Substance Use Disorders American Osteopathic Academy of Addiction - - PowerPoint PPT Presentation
Assessment of Patients with Substance Use Disorders American Osteopathic Academy of Addiction Medicine For This Presentation: Course Objectives At the conclusion of this presentation you will have a general understanding of the, diagnosis
◼At the conclusion of this presentation you will have a general understanding of the, diagnosis and screening of substance use disorders. ◼You will be introduced to DSM-5 criteria ◼You will receive an overview of SBIRT. ◼You will learn about alcohol and drug laboratory testing
◼Removal of Roman numeral to modern Arabic numeral ◼Elimination of multiaxial diagnostic system ◼Elimination of NOS designation ◼Dimensional (as opposed to categorial) approach to diagnosis ◼Cultural formulation
◼Combines the DSM-IV categories of substance abuse and substance dependence into a single disorder ◼Now have 11 criteria for substance-related disorders ◼Eliminated criteria of recurrent substance related legal issues found in DSM-IV ◼Added criteria of “craving, or strong urge to use”
◼Substance use disorders divided into two groups
◼Substance use disorders (SUD) ◼Substance-induced disorders (SID)
◼Each disorder measured on a continuum from mild to severe ◼Addition of first behavioral disorder, “gambling disorder”
According to DSM – 5: A substance use disorder is a problematic pattern of substance use leading to clinically significant impairment or distress as manifested by at least two of eleven criteria occurring in the preceding 12-month period.
changes in frequency and/or dose of substance use individuals own report report of knowledgeable
clinician’s
biological testing
1. Substance is often taken in larger amounts or over a longer period of time than was intended 2. Persistent desire or unsuccessful efforts to cut down or control substance use 3. Great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects 4. Craving or strong desire to use the substance
5. Recurrent use resulting in failure to fulfill major role obligations at work, school, home 6. Continued substance use despite having persistent or recurrent social
7. Important social, occupational, or recreational activities are given up
8. Recurrent substance use in situations in which it is physically hazardous 9. Substance use is continued despite knowledge of having a persistent
been caused or exacerbated by the substance
a. A need for markedly increased amounts of the substance to achieve intoxication or desired effect b. A markedly diminished effect with continued use of the same amount of substance
a. Characteristic withdrawal syndrome for the substance b. Use of the substance or closely related substance is taken to relieve or avoid withdrawal symptoms
impaired control (1 – 4) social impairment (5 – 7) risky use (8 – 9) pharmacological criteria (10 – 11)
◼Pharmacological criteria 10 and 11 which include withdrawal occurring during appropriate medical treatment with prescribed medications are specifically NOT counted when diagnosing a substance use disorder ◼“…the appearance of normal, expected pharmacological tolerance and withdrawal during the course of medical treatment has been known to lead to an erroneous diagnosis of addiction even when these were the
◼“however, prescription medications can be used inappropriately, and substance use disorder can be correctly diagnosed when there are
2-3 4-5 6 >
◼Alcohol ◼Caffeine ◼Cannabis ◼Hallucinogens ◼Inhalants
◼Opioids ◼Sedative-hypnotic, or anxiolytics ◼Stimulants ◼Tobacco ◼Other (or unknown)
◼Gambling disorder ◼Only behaviorally based disorder listed in substance related and addictive disorder chapter ◼Has nine specific criteria
SBIRT (Screening, Brief Intervention, and Referral for Treatment ) will
teach you how to: ◼Conduct a screening ◼Deliver a brief intervention ◼Employ a motivational approach (another lecture)
Screening: Very brief set of questions that identifies risk of substance use related problems. Brief Intervention: Brief counseling that raises awareness of risks and motivates client toward acknowledgement of problem. Brief Treatment: Cognitive behavioral work with clients who acknowledge risks and are seeking help. Referral: Procedures to help patients access specialized care.
