Definitions Prevalence and costs



Yüklə 2,75 Mb.
tarix12.05.2017
ölçüsü2,75 Mb.









Definitions

  • Definitions

  • Prevalence and costs

  • Detection

  • Comorbidity

  • Primary medical care

  • Addiction as a chronic disease

  • Pharmacological and non-pharmacological treatments

  • Risk reduction

  • Future issues



  • Mr. CB, 42 y/o male, presented to ED with chief complaint “belly pain.”

  • Moderately severe mid-abdominal pain increasing over 3 weeks



Addiction

  • Addiction

    • Injection drug use (IDU) for 10 years
    • Heroin withdrawal symptoms
    • Vague alcohol use
  • Endocarditis

    • LVEF 75%, mitral valve vegetation
    • Antibiotics for 6 weeks
  • Abdominal pain onset during hospitalization

    • CT abd & KUB unremarkable
    • Dx: constipation
    • Rx: laxatives & manual disimpaction


“Cramping” pain, constipation, poor PO intake

  • “Cramping” pain, constipation, poor PO intake

  • Intranasal heroin use “to treat abdominal pain” past 10 days

  • No recent IDU

  • Smoked 10 cigarettes/day



Pleasant male NAD

  • Pleasant male NAD

  • P: 95, R: 18, weight: 120 lbs, afebrile

  • Nodes: bilateral cervical and axillary adenopathy

  • CV: III/VI holosystolic murmur RUSB radiating to axilla

  • Abd: tender RLQ and LLQ without rebound

  • Rectal: no focal tenderness; stool brown guaiac negative

  • WBC: 5.1, Hct: 26, Plts: 267K



Definitions

  • Definitions

  • Prevalence and costs

  • Detection

  • Comorbidity

  • Primary medical care

  • Addiction as a chronic disease

  • Pharmacological and non-pharmacological treatments

  • Risk reduction

  • Future issues





Drug/Alcohol abuse

  • Drug/Alcohol abuse

  • Drug/Alcohol dependence

  • Addiction



Recurrent use resulting in failure to fulfill major role obligations

    • Recurrent use resulting in failure to fulfill major role obligations
    • Recurrent use in hazardous situations
    • Recurrent drug-related legal problems
    • Continued use despite social or interpersonal problems caused or exacerbated by drugs


Tolerance

  • Tolerance

  • Withdrawal

  • A great deal of time spent to obtain drugs, use them, or recover from their effects

  • Important activities given up or reduced because of drugs



Characterized by behaviors that include 1 or more of the following:*

  • Characterized by behaviors that include 1 or more of the following:*

    • Loss of control with drug use
    • Compulsive drug use
    • Continued use despite harm
  • A condition involving activation of the brain’s mesolimbic dopamine system; a common denominator in the acute effects of drugs of abuse†





Definitions

  • Definitions

  • Prevalence and costs

  • Detection

  • Comorbidity

  • Primary medical care

  • Addiction as a chronic disease

  • Pharmacological and non-pharmacological treatments

  • Risk reduction

  • Future issues



Substance dependence or abuse 22.2 mil

  • Substance dependence or abuse 22.2 mil

    • Alcohol only 15.4 mil
    • Illicit drugs only 3.6 mil
    • Both alcohol and illicit drugs 3.3 mil
      • Marijuana 4.1 mil
      • Cocaine 1.5 mil
      • Pain relievers 1.5 mil
      • Heroin 0.2 mil










Several urgent care and ED visits over past 10 years

  • Several urgent care and ED visits over past 10 years

  • No prior primary care

  • No mention of alcohol or drug abuse



Definitions

  • Definitions

  • Prevalence and costs

  • Detection

  • Comorbidity

  • Primary medical care

  • Addiction as a chronic disease

  • Pharmacological and non-pharmacological treatments

  • Risk reduction

  • Future issues







Patients presenting for addiction treatment who had a primary care (PC) physician (n=1440)*

  • Patients presenting for addiction treatment who had a primary care (PC) physician (n=1440)*

