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An Internist Encounters Addiction: Heroin, Alcohol, and HIV Infection in a 42-Year-Old Man With Abdominal Pain Jeffrey H. Samet, MD, MA, MPH Professor,

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Presentation on theme: "An Internist Encounters Addiction: Heroin, Alcohol, and HIV Infection in a 42-Year-Old Man With Abdominal Pain Jeffrey H. Samet, MD, MA, MPH Professor,"— Presentation transcript:

1 An Internist Encounters Addiction: Heroin, Alcohol, and HIV Infection in a 42-Year-Old Man With Abdominal Pain Jeffrey H. Samet, MD, MA, MPH Professor, Boston University School of Medicine and Boston University School of Public Health Chief, General Internal Medicine, Boston Medical Center

2 Dick Van Dyke Betty Ford Rush Limbaugh Franklin D Roosevelt Darryl Strawberry Ray Charles ? Tatum O’Neal

3 Dick Van Dyke Betty Ford Rush Limbaugh Franklin D Roosevelt Darryl Strawberry Ray Charles Addiction Tatum O’Neal

4 Alcohol Prescription Opioids Tobacco Cocaine Heroin Addiction

5 Overview Definitions Prevalence and costs Detection Comorbidity Primary medical care Addiction as a chronic disease Pharmacological and non-pharmacological treatments Risk reduction Future issues

6 Case Presentation (12/99) Mr. CB, 42 y/o male, presented to ED with chief complaint “belly pain.” Moderately severe mid-abdominal pain increasing over 3 weeks

7 Hospitalization (11/99) 1 month prior to current admission Addiction –Injection drug use (IDU) for 10 years –Heroin withdrawal symptoms –Vague alcohol use Endocarditis –LVEF 75%, mitral valve vegetation –Antibiotics for 6 weeks Abdominal pain onset during hospitalization –CT abd & KUB unremarkable –Dx: constipation –Rx: laxatives & manual disimpaction -42 y/o male

8 Initial Evaluation (12/99) “Cramping” pain, constipation, poor PO intake Intranasal heroin use “to treat abdominal pain” past 10 days No recent IDU Smoked 10 cigarettes/day -42 y/o male -11/99 endocarditis -LVEF 75% -12/99-c/c- ”abd pain”

9 Physical Exam Pleasant male NAD P: 95, R: 18, weight: 120 lbs, afebrile Nodes: bilateral cervical and axillary adenopathy CV: III/VI holosystolic murmur RUSB radiating to axilla Abd: tender RLQ and LLQ without rebound Rectal: no focal tenderness; stool brown guaiac negative WBC: 5.1, Hct: 26, Plts: 267K -42 y/o male -11/99 endocarditis -LVEF 75% -12/99-c/c- ”abd pain”

10 Overview Definitions Prevalence and costs Detection Comorbidity Primary medical care Addiction as a chronic disease Pharmacological and non-pharmacological treatments Risk reduction Future issues

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12 Definitions Drug/Alcohol abuse Drug/Alcohol dependence Addiction

13 DSM IV Criteria: Drug Abuse Recurrent use resulting in failure to fulfill major role obligations Recurrent use in hazardous situations Recurrent drug-related legal problems Continued use despite social or interpersonal problems caused or exacerbated by drugs 1 or more of the following in a year:

14 DSM IV Criteria: Drug Dependence Tolerance Withdrawal A great deal of time spent to obtain drugs, use them, or recover from their effects Important activities given up or reduced because of drugs Using more or longer than intended Persistent desire or unsuccessful efforts to cut down or control substance use Use continued despite knowledge of having a persistent or recurrent physical or psychological problem caused or exacerbated by drug use 3 or more of the following in a year:

15 Addiction Characterized by behaviors that include 1 or more of the following: * –Loss of control with drug use –Compulsive drug use –Continued use despite harm A condition involving activation of the brain’s mesolimbic dopamine system; a common denominator in the acute effects of drugs of abuse † * American Society of Addiction Medicine † † Leshner AI. JAMA. 1999; 282:

