Substance Abuse

1. In all patients, and especially in high-risk groups (e.g., mental illness, chronic disability),  opportunistically screen for substance use and abuse (tobacco, alcohol, illicit drugs).

• Use random urine drug screen – new kit distinguishes methadone and oxycodone from opiates.
  • Amphetamines, cocaine, etc usually detectable if used within a month
  • make sure UDS is appropriate (if negative for Rx – diverging meds?  or substitution with other people’s urine)
• Perform a quick pharmnet check to avoid Rx abuse – screen for BZD, opiates Rx

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Epidemiology

• 47% substance abusers have mental health problem
• 29% with a mental health disorder have a substance use disorder
• 47% schizophrenia & 25% anxiety disorder have a substance use disorder

Classification of Substances

• Depressants: EtOH, Opioids, Barbiturates, BZD, GHB
• Stimulants: Amphetamines, Methylphenidate, Cocaine
• Hallucinogens: Cannabis, LSD, PCP, ketamine, psilocybin
• Date Rape drugs: GHB, flunitrazepam, ketamine

Types of Substance Use Disorders

• maladaptive pattern of substance use leading to clinically significant impairment or distress

1. Substance abuse: ≥1 within a 12 month period

• Recurrent use resulting in failure to fulfill major role obligation
• Recurrent use in situations in which it is physically hazardous, eg. driving
• Recurrent substance-related legal problems
• continued use despite interference with social or interpersonal function

2. Substance Dependence ≥ 3 in the same 12 month period

• Tolerance
• Withdrawal/use to avoid withdrawal
• Taken in larger amount or over longer period than intended
• Persistent desire or unsuccessful efforts to cut down
• Excessive time to procure, use substance, or recover from its effects
• Important interests/activities given up or reduced
• Continued use despite physical/ psychological problem caused / exacerbated by subatance

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 2 In intravenous drug users: a) Screen for blood-borne illnesses (e.g., human immunodeficiency virus infection, hepatitis).  b) Offer relevant vaccinations.

Summary of recommended screening, counseling, and vaccination services for persons who use drugs illicitly