    • 45% stated their physician was unaware of their substance abuse.
  • 28% of a national sample of PC patients reported alcohol/drug screening, past 12 months (n=7301)†



Recommends screening and behavioral counseling interventions to reduce alcohol misuse by adults in primary care settings

  • Recommends screening and behavioral counseling interventions to reduce alcohol misuse by adults in primary care settings



Recommended screening and brief intervention procedures include 4 steps:

  • Recommended screening and brief intervention procedures include 4 steps:

    • Step 1: ASK about alcohol use
    • Step 2: ASSESS for alcohol-use disorders
    • Step 3: ADVISE and ASSIST
    • Step 4: At Follow-up: CONTINUE SUPPORT


Blood cultures negative

  • Blood cultures negative

  • Methadone

  • Pain medications

  • Abd w/: surg consult, imaging studies UGI SBFT

    • “Focal area of small bowel dilatation and loss of mucosal folds within the mid to distal ileum. Differential diagnosis includes a small bowel lymphoma, however, inflammatory bowel disease and mastocytosis can also be considered.”
  • Cardiac Echo LVEF 70%; vegetation no longer visible



Abd pain and poor PO intake persisted

  • Abd pain and poor PO intake persisted

  • HBSAg-, HBCAb+ (past Hepatitis B, resolved)

  • HCV Ab+ (Hepatitis C)

  • HIV+, CD4 503, HVL 15,085



What is your leading diagnosis?

  • What is your leading diagnosis?

  • What is your next diagnostic test?



CT with angiogram

  • CT with angiogram

    • Superior Mesenteric Artery (SMA) occlusion possibly secondary to mitral valve vegetation embolus
    • Dx: ischemic colitis
    • Transferred to surgery for partial colectomy




Prior to surgery, when Mr. CB complained of ongoing pain, house staff expressed annoyance by his multiple requests for pain medication.

  • Prior to surgery, when Mr. CB complained of ongoing pain, house staff expressed annoyance by his multiple requests for pain medication.



Qualitative analysis of interviews with illicit drug-using patients and their physicians and direct observation of patient care interactions

  • Qualitative analysis of interviews with illicit drug-using patients and their physicians and direct observation of patient care interactions

  • Inpatient medical service of an urban teaching hospital (6/97-12/97)



1. Physician Fear of Deception

  • 1. Physician Fear of Deception

  • Physicians question the “legitimacy” of need for opioid prescriptions (“drug seeking” patient vs. legitimate need).

  • “When the patient is always seeking, there is a sort of a tone, always complaining and always trying to get more. It’s that seeking behavior that puts you off, regardless of what’s going on, it just puts you off.”

  • -Junior Medical Resident



2. No Standard Approach

  • 2. No Standard Approach

  • The evaluation and treatment of pain and withdrawal is extremely variable among physicians and from patient to patient. There is no common approach nor are there clearly articulated standards.

  • “The last time, they took me to the operating room, put me to sleep, gave me pain meds, and I was in and out in two days.. . .This crew was hard! It’s like the Civil War. ‘He’s a trooper, get out the saw’. . .’

  • -Patient w/ Multiple Encounters



3. Patient Fear of Mistreatment

  • 3. Patient Fear of Mistreatment

  • Patients are fearful they will be punished for their drug use by poor medical care.

  • “I mentioned that I would need methadone, and I heard one of them chuckle. . .in a negative, condescending way. You’re very sensitive because you expect problems getting adequate pain management because you have a history of drug abuse. . .He showed me that he was actually in the opposite corner, across the ring from me.”

  • -Patient



Physicians and drug-using patients display mutual mistrust.

  • Physicians and drug-using patients display mutual mistrust.

  • Physicians’ clinical inconsistency, avoidance behaviors and fear of deception, problematically interact with patients’ fear of mistreatment and stigma.

  • Medical education should focus greater attention on addiction medicine and pain management.



  • Manage opioid withdrawal

    • Hospitalized patients with opioid dependence should be treated with methadone.
  • Manage pain

    • Treat with pain relievers in addition to methadone.