16 Neurobiology of Addiction Prefontal cortex Nucleus accumbens VTA

17 Overview Definitions Prevalence and costs Detection Comorbidity Primary medical care Addiction as a chronic disease Pharmacological and non-pharmacological treatments Risk reduction Future issues

18 Prevalence Data, U.S Substance dependence or abuse 22.2 mil –Alcohol only 15.4 mil –Illicit drugs only 3.6 mil –Both alcohol and illicit drugs 3.3 mil Marijuana 4.1 mil Cocaine 1.5 mil Pain relievers 1.5 mil Heroin 0.2 mil

19 Michaud CM, Murray CJL, Bloom BR. JAMA 2001; 285(5): * * * * * * * * * * * Estimated Leading Causes of Disability- Adjusted Life-Years (DALYS) in the U.S., 1996

20 Michaud CM, Murray CJL, Bloom BR. JAMA 2001; 285(5): * * * * * *

21 Estimated Economic Costs of Drug and Alcohol Abuse in the U.S. (in billions) Health care expenditures$42.1 (e.g., Specialty treatment, prevention, research, and medical consequences) Productivity losses$262.8 Other effects$60.5 (e.g., criminal justice, property) Total costs$365.4 Office of National Drug Control Policy The Economic Costs of Drug Abuse in the United States, Harwood H. Updating Estimates of the Economic Costs of Alcohol Abuse in the United States. The Lewin Group for the NIAAA,

22 Who Bears the Cost of Substance Abuse? Swan N. NIDA Notes. Drug Abuse Costs To Society. 1998; Volume 13 (4). Government Drug Abusers Victims Private Insurance & Their Households Billions of Dollars

23 Medical Record Review Several urgent care and ED visits over past 10 years No prior primary care No mention of alcohol or drug abuse -42 y/o male -11/99 endocarditis -LVEF 75% -12/99-c/c- ”abd pain”

24 Overview Definitions Prevalence and costs Detection Comorbidity Primary medical care Addiction as a chronic disease Pharmacological and non-pharmacological treatments Risk reduction Future issues

25 What Do Patients With Substance Abuse Look Like?

26

27 Detection of Alcohol and Drug Abuse in Primary Care Patients presenting for addiction treatment who had a primary care (PC) physician (n=1440) * – 45% stated their physician was unaware of their substance abuse. 28% of a national sample of PC patients reported alcohol/drug screening, past 12 months (n=7301) † * Saitz R, Mulvey KP, Plough A, Samet JH. Am J Drug Alcohol Abuse. 1997;23: † Edlund MJ, Unutzer J, Wells KB. Med Care. 2004;42:

28 U.S. Preventive Services Task Force Screening for Alcohol Misuse Recommends screening and behavioral counseling interventions to reduce alcohol misuse by adults in primary care settings Whitlock EP, Pole MR, Green CA, Orleans T, Klein J. Ann Intern Med. 2004;140: Fleming MF, Barry KL, Manwell LB, Johnson K, London R. JAMA. 1997; 277:

29 NIAAA Guidelines—Screening and Brief Intervention Procedures—2005 Recommended screening and brief intervention procedures include 4 steps: –Step 1: ASK about alcohol use –Step 2: ASSESS for alcohol-use disorders –Step 3: ADVISE and ASSIST –Step 4: At Follow-up: CONTINUE SUPPORT

30 Week 1—Hospitalization (12/99) Blood cultures negative Methadone Pain medications Abd w/: surg consult, imaging studies UGI SBFT –“Focal area of small bowel dilatation and loss of mucosal folds within the mid to distal ileum. Differential diagnosis includes a small bowel lymphoma, however, inflammatory bowel disease and mastocytosis can also be considered.” Cardiac Echo LVEF 70%; vegetation no longer visible -42 y/o male -11/99 endocarditis -LVEF 75% -12/99-c/c- ”abd pain”

31 Week 2—Hospitalization (12/99–1/00) Abd pain and poor PO intake persisted HBSAg -, HBCAb + (past Hepatitis B, resolved) HCV Ab + (Hepatitis C) HIV +, CD4 503, HVL 15, y/o male -11/99 endocarditis -LVEF 75% -12/99-c/c- ”abd pain” -UGI- abnormal

