol Use Disorders Identification

Test)• DAST (The Drug Abuse Screening Test)

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%

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)

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

Quantifying Alcohol and Drug Use

Marijuana• Measured in grams, 1 ounze equals 28

grams• How many grams? Pattern of use.

CocainePowder(snort or IV) or crack/freebase/rock

form (smoke)8 ball equals 3.5 grams; speedball is

cocaine and heroin

Quantifying Alcohol and Drug Use

Benzodiazepines• Total amount used per day, how many years

taking (assessing for risk of withdrawal)• Source of medication

OpioidsWhich opioid? Oxy, Dilaudid (hydromorph),

Fentanyl, morphine, codeine, heroinHow much? What route? (IV, smoked,

snorted, chewed, swallowed) How often?

Canada’s Low-Risk Alcohol Drinking Guidelines 2011

**Guidelines are intended for individuals 25 to 65

Guideline 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.


Guideline 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.

• Plan to drink in a safe environment. Stay within the weekly limits outlined in Guideline 1


Guideline 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


Guideline 4• If you are pregnant, planning to become pregnant, or before

breastfeeding, the safest choice is to drink no alcohol at all.

Guideline 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.

DRINKING DEFINITIONS

• BINGE DRINKING– MEN: consuming 5 or more drinks on any one

occasion– WOMEN: consuming 4 or more drinks on any one

occasion

• AT-RISK DRINKING: consumption of alcohol above the recommended low-risk guidelines, with possible physical or social harm

What to Look for on Physical and Mental Status Exam

P/E in Cases of Suspected SUDs• 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

Common Presentations of Alcohol and Drug Use

Cardiovascular Hypertension, arrythmias, cardiomyopathy

GI Hepatitis, fatty liver, cirrhosis, gastritis, pancreatitis, dyspepsia, viral hepatitis (IVDU)

Neuro Ataxia, tremor, peripheral neuropathy, dementia

MSK Recurrent traumas, infection, abscess (IVDU)

Reproductive Sexual dysfunction, infertility, fetal abnormalities

Common Presentations of Alcohol and Drug Use

Behavioural Missed appointments/work, non-compliance, drug-seeking

Physical exam Weight loss (cocaine, heroin)Pinpoint pupils (opioids)Track Marks (IVDU)

Psychiatric Fatigue, insomnia, depression, anxiety, psychosis, paranoia

Social Abuse, violence, legal problems, isolation, work or school problems

Laboratory Investigations in Cases of Suspected SUDs

• 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)

Urine Drug Testing Methods

• Immunoassay: Based on the principle of competitive binding. An antibody reacts to a portion of a drug or its metabolite. – Point of care testing possible– Not as specific

• Gas Chromotography with mass spectroscopy (GC/MS): couples the separation potential of gas chromatography with the precise detection and identification capability of mass spectroscopy.– More expensive– Gold Standard

Drug Minimum detection (hours) Maximum detection

Ethanol 0 to 4 <=6-12 hours

Benzodiazepines 2 to 7 Infrequent User- 3 daysChronic User- 4-6 weeks

Marijuana metabolite 6 to 18 Infrequent User – up to 10 daysChronic User – 30 days or longer

Cocaine metabolite 1 to 4 2 to 4 days

Amphetamines 2 to 7 2 to 4 days

Methamphatamine 1 to 3 2 to 4 days

MDMA (Ecstasy) 1 2 to 3 days

Opiates (codeine, morphine, heroin) 2 2 to 3 days

Oxycodone 1 1 to 2 days

Methadone 2 2 to 6 days

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 <12 hours

Methadone: chromatography required detection for 1-4 days

Management

Treatment Decision Tree

Want to

stop?

Is it safe to

stop?

Can they

stop?

Yes

Yes

Motivational

Interviewing, and harmreduction strategies

No

Medically

supervised

detox

Inpatient or

outpatient

No

Community

withdrawal

Or

Residential

Withdrawal

Management

level 2

No

Explore

addiction

treatment

options

Yes

Want To Stop?

