Substance Abuse 3 PDF

Substance Use/Abuse HISTORY  Dating back to the Mayflower in 1620 opiates derived from opium were used to cure the symptoms and pain from common ailments of the times like cholera, smallpox, dental pain and dysentery  As late as 1890 Bayer promoted both aspirin and heroin...

Substance Use/Abuse HISTORY  Dating back to the Mayflower in 1620 opiates derived from opium were used to cure the symptoms and pain from common ailments of the times like cholera, smallpox, dental pain and dysentery  As late as 1890 Bayer promoted both aspirin and heroin as cough, cold and pain remedies not only for adults but for children as well Substance Use/Abuse  The Harrison Tax Acts of 1914 were the governments first attempt at drug legislation and imposed a tax on anyone who imported, produced or sold opium derivatives  By 1920, medical professionals were aware of the addictive nature of opiates  Addiction was deemed a moral issue, not a medical one and so began its stigmatization in our society  The 1970’s saw the emergence of synthetic opiates or opioids such as hydrocodone and oxycodone  Illicit drugs are often associated with substance abuse, but alcohol, nicotine, and prescription painkillers are among the most widely abused substances in the United States DEFINITIONS:  Substance Use Disorder (SUD) is a maladaptive pattern of substance use that leads to impairment or distress at school, work, with family, and physical or social difficulties (This was formerly known as Drug addiction) Key Terms: Dependence – psychological or physiologic Withdrawal Detoxification Tolerance Question At what kind of primary care visit should we be screening for Substance Abuse?  Addictive disorders are chronic and relapsing It is believed that addiction Thought to be the result of change brain pathways and interactions among genetic, result in increased temperament, psychosocial vulnerability to drug effects factors, resource availability and continued dependence and substance access Pathophysiolog y Brain reward: multifaceted, Both “brain reward” and involving dopamine, avoidance of withdrawal norepinephrine, endogenous contribute to addictive opioids (endorphins), GABA, substance use serotonin, acetylcholine, and adrenergic systems Common Substances of Abuse Central Opioids Central Psychotomimet Inhalants Anabolic Nervous Nervous ic and Steroids System System Hallucinogens Sedatives Stimulants Alcohol Heroin Cocaine Cannaboids Solvents Synthetic (i.e.: acetone) testosteron Benzodiazepines Morphine Amphetamines LSD e Nitrous Oxide GHB Morphine Methylphenidate PCP Derivatives Volatile Nitrites Synthetic: Methadone Fentanyl Diagnostic Criteria ABUSE DEPENDANCE (1 or more in a 12-month period) (3 or more in a 12-month period)  Tolerance  Failure to fulfill roles or  Withdrawal obligations  Increased use  Hazardous situations  Efforts to “cut down”  Legal problems  Excessive time on activities to  Social/interpersonal problems obtain drug  Important social, occupational, or recreational activities are given up or reduced because of substance use  Continued use despite knowledge of negative consequences  Clinical Presentation Physical Signs Behavioral Signs  Change in overall attitude/personality with no other identifiable cause.  Inability to sleep, awake at unusual times, unusual  Drop in grades at school or performance at work laziness.  Change in activities or hobbies.  Loss of or increased in appetite, changes in eating  habits Chronic dishonesty.  Cold, sweaty palms; shaking hands.  Sudden oversensitivity, temper tantrums, or resentful behavior.  Red, watery eyes; pupils larger or smaller than usual  Difficulty in paying attention; forgetfulness.  Unusual smells on breath, body or clothes.  General lack of motivation, energy, self-esteem, “I don’t care” attitude.  Extreme hyperactivity; excessive talkativeness.  Change in habits at home; loss of interest in family and family activities.  Slowed or staggering walk; poor physical coordination.  Paranoia  Needle marks on lower arm, leg or bottom of feet.  Moodiness, irritability, unusual silliness, nervousness.  Nausea, vomiting or excessive sweating.  Excessive need for privacy; unreachable, secretive  Tremors or shakes of hands, feet or head.  Change in personal grooming habits.  Irregular heartbeat.  Possession of drug paraphernalia.  Runny nose; hacking cough  Changes in friends; friends are known drug users.  Puffy face, blushing, or paleness  Unexplained need for money, stealing money or items  Frequent rubbing of the nose  Possession of a false ID card  Deterioration of hygiene or physical health  Missing prescription pills  CAGE CONCERN Screening ANGER GUILT EYE-OPENER DAST (DRUG ABUSE SCREENING TEST) Physical Frequent Gastrointestinal absences from symptoms, such Exam school or work as epigastric distress, RED FLAG History of diarrhea, or FINDINGS frequent trauma weight changes or accidental injuries Sexual dysfunction Depression or anxiety Sleep disorders Labile hypertension  Mild tremor Odor of alcohol on breath Physical Enlarged, tender liver Exam Nasal irritation (suggestive of cocaine insufflation) Conjunctival irritation Labile blood pressure, tachycardia “Aftershave/mouthwash” syndrome (to mask the odor of alcohol) Odor of marijuana on clothing Signs of chronic obstructive pulmonary disease, hepatitis B or C, HIV infection Chronic disease that fails to respond to normal treatment   Might need to be individualized  Common tests include  CBC with differential  CMP (includes LFT’s, renal function and electrolytes)  Drug screen by urine or blood (several panels Diagnostics  to choose from) Hepatitis Panel  HIV  Syphilis (RPR)  TSH  B-HCG if indicated  Others as needed Management – Overall Strategies  Risk Reduction  Consider inpatient detox  Residential treatment programs  Outpatient treatment program  Alcoholics Anonymous – **most important intervention for alcohol use disorder **  Narcotics Anonymous  Individual Psychotherapy  Medical management of co-morbidities  Pharmacological agents to reduce cravings and control dependence **Development of a Therapeutic Relationship** Pharmacological Management: Alcohol Use Disorder  **12-step program like AA has been shown to be the most effective for long term success even before pharmacologic interventions **  Withdrawal  Librium (chlordiazepoxide): 5-100mg PO (most common)  Can use other benzo’s like lorazepam or Ativan  Cravings  Naltrexone: opioid receptor antagonist that may be helpful  Campral (acaprosate): enhances GABA  Antabuse (dilsufiram): produces severe illness when alcohol is ingested Pharmacological Management: Opioid Use Disorder  **Medications are first line for opioid use disorder, then programs like 12-step (NA). **  Overdose  Naloxone: opioid receptor antagonist that reverses opioid overdose  Withdrawal  Methadone: full opioid agonist - used for withdrawal  Buprenorphine (can be used with Naloxone): partial opioid antagonist - can be used for withdrawal  Clonidine: antihypertensive adrenergic agonist used for withdrawal  Maintenance  Methadone – prescribed by specific clinics and often requires daily visits  Buprenorphine – needs a waiver to prescribe that can be obtained by PCP increasing access NJ STATS 2016 2016  New “safe” opioids Health care policy were developed and marketed and the new stated that pain is a research gave The road to the vital sign and a prescribers security in opioid epidemic disease process of prescribing these was paved with its own that needs medications liberally good intentions treatment to patients With the The risk benefit Opioid Before much was recognition of the suffering, pain ratio was skewed in favor of opioids and Epidemic known about opioids we used control came to the forefront in the the goal of complete pain them 1980’s and opioid control prioritized. indiscriminately prescribing was opened up The result was poor As the dangers pain control and a came to light use reduced quality of was restricted life for sufferers of completely chronic non cancer pain sufferers  In the process of trying to achieve something good, the WE GOT IT pendulum swung too far and WRONG! so began an opioid use epidemic causing addiction and death through our nation.