HIV infection* Testing (at least annually) pt at high risk for HIV infection, eg IVDU and their partners Hepatitis A virus (HAV) infection† Hepatitis A vaccination is recommended for illicit drug users – both injection & noninjection routes. Prevaccination testing is not indicated for the vaccination of adolescents who use drugs illicitly but might be warranted depending on the type and duration of illicit drug use. Hepatitis B virus (HBV) infection§ Hep B vaccination for any pt seek for protection Hep B vaccination in high risk settings, Eg. STD/HIV/substance abuse/IVDU/correctional clinics Offer IVDU & substance abuse Tx pt, screening and counseling for chronic HBV infection Testing: serologic assay for HBsAg as a part of routine care, If HBsAg positive – ref to ID. Previous / current sex partners & household and needle-sharing contacts of HBsAg-positive persons should be identified. Unvaccinated contacts should be tested for HBsAg & anti-HBc Ab or anti-HBsAg Ab. All susceptible persons should receive the first dose of hepatitis B vaccine as soon as the blood sample for serologic testing has been collected unless the patient will return for serologic test results and that vaccination can be initiated at that time if the patient is susceptible. anti-HBs is used to identify immunity after previous HBV infection, HBsAg testing also must be performed to identify persons with chronic HBV infection.  Susceptible persons (i.e., those who have tested negative for HBsAg and anti-HBc) should complete the vaccine series by use of an age-appropriate vaccine dose and schedule. Advise HBsAg-positive pt about preventative measure & refer them for counseling prn Susceptible persons should complete a 3-dose hepatitis B vaccine series to prevent infection from ongoing exposure.   Hepatitis C virus (HCV) infection¶ Offer all IVDU routine screen & couseling for HCV infection. Offer pt with a history of risk (remote IVDU hx) screening & counseling for HCV infection. Tuberculosis (TB)** Screen IVDU –  at high risk for TB Screen for active TB & TB infection to pt with a recent exposure to someone with active TB (BCG) vaccine generally is not recommended in US because of the low risk for infection with Mycobacterium tuberculosis, the variable effectiveness of the vaccine against adult pulmonary TB, and the vaccine’s potential interference with tuberculin skin test reactivity Sexually transmitted diseases (STDs)†† Routine (i.e., at baseline, periodically, and as clinically indicated) sexual Hx from pt and address management of risk reduction. High-intensity behavioral counseling is recommended for all sexually active adolescents and for adults at increased risk for STDs and HIV infection. Questions to identify risk related to IVDU include IVDU Hx and having a partner exchanged sex or money for illicit drugs Pt seek screening / Tx of STD – evaluate all common bacterial and parasitic STDs (e.g., chlamydia, gonorrhea, syphilis, and trichomoniasis) Universal screening of some populations (e.g., adolescent females) for chlamydia and gonorrhea is recommended at intake in juvenile detention and jail facilities. Chlamydia & Gonococcal infections Annual G&C screening for all sexually active women aged <25 yo and older women with risk factors (e.g., those who have a new sex partner or multiple sex partners) Gonorrhea risk factors: Women aged <25 years, a previous gonococcal infection, other STDs, new or multiple sex partners, inconsistent condom use, commercial sex work, and IVDU In correctional facilities, screen all adolescent females (up to 35 yo) at intake. Retest G&C infected women and men, 3 months after treatment. Screen at the first prenatal & if at tested + or at ↑ risk, retest during the 3rd trimester. Screen MSM with insertive or receptive anal intercourse or who have had oral sex in the past year. specimens from the pharynx, urethra, or rectum depending on the site of exposure.  Screening at 3-to 6-month intervals for MSM who have multiple or anonymous sex partners, have sex in conjunction with illicit use of drugs, use methamphetamine, or have partners who participate in these activities. Syphilis*** Syphilis serology – annually for sexually active MSM, universal in correctional facilities. at 3–6 month intervals for MSM who have multiple or anonymous sex partners, have sex in conjunction with illicit drug use, use methamphetamine, or have sex partners who participate in these activities. Syphilis serology for all pregnant women at the first prenatal visit Women at high risk for syphilis, live in areas of high syphilis morbidity, are previously untested, or have positive serology in the first trimester should be screened again early in the third trimester (28 weeks of gestation) and at delivery. Herpes simplex virus-2††† Consider HSV serologic in STD evaluation (especially for those persons with multiple sex partners), persons with HIV infection, and MSM at increased risk for HIV acquisition. Human papillomavirus (HPV)§§§ Routine pre-exposure vaccination of those aged 11 or 12 years is recommended to prevent cervical precancer and cancer caused by high-risk HPV types. Catch-up vaccination is recommended for those aged 13–26 years, as indicated and recommended No vaccines are available for the prevention of infection with HIV, HCV, or any STD other than HPV and HBV.

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3 In patients with signs and symptoms of withdrawal or acute intoxication, diagnose and manage it appropriately.

Patient will have 3 of 7 within 12 month period: “WITHDraw IT”:

• Withdrawal symptoms
• Interest or Important activities given up or reduced
• Tolerance
• Harm to physical and psychosocial known but continue to use
• Desire to cut down, control
• Intended time, amount exceeded
• Time spent too much

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EtOH Intoxication

• Legal limit for impaired driving is 10.6mmol/L (50mg/dl) reached by 2-3 drinks /h for men & 1-2 drinks/h for women
• Coma can occur with >60mmol/L (non-tolerant drinkers) & 90-120mmol/L (tolerant drinker)

EtOH Withdrawal

• Occurs within 12-48hr after prolonged heavy drinking & can be life-threatening (20% mortality if untreated)
• EtOH withdrawal can be described as having 4 stages:
• Stage 1 (6-12hr after last drink): tremor, sweating, agitation, anorexia, cramps, diarrhea, sleep disturbance
• Stage 2 (1-7 d): Visual, auditory, olfactory, tactile hallucinations
• Stage 3 (12-72hr up to 7 days): Sz – usually tonic-clonic, nonfocal, brief
• Stage 4 (3-5d): delirium tremens: autonomic hyperactivity (diaphoresis, tachycardia, tachypnea), hand tremor, insomnia, psychomotor agitation, anxiety, N/V, tonic-clonic Sz, V/T/AH, persecutory delusions