1) Motivational Interviewing2) Harm Reduction

Motivational Interviewing

PrecontemplationIncrease awareness of need to change

ContemplationMotivate and increase confidence

in ability to change

ActionReaffirm commitment

and follow-up

Termination

Stages of Change Model

RelapseAssist in Coping

MaintenanceEncourage activeproblem-solving

PreparationNegotiate a plan

Motivational Interviewing

• Four General Principles1. Express Empathy

• Acceptance facilitates change 2. Develop Discrepancy

• Between behaviour and personal goals3. Roll with resistance

• Patient primary source for solutions 4. Support self-efficacy

• Patient responsible for choosing and carrying out change

FRAMES brief intervention interviewing technique

• Feedback: specifically address concerns about use (i.e. I am concerned about how alcohol is affecting your liver)

• Responsibility: Emphasize that change is up to the patient. (Only you can decide to make your life better)

• Advice: Give specific goals you have for the patient (I want you to be evaluated at a treatment center)

• Menu: Offer alternatives to advice (You could alternatively go to an AA meeting)

• Empathy: I know you find talking about this difficult• Self-efficacy: you deserve better – you can be better with help

Motivational Interviewing Precontemplation

• Patients in precontemplation do not view their substance use as a problem

• Strategies– Provide health information (i.e. low risk drinking

guidelines)Link substance use to patients symptoms and/or conditions– Encourage patients to discuss the role the substance

plays in their life

Motivational Interviewing Contemplation

• Patients in contemplation are ambivalent, patients are weighing the pros and cons of changing versus staying the same

• Strategies– Encourage patients to elaborate on benefits and risks of

continuing substance use and benefits and risks of abstinence or cutting down “Decisional Balance”

Motivational Interviewing Preparation/Action

• Patients in this phase are committed to changing their substance use

• Present treatment options and allow patient to decide starting point

Motivational Interviewing Maintenance

• Patients have completed a treatment program and have reached their treatment goals for 6 months

• Strategies– Emphasize need to attend aftercare and mutual help

meetings– Discuss management of cravings and urges– Acknowledge dry dates and recovery anniversaries

Harm Reduction

Harm Reduction

• Ambiguous term• Harm reduction aims to decrease the adverse

health, social and economic consequences of drug use without necessarily diminishing drug consumption

• World Health Organization Definition of Harm Reduction…a concept aiming to prevent or reduce negative consequences associated with certain behaviours.

Examples of Harm Reduction Strategies

• Safer environment to use substances– Supervised injection sites, Managed Alcohol Programs

• Safer use of substances– Crack pipe programs, needle exchange programs

• Alternative safe substances– Opioid Substitution Therapy

• Modification/Management of related risk behaviours– HIV/STD screening– Safe sex education– Condoms

Safe to Stop?

1) Medically Supervised Detox- Inpatient- Outpatient

Treatment of Withdrawal

• Alcohol

• Benzodiazepines

• Opioids

• Cannabis

• Amphetamines/Cocaine

• May be life-threatening• May require benzodiazepines• Inpatient or outpatient• Vitamin B1 (Thiamine)

• Requires tapering (weeks to months)

• Inpatient or outpatient

• Withdrawal not life-threatening but very distressing

• Likely will require supportive medications +/- opioids

• No medications required

• No medications required• Suicide Risk Assessment

Withdrawal Assessment Tools• Alcohol: CIWA (Nausea & Vomiting, Tactile

Disturbances, Tremor, Auditory Disturbances, Paroxysmal Sweating, Visual Disturbances, Anxiety, Headache/Fullness in the Head, Agitation, Orientation and Clouding of Sensorium

• Opioids: COWS: (Resting Heart Rate, Sweating, Restlessness, Pupil Size, Bone or Joint Aches, Nose Running or Tearing, GI upset, Tremor, Yawning, Anxiety or Irritability, Gooseflesh Skin)

Pharmacological Interventions

Alcohol

– Thiamine (B1) 100mg IM then po to prevent Wernicke-Korsakoff

– Diazepam, Chlorodiazepoxide: long acting for management of withdrawal and prevention of seizures, DT’s

– Lorazepam: short acting, used if respiratory or hepatic compromised

• Antabuse (Disulfiram):• binds irreversibly to aldehyde dehydrogenase • Daily dose of 250mg to 500mg• Must not drink alcohol within 7 days of taking• Common effects with drinking include: flushed face,

vomiting, headache, chest pain, palpitations. • Serious effects include: seizures, hypotension, vagally

induced dysrhythmias. • Contra-indications: unstable angina, recent MI,

schizophrenia and other psychotic states, pregnancy, severe cirrhosis of the liver

• Liver enzymes monitored at quarterly intervals, monitored for visual changes and symptoms of peripheral neuropathy

• Naltrexone (Revia)– Competitive opioid antagonist– Usual dose 50mg po daily

• Indications: – alcohol dependence (reduce craving and intensity and frequency of

alcohol binges) and for– Opioid dependence(for those who wish to remain abstinent from all

opioids)• Side effects: nausea, GI symptoms, headache, dizziness, light-

headedness, weakness• Contra-indications: acute hepatitis, liver failure, opioids

should be discontinued 10 days prior to starting naltrexone, naltrexone should be discontinued 3 days prior to elective surgery

