Recognizing and Managing Substance Use Disorders Katherine Julian, - PDF document

12/10/15 Recognizing and Managing Substance Use Disorders Katherine Julian, M.D. Professor of Medicine UCSF Division of General Internal Medicine December 10, 2015 Disclosures n None 1

12/10/15 Quiz…Your Clinic Panel n In your clinic panel, what percentage of your current clinic patients would be classified as at- risk drinkers? A. <1% B. 2-5% C. 6-9% D. 10% E. >20% Substance Use Issues are Highly Prevalent in Americans (12+years) At Risk Drinking* 27-29% Alcohol Dependence 3.5% Alcohol Dependence among 10.2% binge drinkers National Survey on Drug Use and Health, Prev Chronic Disease, 2014 2

12/10/15 Alcohol Use Disorders in Older Adults n 3% met full criteria for an alcohol use disorder n At-risk drinking was reported in: n 13% of all respondents ages 65+ n Binge drinking was reported in: n 15% of all respondents ages 65+ NSDUH, 2009 Blazer D, Wu L. Am J Psychiatry, 2009 Outline § Substance Use Disorders - Definitions § SBIRT § Screening § Brief Intervention § Referral to Treatment § ETOH Substance Use Pharmacotherapy § Treatment of Non-Cancer Pain: Balance risks/benefits § Opiate Substance Use Pharmacotherapy 3

12/10/15 Quiz… n Which of the following is NOT considered to be “at risk” drinking? A. 45 yo woman who drinks 1-2 glasses of wine each night B. 70 yo man who drinks 1-2 beers each night C. 25 yo woman who drinks 4-5 drinks once a week when she goes out with friends D. 40 yo man who drinks 1-2 glasses of wine each night Definition – At Risk Drinking n Men • >4 drinks/day or • >14 drinks/week n Women (and > than 65 yrs) • >3 drinks/day or • >7 drinks/week n Increased risk of alcohol-related problems 4

12/10/15 What is a Drink? A standard drink is any drink that contains about 14 grams of pure alcohol (about 0.6 fluid ounces or 1.2 tablespoons) DSM5 - Substance Use Disorder n No longer need to differentiate between substance abuse and substance dependence n Each substance can be categorized as a disorder n Ex: Alcohol use disorder, stimulant use disorder, etc n Grade Severity: Mild, Moderate, Severe 5

12/10/15 DSM5 - Substance Use Disorder n “Maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 2 (or more) of the following, occurring within a 12-month period:” n Failure to fulfill role obligations n Recurrent substance use in situations that are physically hazardous n Persistent use despite social/interpersonal problems Criteria for Substance Use Disorder (contd) n Tolerance n Withdrawal n Using more than originally intended n Persistent desire or unsuccessful efforts to cut-down n Time spent obtaining/using substance or recovering from side effects n Reduction of social/occupational activities n Use despite physical/psychological problems n Craving n Need 2 criteria for SUD n 2-3 criteria =mild n 4-5 = moderate n >6 = severe 6

12/10/15 Screening U.S Preventive Services Task Force recommends screening all adult patients for alcohol misuse AND “provide persons engaged in risky drinking with brief behavioral counseling interventions” How to Screen? § Ask permission: “Would it be ok to spend the next few minutes talking about alcohol?” § Pre-screen: Do you sometimes drink beer, wine, or other alcoholic beverages? § Single Alcohol Screen Question: § Men: How many times in the past year have you had 5 or more drinks in one day? § Women (or >65 yo): How many times in the past year have you had 4 or more drinks in one day? § Positive Screen=1 or more Smith PC, et al. J Gen Intern Med 2009;24(7) NIAAA Guidelines 2005 7

12/10/15 How to Screen? § Single Drug Use Screen Question: § How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons? § Positive Screen=1 or more Smith PC, et al. J Gen Intern Med 2009;24(7); NIAAA Guidelines 2005 Evidence for the Single Screen § Single question screen generally equal to other screenings (CAGE, AUDIT) § 82-88% sensitivity for at-risk drinking § 97-100% sensitivity for drug use disorder Smith PC, JGIM 2009; Smith PC, Arch Intern Med 2010 Saitz R et al. J Stud Alcohol Drugs, 2014 8

12/10/15 A Positive Screen… n What to do next? Assess… n Determine how many drinks/day in a week n Ask which drugs the patient has been using n Ask about negative impacts The follow-up questions assess impact and determine whether he/she has a substance use disorder diagnosis. Determining “At Risk” vs. “Substance Use Disorder” n Pts who meet criteria for “at-risk” should get a brief intervention n Patients who meet substance use disorder criteria abuse should get a Brief intervention n AND A referral to specialty care (if they are willing) n AND Be considered for pharmacotherapy n 9

