Learning Objectives:

Transcription

1 Screening and Treatment for Substance Use Disorders Joseph Sakai, MD Associate Professor Division of Substance Dependence Dept of Psychiatry UCD SOM Learning Objectives: Describe the epidemiology of substance use disorders Know approaches to screening and diagnosis of substance use disorders Know basic elements of motivational interviewing and brief interventions Know available pharmacological treatments for alcohol and nicotine dependence Conflicts of interest: none 1

2 Statement of problem: Common in general population Alcohol abuse Alcohol dependence Drug abuse Drug dependence Lifetime 17.8% 12.5% 7.7% 2.6% 12-month 4.7% 3.8% 1.4% 0.6% Hasin, D. S. et al. Arch Gen Psychiatry 2007;64: Compton, W. M. et al. Arch Gen Psychiatry 2007;64: Statement of problem: common in general medical settings such as ER and primary care Actual causes of death in 2000: #1 Tobacco (435,000 deaths per year) #3 Alcohol (85,000 deaths per year) #9 Illicit drugs (17,000 deaths per year) Cherpitel & Ye, Drug & Alcohol Dependence 2008; 97: Mokdad et al. JAMA 2004; 291:

3 Screening? Physicians generally poor job of screening Survey of FP s (n=648) 90% failed dx substance abuse when presented with early symptoms of alcohol abuse in an adult patient Another study in primary care practices patients with alcohol dependence received assessment and referral to treatment only 10% of the time Only about 3% of those with alcohol use disorder in past 12-months report that they had received help from a physician or other health care professional National Center on Addiction and Substance Abuse, 2000 McGlynn et al. NEJM 2003; 348: Hasin, D. S. et al. Arch Gen Psychiatry 2007;64: Screening: Single question about illicit drug use some use past 30 days, others longer periods (any use considered a positive) Single question alcohol use How many times in the past year have you had 4/5 or more drinks in a day? (4 for women and 5 for men, 1 time is considered positive) 88% sensitivity and 67% specificity for current alcohol use disorder in primary care setting. Approaches to screening many options to choose from: MAST Michigan Alcoholism Screening Test CAGE Questionnaire Substance Abuse Subtle Screening Inventory (SASSI) TWEAK Self Administered Alcoholism Screening Test (SAAST) AUDIT Alcohol Use Disorder Identification Test Reinert & Allen. Alcoholism: Clinical & Experimental Research 26:272, 2002 Smith et al., J Gen Intern Med :

4 Screening: AUDIT No copyright fee Add responses with score 8 (males) indicating further evaluation (lower cutoff sensitivity at cost of specificity) substance_abuse/activities/sbi/ en/ / WHO_MSD_MSB_01.6a.pdf Adapted from Reinert & Allen. Alcoholism: Clinical & Experimental Research 26:272, 2002 Screening: Computer, self report, interview Non-threatening, non judgmental Explain purpose of screening (i.e. medical context and concern about patient s well being) Assurance of confidentiality Defining a standard drink Who do you screen? 4

5 Screening: Screening Assessment Education re-screen annually Screening/Assessment At-risk drinking Men 5 standard drinks in a day or > 14 per week Women 4 in a day or > 7 per week risk for alcohol related problems Dawson et al. Alcohol Clin Exp Res 2005; 29:

6 Screening: Screening Assessment at-risk drinking Education Brief re-screen Intervention annually Brief Intervention 1. Discuss finding 2. Assess how ready to change? and how able? Perceived positives and negatives of continued use Stages of change: Pre-contemplation ignorance is bliss Contemplation sitting on the fence Preparation testing the waters Action practicing new behaviors Maintenance commitment to sustain behavior Feedback Responsibility Advice Menu of options Empathy Self efficacy 6

7 Brief Intervention At risk drinking Ready to commit to a change? No Yes - Restate concern - Set goal - Encourage reflection - Plan - Reaffirm willingness to help - Educational materials Brief Intervention Brief interventions: Unsafe drinking levels (n=774) Two minute educational sessions Two nurse telephone contacts Control group booklet on general health issues Efficacy: 40% in the intervention group reduced drinking to safe levels benefit persisted at four year follow up Positive results also emerging for illicit drug use Fleming et al., 1997 Vinson, 2003 Madras et al., Drug and Alcohol Dependence; 2009:

8 Screening: Screening Assessment at-risk Substance abuse drinking or dependence Education Brief Treatment re-screen Intervention Referral (w/d risk) annually Possible medication Screening/Assessment: Substance Abuse Never met criteria for dependence 1/4 in 12 month period Role failures Hazardous use Legal problems Interpersonal problems 8

9 Screening/Assessment: Substance Dependence 3/7 in 12 month period Tolerance Withdrawal More than intended Cut down Time spent using Limit activities Use despite consequences Physiologic dependence diminished control Screening: Screening Assessment at-risk Substance abuse drinking or dependence Education Brief Treatment re-screen Intervention Referral (w/d risk) annually Possible medication 9

10 Substances of Abuse: Alcohol Multiple (GABA) Nicotine Nicotinic Opioids Opioid (i.e. µ) Cocaine dopamine (t) Amphetamines dopamine (t) Sedative-hypnotics GABA THC Cannabinoid PCP NMDA Hallucinogens Multiple Inhalants Multiple (NMDA) Alcohol: Medications - FDA approved Disulfiram Naltrexone Acamprosate 10

11 Alcohol: Medications - FDA approved Disulfiram Naltrexone Acamprosate Disulfiram: How does it work? Alcohol Acetaldehyde X ADH ALDH (alcohol (aldehyde dehydrogenase) dehydrogenase) 11

