Drugs Destroy Families

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1 An Addiction Medicine Patient Care Competency 5 Cases 5 Different Providers Richard D. Blondell, MD University at Buffalo Addiction Medicine Pediatric Grand Rounds Women and Children's Hospital of Buffalo June 12, 2015 Richard D. Blondell, MD NO COMMERCIAL CONFLICTS Drugs Destroy Families Work Supported by an Educational Grant from The Conrad N. Hilton Foundation https://vimeo.com/ A 14-year-old is brought in to the office by her mother for bad moods. Case 1: 14-year-old CC: Bad moods HPI: Depressed since her father died 6 months ago PMH: ADHD, treated with methylphenidate FH: Mother with breast CA, father with alcoholism SH: Lives with mother and step-father Occasional cigarette, denies EtOH & drug School issues, mother requests Adderall PE: Unremarkable, difficult to engage QUESTIONS: What is the DDx? Any testing needed? 1

2 A 15-year-old presents for follow-up of knee pain following a sports injury. Case 2: 15-year-old CC: Knee pain, F/U from Ortho Subjective: About 6 weeks previously, she had arthroscopic treatment of a meniscal tear. She was discharged from the care of orthopedics and was told to follow-up with her PCP for pain management. She is now having PT and requests a refill for a few Lortabs so I can take them after my PT session. Objective: Hair dyed blonde, slight effusion in left knee. Rx report: Hydrocodone/APAP 5/325, #30, refilled twice QUESTIONS: Any testing needed? Would you refill Rx? Case 3: 16-year-old CC: ER F/U, sprained ankle Subjective: On Saturday (2 days ago), she was at her junior prom, drank a couple of drinks afterwards, fell down, and twisted my right ankle. She was seen in the local ER where X- rays were negative, and she was told to follow-up with her PCP. She requests a prescription for a few Lortabs beca ibuprofen is not cutting it. A 16-year-old admits to binge drinking at an ER follow-up visit.. Objective: Lateral ankle with mild swelling and ecchymosis. Rx report: No Rx for controlled substance in past 6 months QUESTIONS: Any testing needed? Would you Rx opiates? A 17-year-old presents for a pre-college examination and disease prevention. Case 4: 17-year-old CC: College physical HPI: No major complaints, but has questions about HPV, otherwise immunizations are up-to-date PMH: ADHD as child, minor injuries, otherwise [-] FH: Heart disease, diabetes, cancer, alcoholism SH: Lives with parents; will start local CC in fall. Smoker, social drinker, denies drug PE: Cutter marks, 2 tattoos, body piercings QUESTIONS: Any testing needed? What advice to give? 2

3 An 19-year-old admitted for cellulitis develops opioid withdrawal. Case 5: 19-year-old CC: My foot s infected. HPI: 5-year history of drug ab, prior Narcan rescue, IV heroin for past 9 months, IV site infected PMH: ADHD, psych problems, chronic pain FH: Mother has drug issues, father died of alcoholism SH: Lives with boyfriend, unemployed Arrested last month, court pending PE: S/P I&D of abscess on dorsal surface of (L) foot Labs: Hepatitis C (+); urine HCG (+) QUESTIONS: How do you treat withdrawal? How would you refer for drug rehab? Etiology Genetic and Environmental Risk Factors for Addiction Family History/Genetics OPRM1 - opioid receptor mu 1 DRD2 - dopamine receptor D2 5-HTTLPR - neurotransmitter serotonin gene Prenatal exposure: animal and human studies Early onset drinking: <14 yrs = 47%; > 21 = 10% Alcohol tolerance ADHD Depression/Anxiety disorders History of physical or sexual ab Alcohol Use, 2013 Epidemiology It s very common Lifetime Annual Binge: past 2 weeks 8 th 10 th 12 th 27.8% 52.1% 68.2% 22.1% 47.1% 62.0% 5.12% 13.7% 22.1% Nackers AM, Weddle MC, Kototailo PK. Epidemiology of adolescent substance. In: Essentials of Addiction Medicine, 2 nd Ed. Wolters Kluwer, 2015 (pages: ) 3

4 Marijuana Use, 2013 Cocaine Use, 2013 Lifetime Annual (synthetic) Daily 8 th 10 th 12 th 16.5% 35.8% 45.5% 12.7% (4.0%) 29.8% (7.4%) 36.4% (7.9%) 1.1% 4.0% 6.5% Lifetime Annual 8 th 10 th 12 th 1.7% 3.3% 4.5% 1.0% 1.9% 2.6% Nackers AM, Weddle MC, Kototailo PK. Epidemiology of adolescent substance. In: Essentials of Addiction Medicine, 2 nd Ed. Wolters Kluwer, 2015 (pages: ) Nackers AM, Weddle MC, Kototailo PK. Epidemiology of adolescent substance. In: Essentials of Addiction Medicine, 2 nd Ed. Wolters Kluwer, 2015 (pages: ) Any Illicit Drug Use, 2013 Non-Medical Use, 2013 Lifetime Annual 8 th 10 th 12 th 20.3% 38.8% 50.4% 14.9% 31.8% 40.3% 8 th 10 th 12 th OxyContin 2.0% 3.4% 3.6% Hydrocodone 1.4% 4.6% 5.3% Tranquilizers 2.9% 5.5% 7.7% Adderall 1.8% 4.4% 7.4% Ritalin 1.1% 1.8% 2.3% Nackers AM, Weddle MC, Kototailo PK. Epidemiology of adolescent substance. In: Essentials of Addiction Medicine, 2 nd Ed. Wolters Kluwer, 2015 (pages: ) Nackers AM, Weddle MC, Kototailo PK. Epidemiology of adolescent substance. In: Essentials of Addiction Medicine, 2 nd Ed. Wolters Kluwer, 2015 (pages: ) Addiction is a Pediatric Disease! Natural History Addiction starts in adolescence Compton Arch Gen Psych 2007;64 4