Transferred to med, endocarditis secondary to central line infection

  • Transferred to med, endocarditis secondary to central line infection

  • Total parenteral nutrition (TPN)

  • Cardiac Echo LVEF  40%

  • Evaluated by CT surgery



Definitions

  • Definitions

  • Prevalence and costs

  • Detection

  • Comorbidity

  • Primary medical care

  • Addiction as a chronic disease

  • Pharmacological and non-pharmacological treatments

  • Risk reduction

  • Future issues





Veterans with HIV (Veterans Aging Cohort Study) (n=881)*

  • Veterans with HIV (Veterans Aging Cohort Study) (n=881)*

    • 36% were current “hazardous” drinkers
  • Patients establishing primary care for HIV infection (Boston Medical Center) (n=664)†

    • 42% had current or past alcohol problems








50%-80% of new injection drug users are infected with HCV within 6–12 months.*

  • 50%-80% of new injection drug users are infected with HCV within 6–12 months.*

  • Alcohol use and HIV co-infection independently increase the risk of HCV disease progression.*†

  • HCV has been associated with increased depressive symptoms in HIV-infected persons.‡

  • HCV is challenging to treat in patients with substance use and psychiatric illnesses.§



Wt  107 125 lbs with TPN

  • Wt  107 125 lbs with TPN

  • Smoking continued

  • No IDU past 4 months

  • CT surgeon: mitral valve replacement after patient in community with 6 wks recovery

  • Upon discharge from rehab hospital patient linked to

    • Primary care
    • Methadone program
    • 12-Step program


Definitions

  • Definitions

  • Prevalence and costs

  • Detection

  • Comorbidity

  • Primary medical care

  • Addiction as a chronic disease

  • Pharmacological and non-pharmacological treatments

  • Risk reduction

  • Future issues



Primary care teams are ideally positioned to support recovery.

  • Primary care teams are ideally positioned to support recovery.

    • Establish a supportive relationship with regular follow up
    • Facilitate involvement in 12-step groups
    • Help patients recognize and cope with relapse precipitants and craving
    • Manage depression, anxiety, and other comorbid conditions
    • Consider adjunctive pharmacotherapy
    • Collaborate with addiction and mental health professionals


Impact of receiving PC on a cohort of alcohol, heroin, or cocaine dependent persons with no prior PC (n=391)

  • Impact of receiving PC on a cohort of alcohol, heroin, or cocaine dependent persons with no prior PC (n=391)

    • Receipt of PC (>2 visits) improved addiction severity
      • Lower odds of drug use or alcohol intoxication (AOR 0.45, 95 % CI 0.29-0.69, P=0.002)
      • Lower alcohol severity (ASI) (P=0.04)
      • Lower drug severity (ASI) (P=0.01)


HIV (CD4 12/99—503, 4/00—373)

  • HIV (CD4 12/99—503, 4/00—373)

  • HCV+

  • Heroin dependence

  • Alcohol abuse

  • Smoking

  • S/P SMA thrombosis with small bowel resection

  • Mitral valve insufficiency & CHF s/p endocarditis

  • Medications: methadone, lisinopril, furosemide



Definitions

  • Definitions

  • Prevalence and costs

  • Detection

  • Comorbidity

  • Primary medical care

  • Addiction as a chronic disease

  • Pharmacological and non-pharmacological treatments

  • Risk reduction

  • Future issues



Pathophysiology

  • Pathophysiology

    • Changes in the brain/dopamine system could be permanent.
  • Diagnosis

    • DSM-IV: explicit criteria
  • Genetic heritability

  • Etiology/Role of personal responsibility

    • Voluntary behaviors interact with genetic factors.