◼Offers clinicians more systematic approach to addressing substance use through the use of evidence based techniques
◼Self-report
◼Interview ◼Self-administered short questionnaires
◼Biological markers
◼Breathalyzer testing ◼Blood alcohol levels ◼Indirect Markers ◼Serum drug testing
Source: https://www.drugabuse.gov/nidamed-medical-health-professionals/tool-resources-your-practice/screening-assessment-drug-testing-resources/chart- evidence-based-screening-tools-adults
◼10-question alcohol use screening instrument ◼Designed for primary health care workers
Hazardous Alcohol Use
◼Question 1: Frequency of Drinking ◼Question 2: Typical quantity ◼Question 3: Frequency of heavy drinking
Dependence Symptoms
◼Question 4: Impaired control over drinking ◼Question 5: Failure to meet expectations because of drinking ◼Question 6: Morning drinking
Harmful Consequences of Alcohol Use
◼Question 7: Guilt after drinking ◼Question 8: Blackouts ◼Question 9: Alcohol-related injuries ◼Question 10: Others’ concerns about drinking
Score Level Action 0-7 Low Encouragement 8-15 Low/Moderate Brief Intervention 16-19 Moderate Brief Intervention or Referral for Treatment 20+ High Brief Cognitive Therapy
A suggested clinical approach Flexibility
See reference list
What is a standard “drink”?
What is at risk drinking*
At-Risk Alcohol Use Men Women Older Adults (65 +) Per occasion >4 >3 >1 Per week >14 >7 >7
*National Institute on Alcohol and Alcoholism (NIAAA) See reference list
First ASK two questions:
(MEN) or more than 3 (WOMEN) drinks in a day?”
See reference list
A positive screen = any number on Q1 and on Q2 Men >14, Women > 7
ASK One Question: ◼"How many times in the past year have you used an illegal drug or used a prescription medication for non-medical reasons?” Positive screen = 1 or more
See reference list
Next Step for a Positive Alcohol or Drug Screen
ASK: 2 Alcohol Pre-
Screen Questions…and if Positive then
Administer the AUDIT
And now what…
Administer the DAST
ASK: 1 Drug Pre-
Screen Question…and if Positive then
At Risk
8-15
1-2
Moderate Risk
16-19
3-5
High Risk
20 >
6-8
“Brief opportunistic interventions are short, face-to-face conversations regarding drinking, motivation to change, and options for change which are provided during a window of opportunity or potentially teachable moment occasioned by a medical event.”
See reference list
◼Brief interventions trigger change. ◼A little counseling can lead to significant change, e.g., 5 min. has same impact as 20 min. ◼Research is less extensive for illicit drugs, but promising. A randomized study with cocaine and heroin users found that patients who received a BI had 50% greater odds of abstinence at follow up compared with controls.
See reference list
◼Approximately 5% of patients screened will require referral to substance use evaluation and treatment. ◼A patient may be appropriate for referral when:
◼Assessment of the patient’s responses to the screening reveals serious medical, social, legal, or interpersonal consequences associated with their substance use.
See reference list
Alcohol
◼The kidney eliminates 5 percent of alcohol/metabolites in the urine. ◼The lungs exhale 5 percent of alcohol, which can be detected by breath testing devices. ◼The liver chemically breaks down the remaining alcohol into acetic acid.