12 Disulfiram : Disulfiram reaction Flushing Headache Nausea Dizziness Tachycardia Disulfiram : Br J Psych study Open label (informant blinded) Supervised N=126 6 month Outcome Increased total abstinent days Decreased amount consumed GGT 21 disulfiram group vs. 13 in placebo group Br J Psychiatry 161: 84 12

13 Disulfiram : Dosage and Administration Breath zero Load 500mg PO QD for 5 days 250mg PO QD or 500mg M-W-F Some patients require higher doses to have disulfiram reaction Supervised administration recommended (spouse, clinic, or some arrangement) Disulfiram : Side effects/complications: Metallic taste Headaches Drowsiness or fatigue Optic neuritis Peripheral neuropathy Hepatitis Rash A few cases of psychotic symptoms (i.e. metronidazole) 13

14 Disulfiram : Interactions: Alcohol Disulfiram rxn Metronidazole Psychosis/confusion Amitriptyline Psychosis/confusion Phenytoin Phenytoin toxicity Diazepam Sedation Perphenazine Breakthrough Isoniazid Nausea/lethargy/ataxia Addiction Treatment, Avoiding Pitfalls, GAP Report 142: p 82 Disulfiram : Some Contraindications Risk for MI Risk for CVA Cognitive dysfunction (can t understand or remember what will happen if drinks) Pregnancy/breast feeding safety unknown 14

15 Alcohol: Medications Disulfiram Naltrexone Acamprosate Naltrexone: Pure opioid antagonist Blocks µ opioid receptors 15

16 Naltrexone: Why might it work? µ agonists dopamine release in Nucleus Accumbens µ agonists drinking in rats Opioid antagonists reduce alcohol consumption in rats Alcohol dependent people may have low baseline betaendorphin levels (stress response) Alcohol consumption endorphin in those with family history of alcoholism Naltrexone blocks euphoria from alcohol Naltrexone: Study 1 Study 2 12 wk 12 wk N=70 veterans N=97 Delayed 1 st drink Replicated findings Decreased relapse Decreased craving Arch Gen Psychiatry 49: 876 and

17 Naltrexone: Naltrexone injectable (Vivitrol) 380mg IM Q month Multi-center trial Fewer drinking days Greater abstinence rates Time to first drink Another Multi-center trial 25% heavy drinking days (380mg) One disadvantage is cost (i.e. ~$900/month) Kranzler et al., 2004; JAMA 293: Naltrexone: Dosage and Administration 50mg PO QD Doses of mg also studied 380mg IM Q month 17

18 Naltrexone: Some side effects/complications: Nausea (10%) Headaches (7%) Anxiety (2%) Sedation (2%) Hepatic failure (rare) Naltrexone: Some Contraindications: Hepatic failure/acute hepatitis At risk for opioid withdrawal Hypersensitivity to naltrexone Pregnancy category C Lactation safety unknown 18

19 Naltrexone: Interactions: Benefit from opioid analgesics Benefit from some antidiarrheal Benefit from opioid containing cough medicines Alcohol: Medications Disulfiram Naltrexone Acamprosate 19

20 Acamprosate: Structurally resembles GABA Enhances GABA transmission Interferes with Glutamate transmission Reduces CNS hyperexcitability Acamprosate: 3 trials: more likely to maintain abstinence 1 trial: dependent on multiple substances no improvement over placebo Meta-analyses: about 1.9 times more likely to remain abstinent and improves days of cumulative abstinence 20

21 Nicotine Dependence: Medications: Bupropion Nicotine replacement Varenicline Nicotine Dependence: Bupropion (Wellbutrin/Zyban): SR (BID), and XL preparations (QD) Start 150mg PO QD, target dose 150 mg PO BID Doubles quit rates Better outcomes when combined with psychosocial treatments Contraindicated: hx seizure disorder, MAO inhibitor, eating disorder Insomnia/agitation common side effects 21

22 Nicotine Dependence: Nicotine replacement: Nicotine content per cigarette varies (by brand, behavior of smoker and physiology) General approximate is 1mg nicotine per cigarette General approximate for 1 pack per day is about 20mg of nicotine Nicotine Dependence: Gum 1 piece 2 mg (4 mg if tx failure) Q 1-2 hours (max 30 per day of 2 mg gum) No food or drink 15 min before Problem include TMJ, hiccups, dyspepsia, difficult with dentures Avoid if 1 month post MI, serious arrhythmias, gastric ulcers Patch : High dose (21 mg) 6-8 weeks, medium dose (14 mg) 2-4 weeks, low dose (7 mg) 2-4 weeks Skin irritation (avoid if systemic eczema), slow delivery, wearing at night may cause sleep problems Same cardiovascular warnings 22

23 Nicotine Dependence: Varenicline (Chantix): FDA-approved 2006 Partial agonist α 4 β 2 nicotinic acetylcholine receptor ~Quadruples quit rates?mood changes, suicidality? Dealing with Ambivalence: Patients may be more open to changing than you expect, but Motivational Interviewing: O pen ended questions A ffirmations R eflective listening S ummarizing Miller et al. Alcohol Alcohol. 2006; 41: Williams et al. Ann Fam Med. 2006; 4:

24 Dealing with Ambivalence: Motivational Interviewing: Strategies Express empathy Roll with resistance Develop discrepancies Support self-efficacy Dealing with Ambivalence: Motivational Interviewing: Withdrawal Wife left Social Bad health I can change the way I feel Unemployed 24

25 Dealing with Ambivalence: Motivational Interviewing: Strategies Express empathy Roll with resistance Develop discrepancies Support self-efficacy Dealing with Ambivalence: Motivational Interviewing: Eliciting self-motivating statements On a scale of 1 to 10 how ready are you to stop? I m not ready. Maybe I m a 2. Responses A) Look at all your problems. I can t believe it s not a 10. B) Good. How can we make you a 3? C) Good. Why aren t you a 1? 25