Demonstrated effectiveness with chronic illnesses

  • Demonstrated effectiveness with chronic illnesses

  • Addresses patient and system barriers to receipt of needed treatment

  • Links primary and specialty health care



Wt  107 125 lb with TPN

  • Wt  107 125 lb with TPN

  • Smoking continued

  • No IDU past 4 months

  • CT surgeon: mitral valve replacement after patient in community with 6 wks recovery

  • Upon discharge from rehab hospital patient linked to

    • Primary care
    • Methadone program
    • 12-Step program


Definitions

  • Definitions

  • Prevalence and costs

  • Detection

  • Comorbidity

  • Linking to primary medical care

  • Addiction as a chronic disease

  • Pharmacological and non-pharmacological treatments

  • Risk reduction

  • Future issues



Opioids

  • Opioids

    • Methadone
    • Buprenorphine
    • Naltrexone
  • Alcohol

    • Naltrexone
    • Acamprosate
    • Disulfiram
  • Cocaine and other psychostimulants

    • No effective medication


Improves overall survival

  • Improves overall survival

  • Improves retention in treatment

  • Decreases heroin and other drug use

  • Decreases HIV and hepatitis seroconversion

  • Decreases criminal activity

  • Increases social functioning

  • Improves birth outcomes



10/02 FDA approval to treat opioid dependence

  • 10/02 FDA approval to treat opioid dependence

  • Partial opioid agonist

  • Available in primary care



  • Decreases abuse potential by injection route

    • Sublingual use: predominantly buprenorphine effect
    • Parenteral use: predominantly naloxone effect


Efficacy and retention comparable to methadone

  • Efficacy and retention comparable to methadone

  • Milder withdrawal symptoms

  • Very low risk of overdose

  • Decreased risk of abuse and diversion (buprenorphine/naloxone)





Alcoholics Anonymous (AA)

  • Alcoholics Anonymous (AA)

  • Narcotics Anonymous (NA)

  • Cocaine Anonymous (CA)

  • Focus on abstinence

  • Life long participation is emphasized

  • Use of sponsor encouraged

  • Free

  • Research on effectiveness*



St. Jude’s prosthetic valve

  • St. Jude’s prosthetic valve

  • Surgery successful without complications



Primary care follow up with HIV RN

  • Primary care follow up with HIV RN

  • Methadone treatment

  • Urine tox screens documented 3-4 months abstinence

  •  alcohol use, 5 drinks/day

  • Returned to full-time employment

  • Weight  123 134 lbs



Heavy alcohol use, withdrawal; alcohol on breath, “had a nip this morning”

  • Heavy alcohol use, withdrawal; alcohol on breath, “had a nip this morning”

  • “Sniffed a bag or so”; no IDU

  • Anhedonia; no suicidal ideation

  • CD4 313

  • Medications: lisinopril, methadone, warfarin

  • Dx: depression

  • Rx: fluoxetine, psychiatric referral

  • ART not prescribed



1 pint vodka/day past several months

  • 1 pint vodka/day past several months

  • Recent IV heroin use

  • Symptoms: sweats, nausea, vomiting, diarrhea, abdominal & muscle cramps, body aches, chills, anxiety, depression, sleep disturbance, and visual hallucinations

  • Discharge summary: PCP never called; no HIV diagnosis



Patient Perspective

  • Patient Perspective

    • Facilitates access to SA treatment and PC
    • Improves substance abuse severity and medical problems
    • Increases patient satisfaction with health care
  • Societal perspective

    • Reduces health care costs
    • Diminishes duplication of services
    • Improves health outcomes


Administrative taper from methadone program for threatening behavior

  • Administrative taper from methadone program for threatening behavior

  • Alcohol use: ½–1 six pack/day

  • New sexual partner

    • 100% condom use
  • CD4 302, HVL 7000

  • No ART



Married (11/01)

  • Married (11/01)

  • Not willing to decrease alcohol use

    • Discussed pros and cons
    • Suggested recovery as “wedding present”
  • ART deferred pending improvement in alcohol use





HIV-infected persons first prescribed ART between 1996-2000 (n=578)

  • HIV-infected persons first prescribed ART between 1996-2000 (n=578)

    • classified as current IDU, former IDU, or non drug user
  • Current IDUs were less likely to suppress their HIV-1 RNA to <500 copies/mL compared to non-drug users.

  • Former IDUs were not less likely to achieve HIV-1 suppression compared to non-drug users.



If in recovery, ART should be considered in the same manner as with a patient without this history.