Biomarker Type of Drinking Sensitivity/ Specificity Sources of False Positives
Aspartate Amino Transferase (AST) Alanine Amino Transferase (ALT) Unknown, but heavy and lasting for several weeks Moderate/ Moderate (somewhat lower than GGT as screen for alcohol dependence) See GGT. Excessive coffee consumption can lower values. Mean Corpuscular Volume (MCV) Unknown, but heavy and lasting at least a few months Low/Moderate- High (sensitivity somewhat below GGT as screen for dependence) Liver disease, hemolysis, bleeding disorders, anemia, folate deficiency, and medications reducing folate
SAMHSA: The Role of Biomarkers in the Treatment of Alcohol Use Disorders: September 2006, Volume 5, Issue 4
Biomarker Type of Drinking Sensitivity/ Specificity Sources of False Positives
Carbohydrate- Deficient Transferrin (CDT%) Probably at least 5 drinks/day for 2 weeks Moderate/High (as screen for alcohol use disorder) Iron deficiency, hormonal status in women, carbohydrate-deficient glycoprotein syndrome, fulminant hepatitis C, and severe alcohol disease. Gamma Glutamyl Transferase (GGT) Probably at least 5 drinks/day for several weeks Moderate/ Moderate (as screen for alcohol use disorder) Liver and biliary disease, smoking, obesity, and medications inducing microsomal enzymes, gender
Biomarker Type of Drinking Sensitivity/ Specificity Sources of False Positives
Ethyl Glucuronide (EtG) Perhaps as little as a single drink High/Unknown Unknown, but alcohol is
hygiene products, cosmetics, foods,
determine how incidental alcohol exposure can substantially influence the biomarkers. Ethyl Sulfate (EtS) Perhaps as little as a single drink High/Unknown
Initial test analyte Initial Test Cutoff Confirmatory test analyte Confirmed Test Cutoff Marijuana metabolites 50 ng/mL THCA1 15 ng/mL Cocaine metabolites 150 ng/mL Benzoylecgonine 100 ng/mL Opiate metabolites Codeine/Morphine2 2000 ng/mL Morphine 2000 ng/mL Codeine 2000 ng/mL 6-Acetylmorphine (6-AM) 10 ng/mL 6-AM 10 ng/mL Phencyclidine 25 ng/mL Phencyclidine 25 ng/mL Amphetamines3 500 ng/mL Amphetamines: Amphetamine/Methamphetamine4 Amphetamine 250 ng/mL Methamphetamine5 250 ng/mL MDMA6 500 ng/mL MDMA 250 ng/mL MDA7 250 ng/mL MDEA8 250 ng/mL
1Delta-9-tetrahydrocannabinol-9-carboxylic acid (THCA) 2Morphine is the target analyte for codeine/morphine testing. 3Either a single initial test kit or multiple initial test kits may be used provided the single kit detects each
target analyte independently at the specified cutoff.
4Methamphetamine is the target analyte for amphetamine/methamphetamine testing. 5To be reported positive for methamphetamine, the specimen must also have an amphetamine
concentration equal to or greater than 100 ng/mL.
6Methylenedioxymethamphetamine 7Methylenedioxyamphetamine 8Methylenedioxyethylamphetamine
Department of Health and Human Services Substance Abuse and Mental Health Services Administration Center for Substance Abuse Prevention Medical Review Officer Manual For Federal Agency Workplace Drug Testing Programs
The term “opiate” specifically refers to natural alkaloids extracted from the opium poppy. The term “opioid” refers to synthetic opiates and opiate-like drugs in addition to the naturally occurring opiates.
Synthetic or semi-synthetic narcotics do not metabolize to codeine, morphine, or 6-acetylmorphine. These include, but are not limited to:
◼ alphaprodine ◼ hydromorphone ◼ oxymorphone ◼ hydrocodone ◼ dihydrocodeine ◼ oxycodone ◼ propoxyphene ◼ methadone ◼ meperidine ◼ fentanyl ◼ pentazocine ◼ buprenorphine ◼ tramadol
As a Consequence
Must each be tested for individually
◼Urine positive: 2-4 days
◼Urine positive: 1-21 days (infrequent vs. frequent use) ◼Using current cutoff values an infrequent user will test positive for
◼Urine positive: 2-4 days ◼Confirmed with Benzoylecgonine
◼Medical use: None ◼Urine positive: 2-4 weeks
◼Reviewed DSM-5 ◼SBIRT ◼Screening Assessments
◼Alcohol ◼Drugs
◼Laboratory Assessments
◼Alcohol ◼Drugs