Substance-Use-Disorders课件

,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level, Copyright Annals of Internal Medicine, 2016,Ann Int Med. 164 (4): ITC4-1., Copyright Annals of Internal Medicine, 2016,Ann Int Med. 164 (4): ITC4-1.,In the Clinic,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Substance Use Disorders,How common are substance use disorders?,Alcohol use,30% Americans 18 years old exceed recommended limits,Smaller percentage have alcohol use disorder,Illicit drugs,9% Americans 12 years use,Marijuana (7.5%),Prescription drugs (2.5%, mostly opioids), Heroin (0.1%),Cocaine (0.6%), Hallucinogens (0.5%), Inhalants (0.2%),Methamphetamine a major problem in some regions,Designer drug use increasing (synthetic cannabinoids),What are the risk factors?,Genetic polymorphisms,May contribute 40% to 60% of an individuals risk,Environmental factors in childhood or adolescence,Age of first exposure to alcohol or drugs,Adverse childhood experiences,Psychiatric comorbidities,Depression, anxiety, bipolar disorder,May contribute to vulnerability to addiction,Anxiety and depressive symptoms may be a consequence of long-term substance use,Unhealthy substance use,Alcohol: consumption at a level that has negative health consequences,Men 65 years: risky use 4 drinks per occasion or 14 drinks per week,Men 65 years and women, risky use 3 drinks per occasion or 7 drinks per week,Unhealthy alcohol becomes a disorder when person experiences negative consequences and/or loss of control around their drinking,Drugs: ANY use,What health system measures are effective in reducing or preventing unhealthy substance use?,Risky alcohol use: brief interventions can be effective,SBIRT: screening, brief intervention, referral to treatment,If screening positive: assess further and refer for treatment,Clinical cues should trigger investigation about alcohol use (pancreatitis, elevated liver function test results),For drug use, brief interventions not shown effective,Use safe practices when prescribing opioids for pain,Ask about use: when social functioning deteriorates, family history is present, or associated comorbidities diagnosed (,hep C, upper extremity abscess),How can opioids for chronic pain be prescribed safely and effectively?,Monitor for behaviors that indicate opioid use disorder,Predictors of opioid use disorder include,History or family history of substance use disorders,Mental health diagnosis,Current cigarette smoking,History of legal problems,Concurrent benzodiazepines, and higher opioid doses,Only consider long-term opioid treatment when,Moderate to severe pain affects function and/or QOL,Potential therapeutic benefits outweigh risks,Use risk management strategies,Optimize alternatives to opioid treatment for chronic pain,Assess for risk for aberrant drug-related behaviors,Structure appropriate treatment and monitoring plan,Consider a medication agreement,Regularly assess opioid benefit and decision to use,Regularly assess drug-related behaviors, using urine drug testing, pill counts, state prescription monitoring data,Discontinue (tapering) if benefits are not commensurate with risks or if drug taking behaviors are aberrant,Seek appropriate specialist assistance,Diagnosis,Screening for alcohol use,Single-item: How many times have you consumed alcohol over the recommended limits?,AUDIT-C: 3-item survey more specific for unhealthy use,AUDIT: 10-item survey often used as follow-up to single-item question or as initial screening tool,CAGE: assesses lifetime rather than current use pattern,Screening for drug use,Single-item: How many times in the last year have you used an illegal drug, or a prescription medication for a nonmedical reason (bc of experience or feeling it caused)?,DAST-10: initial screening or follow up on single-item,Pay attention to key aspects of history,Assess withdrawal in patients with alcohol or opioid disorder who report recently stopping use,History and physical examination,CIWA (Clinical Institute Withdrawal Assessment) for alcohol withdrawal,COWS (Clinical Opiate Withdrawal Scale) score for opioid withdrawal,To further assess for complications of substance use,Laboratory evaluation often important,Diagnosis,Complications,Injection drugs,Local infections (abscesses, cellulitis),Blood-borne infections (bacterial and viral),Opioids (in addition to complications of opioid injection),Nausea and constipation,Effects of HPA axis