  • If in recovery, ART should be considered in the same manner as with a patient without this history.

  • It is reasonable to defer ART in active drug or alcohol users depending on CD4 count.

  • Promoting optimal adherence and substance abuse treatment will influence positive outcomes.



VA opioid treatment program on LAAM

  • VA opioid treatment program on LAAM

  • Alcohol: 2-3 days/week with 3 drinks/day

  • Court mandated breathalyzers, moderated alcohol use

  • Attended AA meetings 4X/week, no sponsor

  • Flu shot

  • Advised clean needles from NEP, if relapse



Definitions

  • Definitions

  • Prevalence and costs

  • Detection

  • Comorbidity

  • Primary medical care

  • Addiction as a chronic disease

  • Pharmacological and non-pharmacological treatments

  • Risk reduction

  • Future issues





Review of 42 studies from 1989-1999

  • Review of 42 studies from 1989-1999

    • Substantial evidence that NEPs decrease HIV risk behavior and HIV seroconversion among injection drug users




Mr. CB collapsed at home

  • Mr. CB collapsed at home

  • Wife performed CPR and called EMS

  • EMS

    • BP unobtainable
    • Administered naloxone with effect
  • In Emergency Department

    • Fresh track marks bilateral
    • Alcohol level 188
    • pH 6.88
    • RR 2
    • Hematocrit 21
  • 4 hours later pronounced dead



Altered level of consciousness plus 1 of the following:

  • Altered level of consciousness plus 1 of the following:

    • Respiratory rate <12 breaths/min
    • Miotic pupils
    • Circumstantial evidence or history of heroin use
  • Response to naloxone usually a confirmation of heroin intoxication



Major cause of death among heroin users

  • Major cause of death among heroin users

  • Most commonly a result of intravenous administration in drug dependent persons

  • Not usually due to a toxic quantity but polydrug use (e.g., alcohol, benzodiazepines)



68% of active users*

  • 68% of active users*

  • Reasons

    • Higher than usual dose
    • Stronger than usual heroin
    • Heroin combined with alcohol
    • Use of heroin after abstinence
    • Deliberate self-harm


Drug abuse is a risk factor for suicidal behavior, however, little is known of the causal relationship.

  • Drug abuse is a risk factor for suicidal behavior, however, little is known of the causal relationship.

  • A better understanding of this relationship will help with suicide prevention efforts.



Cohort of detox patients (n=470)

  • Cohort of detox patients (n=470)

    • Lifetime history of
      • Suicidal ideation (SI): 29%
      • Suicide attempt (SA): 22%
    • Two year follow-up prevalence of
      • SI: 20%
      • SA: 7%


Cohort of patients in addiction treatment (n=845;1972-1983)*

  • Cohort of patients in addiction treatment (n=845;1972-1983)*

    • 241 deaths
      • 51% tobacco-related
      • 34% alcohol-related
  • Cohort of injection drug users in primary care (n=667;1980–2001)†

    • 153 deaths
      • 1980–1990, principal cause of death was overdose
      • 1990–2002, principal cause of death was HIV/AIDS
      • 1992–2002, HCV emerged as a cause of death


Negative

  • Negative

    • Relapses to substance use despite addiction treatment and medical care
    • Communication between addiction treatment hospital and PC suboptimal


Definitions

  • Definitions

  • Prevalence and costs

  • Detection

  • Comorbidity

  • Primary medical care

  • Addiction as a chronic disease

  • Pharmacological and non-pharmacological treatments

  • Risk reduction

  • Future issues





Address the quality chasm for mental health and addictive disorders (IOM)

  • Address the quality chasm for mental health and addictive disorders (IOM)

  • Develop and use effective pharmacotherapy

  • Incorporate optimal organization of health services

  • Mainstream addictive disorders into medical care






Yüklə 2,75 Mb.

Dostları ilə paylaş:




Verilənlər bazası müəlliflik hüququ ilə müdafiə olunur ©www.azkurs.org 2020
rəhbərliyinə müraciət

    Ana səhifə