Management of EtOH Withdrawal – CIWA-A

• Areas of assessment: – scored 0-7 (orientation/sensorium 0-4)
  • N/V, tremor, paroxysmal sweats, headache, fullness in head
  • Tactile, auditory, vidual disturbances
  • Agitation, anxiety, orientation & clouding of sensorium
• Mild <10, moderate 10-20, Severe >20, max score 67
• Basic Protocol:
  • Diazepam 20mg po q1-2h until CIWA-A <10, observe 1-2h after last dose & re-assess
  • Thiamine 100mg IM then 100mg po daily x 3d
  • Supportive Care: hydration, nutrition
• Hx of Withdrawal Sz: Diazepam 20mg po q1h ≥ 3 regardless of CIWA
• >65, Severe liver dz, severe asthma, resp failure: short acting BZD
• + Hallucinations –
  • Haloperidol 2-5mg IM/PO Q1-4h – max 5 doses/day or atypical antipsychotics (olanzapine, riseperidone)
  • Diazepam 20mg x 3 as Sz prophylaxis (haloperidol lowers Sz threshold)
• Admit if still in withdrawal after 80mg of diazepam, delirium tremens, recurrent arrhythmias, multiple Sz, medically ill or unsafe to d/c

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Opioids

Acute Intoxication

• Direct effect on receptors in CNS – decreased pain perception, sedation, decreased sex drive, N/V, decreased GI motility, and respiratory depression

Toxic Reaction

• typical syndrome includes shallow respirations, miosis, bradycardia, hypothermia, decreased LOC
• Tx: ABCs, IV glucose, naloxone (Narcan) 0.4mg up to 2mg IV – Intubation and mechanical ventilation, ± naloxone drip until pt alert w/o naloxone (up to 48h w/ long-acting opioids)
• caution with longer half-life – may need to observe for toxic reaction for >24hr

Withdrawal

• Depression, insomnia, drug-craving, myalgias, nausea, chills, autonomic instability (lacrimation, rhinorrhea, piloerection)
• Onset 6-12 hr, duration 5-10d
• C/I: loss of tolerance (overdose on relapse), miscarriage, premature labour
• Management: long-acting oral opioid (methadone, buprenophine), α-adrenergic agonists (clonidine)

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Cocaine

Intoxication

• Elation, euphoria, pressured speech, restlessness, sympathetic stimulation (tachycardia, mydriasis, sweating)
• Prolonged use may result in paranoia & psychosis

Overdose – Medical emergency

• HTN, tachycardia, tonic-clonic Sz, dyspnea, ventricular arrhythmias
• Tx: IV diazepam to control Sz & propanolol / labetalol to manage HTN & arrhythmias

Withdrawal

• Initial crash (1-48hr): increased sleep, increased appetite
• Withdrawal (1-10wks): dysphoric mood plus fatigue, irritability, vivid unpleasant dreams, insomnia or hypersomnia, psychomotor agitation or retardation
• C/I: relapse, suicide (sig increase during withdrawal period)
• Management: supportive management

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 Amphetamines

• Intoxication: Euphoria, improved concentration, sympathetic & behavioural hyperactivity & at high doses can cause coma
• Chronic use: paranoid psychosis – similar to schizophrenia with agitation, paranoia, delusions & hallucinations
• Withdrawal symptoms: dysphoria, fatigue, restlessness
• Tx of stimulant psychosis: antipsychotics

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 Cannabis

• Marijuana – most often used illicit drug
• Psychoactive – Δ9-THC
• Cessation does not produce sig withdrawal phenomenon

Intoxication

• tachycardia, conjunctival vascular engorgement, dry mouth, altered sensorium, increased appetite, increased sense of well-bing, euphoria/laughter, muscle relaxation, impaired performance on psychomotor tasks including driving
• High dose – depersonalization, paranoia, anxiety, trigger psychosis & schizophrenia if predisposed

Chronic use – tolerance & an apathetic, amotivational state

Tx of dependence: behavioural & psychological interventions to maintain an abstinent state