suppression (amenorrhea, low bone density, loss of libido,Hyperalgesia,Overdose,Complications,Marijuana,Pulmonary complications (cough, bronchitis, asthma),Possible lung cancer or other cancers,Hyperemesis,In adolescents: abnormal development neural pathways,Possble depression and anxiety, psychotic disorders,Designer drugs,Synthetic cannabinoids: seizures, acute renal failure, myocardial infarction (long-term effects not well-known),“Bath salts”: muscle spasm, bruxism, palpitations, tachycardia, hypertension; psychiatric effects,Oral health problems common with substance disorders,CLINICAL BOTTOM LINE:,Complications.,Substance use disorders have myriad medical complications,Unhealthy alcohol use: liver disease as well as causing or contributing to a host of other medical conditions,Injection drug use: local and systemic bacterial infections and blood-borne viruses, including HIV and hepatitis C,Cocaine: cardiovascular effects,Marijuana: pulmonary complications, neurocognitive impairment that may be particularly serious in adolescents,Alcohol: c,riteria for outpatient detoxification,CIWA score 8 - 15,without,seizures or delirium tremens,Ability to take oral medications,Presence of reliable support person who can stay throughout the detox period and monitor symptoms,Ability to commit to daily medical visits,No unstable medical condition and not pregnant,Not psychotic, suicidal, or cognitively impaired,No concurrent substance use that may lead to withdrawal,No history delirium tremens or alcohol withdrawal seizures,Contraindications: 60 y, evidence alcohol-related end-organ damage,Benzodiazepines may help manage symptoms and prevent complications,Opioids,Treating as outpatients depends on treatment goals and treatment availability,Refer patients experiencing withdrawal and interested in methadone / buprenorphine treatment for such care,For oral naltrexone use, patient must be opioid abstinent 37 d before initiation; for intramuscular formulation 7 d,Patients often require structure and supervision of inpatient setting during this transition,In outpatient setting, manage symptoms with nonopioid medications for anxiety, cramps, diarrhea,Benzodiazepines,Manage severe withdrawal as inpatients so that IV benzodiazepines can be given and titrated to effect,Afterward, motivated patients can receive gradually tapering dose in outpatient setting over several months,What medications are available for treatment?,Alcohol,Naltrexone,Acamprosate,Disulfiram,Opioids,Methadone,Buprenorphine,Sustained-release naltrexone,Cocaine,No FDA-approved medication,What other treatments are available for substance use disorders?,Psychosocial treatment,Helps achieve sobriety, rebuild other aspects of life,Counseling,Peer-support groups (Alcoholics Anonymous),Residential treatment,Contingency management,Motivational interviewing,For patients who continue to use substances, how can physicians help reduce harms?,Needle exchange services: injection drug users,Intranasal naloxone: opioid use disorder,Tetanus, hepatitis A & B vaccination: injection drug users,Pneumonia vaccination: alcohol use disorders,Preexposure prophylaxis against HIV: high-risk patients,Counsel to avoid driving after unhealthy alcohol, drug use,Offer birth control, condom counseling, frequent STI testing to women with heroin use disorders,Engage patients in discussions about readiness for change,Address tobacco use just as with any other patient,What is the role of primary care physicians vs. addiction physicians and other specialists?,Primary care physicians,Central roles in prevention, diagnosis, and management,May treat patients with substance use disorders,Referral to addiction specialist and/or treatment program,Addiction specialists,Complex patients with substance use disorders,Addiction psychiatry subspecialists,Patients with mental health condition,Pain specialists,Optimize nonopioid treatments of chronic pain,CLINICAL BOTTOM LINE:,Management.,Withdrawal management,Necessary bridge to further treatment for many patients,Outpatient management appropriate only for highly motivated patients with ample support at home,Treatment options,Medications available for alcohol and opioid use disorders,Psychosocial treatments effective for many patients,Peer-support groups (Alcoholics Anonymous) may benefit,Educate patients who are in early recovery or who are not ready to stop substance use about harm reduction,