32 Mr. CB What is your leading diagnosis? What is your next diagnostic test? -42 y/o male -11/99 endocarditis -LVEF 75% -12/99-c/c- ”abd pain” -UGI- abnormal -HIV +, HCV + CD4 503

33 Week 2—Hospitalization (1/00) CT with angiogram –Superior Mesenteric Artery (SMA) occlusion possibly secondary to mitral valve vegetation embolus –Dx: ischemic colitis –Transferred to surgery for partial colectomy -42 y/o male -11/99 endocarditis -LVEF 75% -12/99-c/c- ”abd pain” -UGI- abnormal -HIV +, HCV + CD4 503

34 Mesenteric Vascular Occlusion F. Netter, MD  CIBA

35 Week 2—Hospitalization (1/00) Prior to surgery, when Mr. CB complained of ongoing pain, house staff expressed annoyance by his multiple requests for pain medication. -42 y/o male -11/99 endocarditis -LVEF 75% -12/99-c/c- ”abd pain” -UGI- abnormal -HIV +, HCV + CD4 503

36 Merrill JO, Rhodes LA, Deyo RA, Marlatt GA, Bradley KA. J Gen Intern Med. 2002;17: Physician Management of Opioid Addiction Qualitative analysis of interviews with illicit drug-using patients and their physicians and direct observation of patient care interactions Inpatient medical service of an urban teaching hospital (6/97-12/97)

37 Physician Management of Opioid Addiction: Themes 1. Physician Fear of Deception Physicians question the “legitimacy” of need for opioid prescriptions (“drug seeking” patient vs. legitimate need). “When the patient is always seeking, there is a sort of a tone, always complaining and always trying to get more. It’s that seeking behavior that puts you off, regardless of what’s going on, it just puts you off.” -Junior Medical Resident

38 Physician Management of Opioid Addiction: Themes 2. No Standard Approach The evaluation and treatment of pain and withdrawal is extremely variable among physicians and from patient to patient. There is no common approach nor are there clearly articulated standards. “The last time, they took me to the operating room, put me to sleep, gave me pain meds, and I was in and out in two days....This crew was hard! It’s like the Civil War. ‘He’s a trooper, get out the saw’...’” -Patient w/ Multiple Encounters

39 Physician Management of Opioid Addiction: Themes 3. Patient Fear of Mistreatment Patients are fearful they will be punished for their drug use by poor medical care. “I mentioned that I would need methadone, and I heard one of them chuckle...in a negative, condescending way. You’re very sensitive because you expect problems getting adequate pain management because you have a history of drug abuse...He showed me that he was actually in the opposite corner, across the ring from me.” -Patient

40 Physician Management of Opioid Addiction: Conclusions Physicians and drug-using patients display mutual mistrust. Physicians’ clinical inconsistency, avoidance behaviors and fear of deception, problematically interact with patients’ fear of mistreatment and stigma. Medical education should focus greater attention on addiction medicine and pain management.

41 Addressing Opioid Withdrawal and Pain Management Manage opioid withdrawal –Hospitalized patients with opioid dependence should be treated with methadone. Manage pain –Treat with pain relievers in addition to methadone. O’Connor PG, Samet JH, Stein MD. Am J Med. 1994; 96: Alford DP, Compton P, Samet JH. Ann Intern Med. 2006; 144:

42 Week 4—Treatment (1/00) Transferred to med, endocarditis secondary to central line infection Total parenteral nutrition (TPN) Cardiac Echo LVEF  40% Evaluated by CT surgery -42 y/o male -11/99 endocarditis -LVEF 75% -HIV +, HCV + CD /00 SMA thrombosis, small bowel resection

43 Overview Definitions Prevalence and costs Detection Comorbidity Primary medical care Addiction as a chronic disease Pharmacological and non-pharmacological treatments Risk reduction Future issues