Medical Uses

• Anorexia-cachexia (AIDS, Cancer)
• Spasticity, muscle spasms (MS, spinal cord injury)
• Levodopa-induced dyskinesia (Parkinson’s dz)
• Controlling tics & OCD (Tourette’s syndrome)
• Reducing intra-ocular pressure (glaucoma)

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 Hallucinogens

• types of hallucinogens: LSD, mescaline, psilocybin, PCP, cannabis, ecstasy, salvia
• LSD intoxication – tachycardia, HTN, mydriasis, tremor, hyperpyrexia, perceptual / mood changes
• High dose – depersonalization, paranoia, anxiety
• No specific withdrawal syndrome characterized
• Tx of agitation & psychosis: support, reassurance, diminished stimulation
  • BZD / high potency antipsychotics seldom required

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4 Discuss substance use or abuse with adolescents and their caregivers when warning signs are present (e.g., school failure, behaviour change).

Common Presentations of Drug Use

• General: Wt loss (cocaine, heroin, injected cannabis), pinpoint pupils (opioids), track marks (IVDU)
• MSK: trauma
• GI: Viral hepatitis (IVDU), unexplained elevations in ALT
• Behavioural: missed appointments, non-compliance, drug seeking (BZD, opioids)
• Psychological: insomnia, fatigue, depression, flat affect (BZD, barbiturates), paranoia (cocaine), psychosis (cocaine, cannabis, hallucinogens)
• Social: Marital discord, family violence, work/school absenteeism & poor performance

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 5 Consider and look for substance use or abuse as a possible factor in problems not responding to appropriate intervention (e.g., alcohol abuse in patients with hypertriglyceridemia, inhalational drug abuse in asthmatic patients). 

6 Offer support to patients and family members affected by substance abuse. (The abuser may not be your patient.)

Summary of recommended messages for persons who use drugs illicitly to reduce drug use and infectious disease–related risks

Get tested for human immunodeficiency virus, hepatitis B, and hepatitis C. Get vaccinated against hepatitis A and hepatitis B. Stop injection drug use to eliminate the risk for bloodborne infections. Get counseling and treatment to stop or reduce drug use. Never reuse or share syringes or drug-preparation equipment. Use a new, sterile syringe from a reliable source (e.g., a pharmacy or syringe exchange program). Use sterile water to prepare drugs, if possible; otherwise, use clean water from a reliable source, such as fresh tap water. Use a new container (i.e., cooker) and a new filter (i.e., cotton) to prepare drugs. Clean the injection site with a new alcohol swab before injection. Dispose of syringes safely after using them. Participate in risk-reduction programs. Obtain medical treatment for infectious diseases. Obtain treatment for substance use and mental disorders.

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7 In patients abusing substances, determine whether or not they are willing to agree with the diagnosis.
8 In substance users or abusers, routinely determine willingness to stop or decrease use.
9 In patients who abuse substances, take advantage of opportunities to screen for co-morbidities (e.g., poverty, crime, sexually transmitted infections, mental illness) and long-term complications (e.g., cirrhosis)

Principles for managing health-care relationships between providers and persons who use drugs illicitly

Develop a professional relationship that shows mutual respect and avoids blame or judgment. Educate persons who use drugs illicitly about health care and how to advocate for their own health. Include persons who use drugs illicitly in decisions about their treatment. Establish, where practical and affordable, a multidisciplinary case-management team. Have a primary care provider be responsible for coordinating care. Develop an understanding about the responsibilities of persons who use drugs illicitly and their service providers. Respond to behaviors that run against agreed-upon expectations or limits. Reduce barriers to accessing health care. Establish realistic healthful behavior goals to which persons who use drugs illicitly can commit. Emphasize the importance of risk reduction measures. Recognize that success in building relationships and healthful behaviors might require several attempts. Learn about local health service resources for persons who use drugs illicitly. Avoid common pitfalls in treating persons who use drugs illicitly (e.g., having unrealistic expectations, becoming frustrated or angry, moralizing, assigning blame, and withholding therapy).

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References:

• TN2013
• CDC 2011: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6105a1.htm?s_cid=rr6105a1_w