• Monitor ALT, AST and bilirubin

• Campral (Acamprosate): – amino acid derivative that increases GABA and has

complex effects on excitatory amino acid (i.e. Glutamate) neurotransmission

– Positive and negative studies– Dosing 2 333mg tablets TID– Side effects: GI (diarrhea, bloating), pruritis– Excreted unmetabolized thorugh the kidney’s,

must evaluate renal function prior to initiations

Opioids

– Dimenhydrinate (vomiting, nausea), Immodium (diarrhea), ibuprofen (aches and pain), meds for insomnia

– Clonidine: Alpha 2 Adrenergic agonist• 0.05-0.2mg po TID prn • Most effective in suppressing autonomic signs and symptoms of

opioid withdrawal • warn of sedation and orthostatic hypotension • BP must be greater than 90/60 to take

– Methadone: long-acting (>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

Nicotine

– NRT (patch, gum, lozenge, inhaler)– Zyban (Wellbutrin, Bupropion)- not if seizure d/o– Champix (Varenicycline)-monitor for psych

symptoms

Treatment Resources

• Mutual Help Groups: Alcoholics Anonymous (>150 meetings per week in Ottawa), Narcotics Anonymous (>20 meetings per week in Ottawa)

• Individual Counseling • Outpatient Treatment (once weekly, daily)• Residential Treatment programs (ranging from

21 days to 9 months+)• Medically Supervised Treatment programs• Opioid Substitution Therapy (for opioid use

disorders only)• Other Harm Reduction Strategies

Guidelines for Referral to Outpatient Treatment Services

• Client choice• Client may be in “Precontemplation” Stage of

Change • Client has family support, housing, and

employment or school • Client has had periods of abstinence• Client may have moderation as a goal• Client may not be able to work in group due to

trauma, anxiety, or other physical conditions

Community Outpatient Treatment in Ottawa

• The Royal Substance Use and Concurrent Disorders Program

• Sandy Hill Addictions and Mental Health• Rideauwood Addiction and Family Services• Amethyst Women’s Centre• Serenity Renewal for Families• LESA (Lifestyle Enrichment for Senior Adults)• CMHA

Guidelines for Referral to Residential Services

• Client expresses desire to participate in residential services

• Client at risk for homelessness or without a fixed address

• Client feels at high risk for continued substance use in his/her living environment

• Client has a lack of peer and family supports• If concurrent disordered fairly compliant with

medications

Guidelines for Referral to Residential Services (continued)

• Client is capable of participating in group work and able to reside in a group setting

• Client has sufficiently detoxed from substances of concern

• Client has attempted outpatient/community treatment but continues to relapse

Residential Treatment Programs in Ottawa

• Dave Smith Youth Treatment Centre• Empathy House• Serenity House• Sobriety House• VESTA• Maison Fraternité• The Royal Meadow Creek• Anchorage• Harvest House

How to Access Treatment in Ottawa/Ontario

• OAARS Ottawa Addictions Access & Referral Service 613-241-5202

• OWMC Ottawa Withdrawal Management Centre1777 Montreal Road 613-241-1525

• Connex Ontario www.connexontario.ca 1-800-565-8603

http://www.connexontario.ca/

References

• DSM 5 Diagnostic & Statistical Manual of Mental Disorders 5th Ed. Test Revision 2013

• Principles of Addiction Medicine 4th ed. , American Society of Addiction Medicine. 2009

• Drug use among Ontario students,1977-2013: OSDUHS highlights. Boak, A.; Hamilton, HE, Adlaf, EM, Mann, RE (2013). (CAMH Research Document Series No. 36). Toronto, ON: Centre for Addiction and Mental Health.

References• Substance Abuse: A Comprehensive Textbook

4th Ed. Lewinson et al. 2005• Management of Alcohol, Tobacco, & Other

Drug Problems, Edited by Bruno Brands Phd. Addiction Research Foundation 2000

• 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.

References

• NIDA National Institute on Drug Abuse• NIAAA National Institute on Alcohol Abuse

and Alcoholism• CADUMS 2011

Websites

• www.connexontario.ca• www.camh.net• www.ccsa.ca• www.asam.org• www.csam.org• www.nida.nih.gov• www.niaaa.nih.gov

http://www.camh.net/

http://www.csam.org/

http://www.nida.nih.gov/

http://www.niaaa.nih.gov/

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


• 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


• 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


• 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


• 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


• 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


• 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


• 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


• 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


• 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.

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 ½ 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

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

COWS (Clinical Opioid Withdrawal Scale)

• GI Upset: over last ½ 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

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

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