5 Neurobiology Addiction is a brain disease https://vimeo.com/ What I learned from gynecologists about addiction We can't treat our way out of this addiction epidemic. The Spectrum of Cervical Cancer The Spectrum of Addiction Metastatic Dependent Vaccine Colposcopy Cone Hysterectomy Pelvic Surgery Prevention Education Advice Intervention Refer to treatment 5

6 Prevention Prevention 1. Screen: ask about risk factors 2 Teach: educate about addiction risks 3. Do no harm: caution with Rx meds https://www.youtube.com/watch?v=_tsdcksjgra&feature=share SBIRT 1. Screening 2. Brief Intervention 3. Referral to Treatment NIAAA & AAP SIMPLE QUESTIONS Screening Do you have any friends who drink beer, wine, or any drink containing alcohol in the past year? In the past year, on how many days have you had more than a few sips of beer, wine, or any drink containing alcohol in the past year? NIH Publication No

7 CeASAR & AAP CRAFFT C: ridden in a CAR R: to RELAX A: ever ALONE F: FORGET things F: FRIENDS ever tell you T: gotten into TROUBLE Arch Ped Adoles Med 2010; 156:607 Am Psych Assoc VALIDATED INSTRUMENTS Useful for research Often with quantitative scoring Many are automated Most are for adults TWEAK for pregnancy American Psychiatric Publishing, 2007 Brief Intervention FRAMES Based on Motivational Interviewing Feedback with concern Reinforce Responsibility I'm concerned about your drinking. Only you can decide what to do. 7

8 Advise Action I recommend that you wait until 21 Menu of options You could continue to drink and risk your future I recommend that you wait until 21 to preserve your future Promise me that you will never drink and drive, or ride in car with a driver who has been drinking Express Empathy Support Self-efficacy I know that this is not an easy conversation to have It is not always easy to not do what your friends want you to do I think you are smart enough to think for yourself and this information to make the right choice Referral to Treatment Offer Hope https://vimeo.com/

9 Buprenorphine Detox Management of Withdrawal Day 1: 4 mg in AM, 2 mg Q 4 hours PRN Day 2: 4 mg in AM, 2-4 mg at HS PRN Day 3: 4 mg in AM, 2 mg at HS PRN Day 4: 2 mg in AM PRN, 2 mg at HS PRN Day 5: 2 mg in AM PRN Methadone Federal Regulations Day 1: mg in AM, 5 mg Q 4 hours PRN Day 2: mg in AM, 5 mg at HS PRN Day 3: 5-10 mg in AM, 5 mg at HS PRN Day 4: 5 mg in AM PRN Day 5: 5 mg in AM PRN Buprenorphine requires special DEA permit Methadone requires DEA Schedule II permit - Only if hospitalized for another condition - Maximum of 5 days An 19-year-old admitted for cellulitis develops opioid withdrawal. Case 5 Recommendations 1. Detox 2. Perform a detailed intervention - FRAMES/motivational therapy - Show a video 3. Refer to treatment (Offer Hope) 9

10 Case 4 A 17-year-old presents for a pre-college examination and disease prevention. PMHx : ADHD PSHx: Rx opiate exposure FHx: alcoholism SHx: smoker, drinker PE: cutter marks, tattoos Case 4 Recommendations 1. Screening: Consider urine tox 2. Perform a Brief Intervention - FRAMES - Show a video/give printed info 3. Refer to treatment ( evaluation ) Case 3 A 17-year-old presents for a pre-college examination and disease prevention. Drinking probably > HPI Injury while drinking Asking for Lortabs Case 3 Recommendations 1. Screening: more questions, UDT 2. Perform an intervention - FRAMES - Show a video/give printed info 3. Refer to treatment (PCP follow-up) Case 2 A 15-year-old presents for follow-up of knee pain following a sports injury. Bleach blonde Excessive Rx med Asking for Lortabs Case 2 Recommendations 1. Screening: more questions, UDT 2. Perform an intervention - FRAMES - Do no harm: no more opiates 3. Refer to treatment PRN 10

11 Case 1 A 14-year-old is bought into the office by her mother beca of bad moods. HPI: Requesting Adderall PMHx : ADHD PSHx: Rx opiates FHx: alcoholism (father s death?) SHx: smoker, school problems PE: difficult to engage Case 1 Recommendations 1. Make an accurate diagnosis - Detailed history of current substance - Detailed history for ab/neglect - Is the diagnosis of ADHD accurate? - Detailed family history of alcohol/drug issues - Nature of school problems - Consider urine toxicology 2. Consider referral for evaluation 3. Follow-up Summary If you fail 70% of the time, they'll put you in the Hall of Fame. Ask every patient about substance (Screen) Advise by giving a clear message (Intervention) Assess willingness to make a change Assist those willing to change (Refer PRN) Arrange for follow-up lifetime batting average Suggested Reading Principles of Addiction Medicine, 5 th Ed. Wolters Kluwer (Chapters ) Essentials of Addiction Medicine, 2 nd Ed. Wolters Kluwer (Chapters ) I am the face of addiction NIAAA Guide, NIH Publication No AHRQ Guide, AHRQ Publication No. 06-E015 NIDA Guide, NIH Publication No (A) https://vimeo.com/

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