44 In the US, 25% of AIDS is from IDU. Centers forDisease Controland Prevention.HIV/AIDSSurveillanceReport, 2003 (Vol. 15).Atlanta: USDepartment ofHealth andHumanServices,Centers forDisease Controland Prevention;2004:[inclusivepagenumbers]. Alsoavailable at:http://www.cdc.gov/hiv/stats/hasrlink.htm. AIDS_16.ppt

45 Alcohol Problems among HIV-Infected Persons Veterans with HIV (Veterans Aging Cohort Study) (n=881) * –36% were current “hazardous” drinkers Patients establishing primary care for HIV infection (Boston Medical Center) (n=664) † –42% had current or past alcohol problems *Conigliaro J, Gordon AJ, McGinnis KA, Rabeneck L, Justice AC. JAIDS. 2003;33: † Samet JH, Phillips SJ, Horton NJ, Traphagen ET, Freedberg KA. AIDS Res Hum Retroviruses. 2004; 20:

46 — Febrile Injection Drug Users — Major Illness at Presentation n=180 Samet JH, Shevitz A, Fowle J, Singer DE. Am J Med. 1990;89: % 34% 6% 17%

47 Med/Psych DX% of AOD Pts% of Controls Acid-related Arthritis Asthma COPD Headache Hypertension Low back pain Injury/OD Liver cirrhosis Hepatitis C Depression Anxiety disorder Major psychosis Mertens JR, Lu YW, Parthasarathy S, Moore C, Weisner CM. Arch Intern Med 2003; 163: Comorbidities in Patients With Alcohol or Other Drug Disorders (AOD)

48 Med/Psych DX% of AOD Pts% of Controls Acid-related Arthritis Asthma COPD Headache Hypertension Low back pain Injury/OD Liver cirrhosis Hepatitis C Depression Anxiety disorder Major psychosis Mertens JR, Lu YW, Parthasarathy S, Moore C, Weisner CM. Arch Intern Med 2003; 163: Comorbidities in Patients With Alcohol or Other Drug Disorders (AOD)

49 Hepatitis C (HCV) 50%-80% of new injection drug users are infected with HCV within 6–12 months. * Alcohol use and HIV co-infection independently increase the risk of HCV disease progression. *† HCV has been associated with increased depressive symptoms in HIV-infected persons. ‡ HCV is challenging to treat in patients with substance use and psychiatric illnesses. § * NIDA Drug Alert Bulletin—Hepatitis.www.drugabuse.gov/HepatitisAlert/HepatitisAlert.html. † Sulkowski MS, Moore RD, Mehta SH, Chaisson RE, Thomas DL. JAMA. 2002;288: ‡ Libman H, Saitz R, Nunes D, Cheng DM, Samet JH. J Gastroenterol. 2006; 101:1804–1810. § Nunes D, Saitz R, Libman H, Cheng DM, Samet JH. Alcohol Clin Exp Res. 2006;30:

50 Rehab Hospitalization (2/00- 3/00) Wt  lbs with TPN Smoking continued No IDU past 4 months CT surgeon: mitral valve replacement after patient in community with 6 wks recovery Upon discharge from rehab hospital patient linked to –Primary care –Methadone program –12-Step program -42 y/o male -11/99 endocarditis -HIV +, HCV + CD /00 SMA thrombosis, small bowel resection -LVEF 40%

51 Overview Definitions Prevalence and costs Detection Comorbidity Primary medical care Addiction as a chronic disease Pharmacological and non-pharmacological treatments Risk reduction Future issues

52 Management of Adults Recovering From Alcohol or Other Drug Problems Primary care teams are ideally positioned to support recovery. –Establish a supportive relationship with regular follow up –Facilitate involvement in 12-step groups –Help patients recognize and cope with relapse precipitants and craving –Manage depression, anxiety, and other comorbid conditions –Consider adjunctive pharmacotherapy –Collaborate with addiction and mental health professionals Friedmann PD, Saitz R, Samet JH. JAMA. 1998;279: Friedmann PD, Rose J, Hayaki J, et al. J Gen Intern Med. 2006;21:

53 Receipt of Primary Care (PC) Impact of receiving PC on a cohort of alcohol, heroin, or cocaine dependent persons with no prior PC (n=391) –Receipt of PC (>2 visits) improved addiction severity Lower odds of drug use or alcohol intoxication (AOR 0.45, 95 % CI , P=0.002) Lower alcohol severity (ASI) (P=0.04) Lower drug severity (ASI) (P=0.01) Saitz R, Horton NJ, Larson MJ, Winter M, Samet JH. Addiction. 2005; 100:70-78.