12/10/15 What is a Brief Intervention? n Short motivational interviews that encourage patients to create a plan of action that is based on their willingness to change their behavior n Non-judgmental, direct, honest feedback n If not ready to change → harm reduction n Plan for follow-up Brief Intervention n “You are drinking more than is medically safe” n “I strongly recommend that you cut down or quit and I’m willing to help” n “Are you willing to consider making changes in your drinking?” How to Help Patients: A Clinical Approach: NIAAA 2005 Resource for Clinicians 10

12/10/15 Motivational Interviewing n Express empathy, develop discrepancy, support self-efficacy n Tools: n Listen for “change talk” n Readiness to change ruler n Importance/confidence ruler Pharmacotherapy 11

12/10/15 Addiction Treatment Model: Treating Limbic Drive and Cortical Thinking Structures Decision Making (Counseling) Limbic Drive (Pharmacotherapy) From Pettinati, NIH 2006 Alcohol Use Disorder Pharmacotherapy Two Phases of Alcohol Use Disorder Treatment: Acute Alcohol Withdrawal n Maintenance medications to reduce use or prevent n relapse (FDA approved) Disulfiram n Acamprosate n Naltrexone (oral and injectable) n http://store.samhsa.gov/shin/content/SMA15-4907/SMA15-4907.pdf 12

12/10/15 Alcohol Relapse Prevention Meds: Disulfiram (Antabuse) Blocks alcohol metabolism (prevents acetaldehyde → acetate); n increase in blood acetaldehyde levels Antabuse reaction: flushing, weakness, nausea, tachycardia, n hypotension VA Cooperative Study of Disulfuram in 605 men n High rate of non-compliance: 80% n If adherent, more likely to be abstinent n Works best if given in monitored fashion n Clinical Dose: 250mg daily (range 125-500mg/d) n SE: Hepatotoxicity (check LFTs qmo x 3 then q3 mo) n Fuller RK, et al. JAMA, 1986;256 Naltrexone for Alcohol Use Disorder n Similar structure to naloxone (Narcan) n Potent inhibitor of Mu opioid receptor binding n Endogenous opioids involved in the craving and reinforcing (pleasure) effects of alcohol 13

12/10/15 Naltrexone for Alcohol Use Disorder n Cochrane Review of NTX (based on 50 RCT) n Reduced risk of heavy drinking to 83% of the risk vs. placebo (RR 0.83; CI 0.76-0.90) n Decreased drinking days by 4% n Not significant for return to any drinking (RR 0.96; CI 0.92-1.00) n Estimate…helps 1 out of 9… Srisurapanont & Jarusuraisin (2005) Cochrane Database Syst Rev. 2010 Jan 25;(1):CD001867 Pharmacotherapy of Alcohol Dependence: Naltrexone n Oral Naltrexone Hydrochloride n DOSE: 50 mg per day n Extended-Release Injectable Naltrexone (Vivitrol) n 380mg IM per month n Must be opioid-free for 7-10 days before starting n Contraindicated in liver failure or acute hepatitis Garbutt et al. JAMA, 2005 14

12/10/15 Alcohol Relapse Prevention Meds: Acamprosate § Acts on GABA and glutamate neurotransmitter systems § Impact is anti-craving, reduced protracted withdrawal § Dose: 2 g daily (6 pills/day= TWO 333 mg pills three times/d) § SE: Diarrhea (up to 16%), nausea, itching (up to 4%) § Contraindications: severe renal disease (creat cl < 30 ml/min); dose adjust if CrCl 30-50 § Only approved for people who are abstinent Alcohol Relapse Prevention Meds: Acamprosate § Recommended length of treatment: 1 year § Effective in reducing relapse to alcohol use in studies leading to FDA approval § Meta-analysis of European trials: 36% on acamprosate abstinent at 6 months vs. 23% on placebo § Not effective in Project COMBINE: 1383 patients § Only naltrexone effective § More severe dependence in European trials (acamprosate with greater effect in longer h/o dependence)? § Fewer abstinence days required to enter COMBINE Mann K et al. Alcohol Clin Exp Res, 2004 Anton RF et al. JAMA, 2006 15

12/10/15 Summary – Alcohol Use Disorder n If abstinent: n Consider disulfiram as “insurance” (if monitored) n Consider naltrexone for relapse prevention n Can consider acamprosate n If still drinking n Consider naltrexone n If on opioids n Consider acamprosate Quiz… n Which of the following is the most commonly misused class of prescription drugs? A. Opiates Stimulants B. C. Benzodiazepines 16