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WHO IS ADDICTED? JUDITH MARTIN, MD MEDICAL DIRECTOR OF SUBSTANCE USE SERVICES, SFDPH.

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Presentation on theme: "WHO IS ADDICTED? JUDITH MARTIN, MD MEDICAL DIRECTOR OF SUBSTANCE USE SERVICES, SFDPH."— Presentation transcript:

1 WHO IS ADDICTED? JUDITH MARTIN, MD MEDICAL DIRECTOR OF SUBSTANCE USE SERVICES, SFDPH

2 DISCLOSURES Dr. Martin has no conflict of interest to disclose. Dr. Martin’s bias is that evidence-supported, safe treatment for SUDs should be equitably available throughout our system of care, including medication treatment. Dr. Martin’s bias is that continuing education improves patient care.

3 EDUCATIONAL OBJECTIVES: 3 learning objectives - use alcohol screening - list spectrum of alcohol use - know about DSM 5 criteria for SUD, practice with a clinical case.

4 QUESTION FOR YOU: 1) A 40 year-old woman tells you that she has two drinks every evening. This is: a) Alcoholism. b) Normal risk as long as she doesn’t drive in the evening. c) Alcohol abuse. d) None of the above.

5 WHY DO PEOPLE GET ADDICTED? Genetic vulnerability – may account for 50% to 60% of addiction High exposure Early exposure (adolescents vulnerable) Impulsivity/risk taking Stressors ( many of these are psychosocial)

6 THE SPECTRUM OF ALCOHOL USE heavy severe consumption none consequences Risky Lower risk Alcohol Use Disorders Abstinence Harmful, abuse Problem Alcoholism Dependence Unhealthy alcohol use

7 WHAT IS RISKY USE? How often is harmful? What type of risk? Risk of addiction? Risk of medical complications? Risk of arrest and incarceration? Risk of auto accidents? health/overview-alcohol-consumption

8 SCREENING The USPSTF recommends that clinicians screen adults aged 18 years or older for alcohol misuse and provide persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce alcohol misuse. Recommendation, 2013 Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse

9 ASK “Do you sometimes drink alcoholic beverages?” “How many times in the past year have you had…” …5 or more drinks* in a day (for men) …4 or more drinks* in a day (for women) *One “standard drink” is 12 ounces of beer, 5 ounces of wine, or 1.5 ounces of 80-proof spirits. Define alcohol (e.g. beer, wine or liquor).

10 RISKY DRINKING Screen for at-risk drinking is positive if: Men: > 14 drinks/wk or > 4 drinks per occasion Women: > 7 drinks per week or > 3 per occasion Both genders over 65: same as women. Anyone who screens positive gets a brief intervention, for example motivational interview.

11 QUESTION FOR YOU, REVIEW: 1) A 40 year-old woman tells you that she has two drinks every evening. This is: a) Alcoholism. b) Normal risk as long as she doesn’t drive in the evening. c) Alcohol abuse. d) None of the above. Answer: With this limited information, D is the answer: 14 drinks a week for a woman is ‘at risk drinking.’

12 ANOTHER QUESTION FOR YOU: A client aks for referral to addiction treatment. She says “I’m hooked on my pain pills.” When you ask for details, she says she notices that if she forgets to take her long-acting morphine she gets nauseated and sweaty and her pain returns. All those symptoms go away if she takes the morphine. She takes her medication as prescribed and doesn’t run out early or use other people’s tablets. You would: A.Refer to methadone maintenance B.Ask the nurse or pharmacist to put her medication in a pill organizer so she doesn’t forget to take her pills. C.Ask the physician to take her off morphine. D.Tell her she’s OK and not to worry about addiction.

13 ADDICTION DIAGNOSIS: DSM 5 Continued use despite adverse consequences, often with physical dependence (tolerance, withdrawal) and craving. Main difference between ‘use’ and ‘use disorder’ is loss of control and loss of function in life. With DSM 5, the word ‘abuse’ disappears from diagnosis, and addiction is evaluated along a continuum or ‘mild, moderate or severe use disorder.’ Craving is added as a criterion. Legal problems removed as a criterion. Caveat for prescriptions appropriately prescribed and taken as directed. (ie, differentiates between physical dependence and addiction) Criteria from American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition,. Washington, DC, American Psychiatric Association.

14 DSM 5 CRITERIA 1. Substance is often taken in larger amounts or over a longer period of time than intended. 2. There is a persistent desire or unsuccessful efforts to cut down or control substance use. 3. A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects. 4. Craving,or a strong desire to use the substance. 5. Recurrent substance use resulting in failure to fulfill major role obligations at work, school or home.

15 DSM 5 CRITERIA, CONTINUED 6. Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance. 7. Important social, occupational or recreational activities are given up or reduced because of substance use. 8. Recurrent substance use in situations in which it is physically hazardous 9. Continued use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance.

16 DSM 5 CRITERIA, CONCLUDED 10. *Tolerance, as defined by either of the following: (a) a need for markedly increased amounts of the substance to achieve intoxication or desired effect (b) markedly diminished effect with continued use of the same amount of the substance. 11. *Withdrawal, as manifested by either of the following: (a) the characteristic withdrawal syndrome (b) the same (or a closely related) substance are taken to relieve or avoid withdrawal symptoms *This criterion is not considered to be met for those individuals taking substance solely under appropriate medical supervision.

17 DSM 5 CRITERIA, SCORING Severity is scored along a continuum of illness by counting number met. Severity: Mild: 2-3 symptoms, Moderate: 4-5 symptoms. Severe: 6 or more symptoms.

18 ANOTHER QUESTION FOR YOU, REVIEW: A client asks for referral to addiction treatment. She says “I’m hooked on my pain pills.” When you ask for details, she says she notices that if she forgets to take her long-acting morphine she gets nauseated and sweaty and her pain returns. All those symptoms go away if she takes the morphine. She takes her medication as prescribed and doesn’t run out early or use other people’s tablets. You would: A.Refer to methadone maintenance B.Ask the nurse or pharmacist to put her medication in a pill organizer so she doesn’t forget to take her pills. C.Ask the physician to take her off morphine. D.Tell her she’s OK and not to worry about addiction. Answer: B is most useful for this patient, to prevent spiraling or erratic use or her pills.

19 NEXT: DISCUSS A CASE Thank you!


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