54 Primary Care Problem List (4/00) HIV (CD4 12/99—503, 4/00—373) HCV + Heroin dependence Alcohol abuse Smoking S/P SMA thrombosis with small bowel resection Mitral valve insufficiency & CHF s/p endocarditis Medications: methadone, lisinopril, furosemide -42 y/o male -11/99 endocarditis -HIV +, HCV + CD /00 SMA thrombosis, small bowel resection -LVEF 40%

55 Overview Definitions Prevalence and costs Detection Comorbidity Primary medical care Addiction as a chronic disease Pharmacological and non-pharmacological treatments Risk reduction Future issues

56 Drug Dependence — A Chronic Disease Pathophysiology –Changes in the brain/dopamine system could be permanent. Diagnosis –DSM-IV: explicit criteria Genetic heritability –Significant genetic component of addiction Etiology/Role of personal responsibility –Voluntary behaviors interact with genetic factors. McLellan AT, Lewis DC, O’Brien CP, Kleber HD. JAMA. 2000; 284:

57 Chronic Disease Management: A Collaborative Clinical Approach Demonstrated effectiveness with chronic illnesses Addresses patient and system barriers to receipt of needed treatment Links primary and specialty health care Wagner EH. BMJ. 2000;320: Casalino LP. JAMA. 2005;293:

58 Rehab Hospitalization (2/00-3/00) Wt  lb with TPN Smoking continued No IDU past 4 months CT surgeon: mitral valve replacement after patient in community with 6 wks recovery Upon discharge from rehab hospital patient linked to –Primary care –Methadone program –12-Step program -42 y/o male -11/99 endocarditis -HIV +, HCV + CD /00 SMA thrombosis, small bowel resection -LVEF 40%

59 Overview Definitions Prevalence and costs Detection Comorbidity Linking to primary medical care Addiction as a chronic disease Pharmacological and non-pharmacological treatments Risk reduction Future issues

60 Pharmacotherapy Opioids –Methadone –Buprenorphine –Naltrexone Alcohol –Naltrexone –Acamprosate –Disulfiram Cocaine and other psychostimulants –No effective medication

61 Methadone Efficacy Improves overall survival Improves retention in treatment Decreases heroin and other drug use Decreases HIV and hepatitis seroconversion Decreases criminal activity Increases social functioning Improves birth outcomes Strain EC, Stitzer ML. Methadone Treatment for Opioid Dependence

62 Buprenorphine 10/02 FDA approval to treat opioid dependence Partial opioid agonist Available in primary care Fiellin DA, O’Connor PG. N Engl J Med. 2002;347:

63 Buprenorphine/Naloxone (Suboxone ® ): Decreases abuse potential by injection route –Sublingual use: predominantly buprenorphine effect –Parenteral use: predominantly naloxone effect

64 Buprenorphine Treatment Efficacy and retention comparable to methadone Milder withdrawal symptoms Very low risk of overdose Decreased risk of abuse and diversion (buprenorphine/naloxone) Johnson RE, Chutuape MA, Strain EC, Walsh SL, Stitzer ML, Bigelow GE. New Engl J Med. 2000;343:

65 12-Step Programs

66 Alcoholics Anonymous (AA) Narcotics Anonymous (NA) Cocaine Anonymous (CA) Focus on abstinence Life long participation is emphasized Use of sponsor encouraged Free Research on effectiveness* *Morgenstern J, Bux D, Labouvie E, Blanchard KA, Morgan TJ. J Stud Alcohol. 2002;63:

67 Mitral Valve Replacement (5/00) St. Jude’s prosthetic valve Surgery successful without complications -42 y/o male -11/99 endocarditis -HIV +, HCV + CD /00 SMA thrombosis, small bowel resection -LVEF 40% -3/00 Methadone program

68 Primary Care (11/00) Primary care follow up with HIV RN Methadone treatment Urine tox screens documented 3-4 months abstinence  alcohol use, 5 drinks/day Returned to full-time employment Weight  lbs -42 y/o male -11/99 endocarditis -HIV +, HCV + CD /00 SMA thrombosis, small bowel resection -LVEF 40% -3/00 Methadone program -5/00 MVR

69 Primary Care (4/01) Heavy alcohol use, withdrawal; alcohol on breath, “had a nip this morning” “Sniffed a bag or so”; no IDU Anhedonia; no suicidal ideation CD4 313 Medications: lisinopril, methadone, warfarin Dx: depression Rx: fluoxetine, psychiatric referral ART not prescribed -42 y/o male -11/99 endocarditis -HIV +, HCV + CD /00 SMA thrombosis, small bowel resection -LVEF 40% -3/00 Methadone program -5/00 MVR

70 Addiction Hospital (7/01) 1 pint vodka/day past several months Recent IV heroin use Symptoms: sweats, nausea, vomiting, diarrhea, abdominal & muscle cramps, body aches, chills, anxiety, depression, sleep disturbance, and visual hallucinations Discharge summary: PCP never called; no HIV diagnosis

71 Potential Benefits of Linking Primary Care (PC) and Substance Abuse (SA) Services Patient Perspective –Facilitates access to SA treatment and PC –Improves substance abuse severity and medical problems –Increases patient satisfaction with health care Societal perspective –Reduces health care costs –Diminishes duplication of services –Improves health outcomes Samet JH, Friedmann P, Saitz R. Arch Intern Med. 2001; 161:

72 Primary Care (10/01) Administrative taper from methadone program for threatening behavior Alcohol use: ½–1 six pack/day New sexual partner –100% condom use CD4 302, HVL 7000 No ART -42 y/o male -11/99 endocarditis -HIV +, HCV +, CD /00 SMA thrombosis, small bowel resection -LVEF 40% -3/00 Methadone program -5/00 MVR -7/01 Addiction treatment

73 Primary Care (12/01) Married (11/01) Not willing to decrease alcohol use –Discussed pros and cons –Suggested recovery as “wedding present” ART deferred pending improvement in alcohol use -42 y/o male -11/99 endocarditis -HIV +, HCV +, CD /00 SMA thrombosis, small bowel resection -LVEF 40% -3/00 Methadone program -5/00 MVR -7/01 Addiction treatment

74 Should Antiretroviral Therapy Be Started in the Patient Who Continues to Abuse Substances?

75 Current IDU and ART HIV-infected persons first prescribed ART between (n=578) –classified as current IDU, former IDU, or non drug user Current IDUs were less likely to suppress their HIV-1 RNA to <500 copies/mL compared to non-drug users. Former IDUs were not less likely to achieve HIV-1 suppression compared to non-drug users. Palepu A, Tyndall M, Yip B, O’Shaughnessy MV, Hogg RS, Montaner JSG. JAIDS.2003;32:

76 Treatment Options If in recovery, ART should be considered in the same manner as with a patient without this history. It is reasonable to defer ART in active drug or alcohol users depending on CD4 count. Promoting optimal adherence and substance abuse treatment will influence positive outcomes. Sherer R. JAMA. 1998;280:

77 Primary Care (10/02) VA opioid treatment program on LAAM Alcohol: 2-3 days/week with 3 drinks/day Court mandated breathalyzers, moderated alcohol use Attended AA meetings 4X/week, no sponsor Flu shot Advised clean needles from NEP, if relapse -42 y/o male -11/99 endocarditis -HIV +, HCV +, CD /00 SMA thrombosis, small bowel resection -LVEF 40% -3/00 Methadone program -5/00 MVR -7/01 Addiction treatment

78 Overview Definitions Prevalence and costs Detection Comorbidity Primary medical care Addiction as a chronic disease Pharmacological and non-pharmacological treatments Risk reduction Future issues

79

80 Needle Exchange Program (NEP) Review of 42 studies from –Substantial evidence that NEPs decrease HIV risk behavior and HIV seroconversion among injection drug users Gibson DR, Flynn NM, Perales D. AIDS. 2001;15:

81

82 Emergency Department (3/16/03) Mr. CB collapsed at home Wife performed CPR and called EMS EMS –BP unobtainable –Administered naloxone with effect In Emergency Department –Fresh track marks bilateral –Alcohol level 188 –pH 6.88 –RR 2 –Hematocrit 21 4 hours later pronounced dead -42 y/o male -11/99 endocarditis -HIV +, HCV +, CD /00 SMA thrombosis, small bowel resection -LVEF 40% -3/00 Methadone program -5/00 MVR -7/01 Addiction treatment

83 Acute Heroin Overdose Altered level of consciousness plus 1 of the following: –Respiratory rate <12 breaths/min –Miotic pupils –Circumstantial evidence or history of heroin use Response to naloxone usually a confirmation of heroin intoxication Diagnosis

84 Fatal Heroin Overdose Major cause of death among heroin users Most commonly a result of intravenous administration in drug dependent persons Not usually due to a toxic quantity but polydrug use (e.g., alcohol, benzodiazepines) Darke S, Zador D. Addiction. 1996;91: Sporer KA. Ann Intern Med. 1999;130:

85 Non-Fatal Heroin Overdose 68% of active users * Reasons –Higher than usual dose –Stronger than usual heroin –Heroin combined with alcohol –Use of heroin after abstinence –Deliberate self-harm *Darke S, Zador D. Addiction. 1996;91: Sporer KA. Ann Intern Med. 1999;130: Wines JD, Saitz R, Horton NJ, Lloyd-Travaglini C, Samet JH. Drug Alcohol Depend. In press.

86 Drug Abuse and Suicidal Behavior Drug abuse is a risk factor for suicidal behavior, however, little is known of the causal relationship. A better understanding of this relationship will help with suicide prevention efforts. Erinoff L, Compton WM, Volkow ND. Drug Alcohol Depend. 2004; 76S:S1-S2.

87 Drug Abuse and Suicidal Behavior Cohort of detox patients (n=470) –Lifetime history of Suicidal ideation (SI): 29% Suicide attempt (SA): 22% –Two year follow-up prevalence of SI: 20% SA: 7% Wines JD, Saitz R, Horton NJ, Lloyd-Travaglini C, Samet JH. Drug Alcohol Depend. 2004; 76S:S21-S29.

88 Mortality in Persons With Substance Dependence Cohort of patients in addiction treatment (n=845; ) * –241 deaths 51% tobacco-related 34% alcohol-related Cohort of injection drug users in primary care (n=667;1980–2001) † –153 deaths 1980–1990, principal cause of death was overdose 1990–2002, principal cause of death was HIV/AIDS 1992–2002, HCV emerged as a cause of death * † * Copeland L, Budd J, Robertson JR, Elton RA. Arch Intern Med. 2004;164: † Hurt RD, Offor KP, Corghan IT et al. JAMA. 1996;275: Saitz R, Gaeta J, Cheng DM, Richardson JM, Samet JH. J Urban Health. In press.

89 Post-Mortem Negative –Relapses to substance use despite addiction treatment and medical care –Communication between addiction treatment hospital and PC suboptimal Positive –Effective treatment for complicated medical, surgical, addiction, and psychiatric problems –Improved function and quality of life –Maintained relationships and responsibilities –Collaborative care between medical and methadone providers

90 Overview Definitions Prevalence and costs Detection Comorbidity Primary medical care Addiction as a chronic disease Pharmacological and non-pharmacological treatments Risk reduction Future issues

91

92 Future Issues Address the quality chasm for mental health and addictive disorders (IOM) Develop and use effective pharmacotherapy Incorporate optimal organization of health services Mainstream addictive disorders into medical care

93 Thank You!


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