1. Screening for Substance Abusers in a Primary Care Setting Matthew Torrington, M.D., Richard Rawson, Ph.D. Matthew Torrington, M.D., Richard Rawson, Ph.D. UCLA Integrated Substance Abuse Programs UCLA Integrated Substance Abuse Programs www.uclaisap.org www.uclaisap.org www.uclaisap.org Third Annual Statewide Co-Occurring Disorders Conference June 21-22, 2004 Long Beach, CA

2. Identifying Substance Abuse in the General Medical Population PART 1

3. National Household Survey on Drug Abuse (NHSDA) 2001  In 2001 an estimated 15.9 million Americans age 12 years or older used an illicit drug during the month immediately prior to the survey interview.  7.1 % of the population 12 years or older; up from 6.3 % of this population in 2000.

4. National Household Survey on Drug Abuse (NHSDA) 2001 (cont.)  The survey also found statistically significant increases between 2000 and 2001 in the use of particular drugs or groups of illicit drugs  marijuana (from 4.8 to 5.4 %)  cocaine (0.5 to 0.7 %)  the nonmedical use of pain relievers (1.2 to 1.6 %)  tranquilizers (0.4 to 0.6 %) Cost in health and job loss is $144 billion per year. Cost in health and job loss is $144 billion per year.

5. Identifying Patients at Risk Screening instruments: Screening instruments: History: personal history & family history History: personal history & family history Behavioral check lists Behavioral check lists Therapeutic maneuver Therapeutic maneuver

6. History What predicts addiction? What predicts addiction?  Personal history of drug abuse  Family history of drug abuse  Current addiction to alcohol or cigarettes  History of problems with prescriptions  Co-morbid psychiatric disorders

7. Behavior Suggestive of Addiction Buying, selling, and forging prescriptions Buying, selling, and forging prescriptions Stealing drugs Stealing drugs Injecting oral formulations Injecting oral formulations Abusing alcohol and other drugs Abusing alcohol and other drugs Persistent non-compliance Persistent non-compliance “Dr. and ER shopping” “Dr. and ER shopping” Drug-related functional deterioration Drug-related functional deterioration Resistance to change despite adverse effects Resistance to change despite adverse effects

8. Substance-related Disorders  Intoxication  use of substance resulting in maladaptive behavior  Acute Withdrawal  negative reactions that occur when use is discontinued or drastically reduced can include:  Delirium, Psychosis, Physical Discomfort, Seizures,  Death (with some types of withdrawal

9. Substance-related Disorders  Protracted Withdrawal (can include)  Mood disorder  Anxiety  Sexual dysfunction  Sleep disorder  Anhedonia  Memory and Concentration Problems

10. DSM IV Criteria for Substance Abuse  Significant impairment or distress resulting from use  Failure to fulfill roles at work, home, or school  Persistent use in physically hazardous situations  Recurrent legal problems related to use  Continued use despite interpersonal problems

11. DSM IV criteria for Substance Depend. ≥ 3 of the following occurring in the same 12- month period 1. Desire or unsuccessful efforts to cut down on use 2. Large amount of time spent obtaining drug, using drug, or recovering from drug effects 3. Social, occupational, or recreational activities reduced because of drug use 4. Opiate use continued despite knowledge that a physical or psychological problem is being caused or exacerbated by use 5. Tolerance to drug 6. Withdrawal upon cessation of use

12. EtOH Stats U.S. Department of Justice Bureau of Justice Statistics  48.3 % or 109 million persons were current drinkers in the 2001 survey  Almost half of all Americans age 12 or older

13. EtOH Stats Continued U.S. Department of Justice Bureau of Justice Statistics  About 10.1 million persons age 12 to 20 years reported current use of alcohol in 2001.  28.5 % of this age group for whom alcohol is an illicit substance.  Of this number, nearly 6.8 million or 19.0 % were binge drinkers and 2.1 million or 6.0 % were heavy drinkers.

14. Drinking and Driving  In 2001, more than 1 in 10 Americans or 25.1 million persons reported driving under the influence of alcohol at least once in the 12 months prior to the interview.  The rate of driving under the influence of alcohol increased from 10.0 to 11.1 % between 2000 and 2001.  Among young adults age 18 to 25 years, 22.8 % drove under the influence of alcohol.

15. EtOH Effects  SPEED OF DRINKING - The liver metabolizes ≈1/2 ounce of alcohol per hour.  PRESENCE OF FOOD IN THE STOMACH – STOMACH – When alcoholic beverages are taken with a substantial meal, peak BAC may be reduced by as much as 50%.  BODY WEIGHT  DRINKING  HISTORY/TOLERANCE –  ENVIRONMENT

16. EtOH Effects  THE DRINKER'S  EXPECTATIONS  GENERAL STATE OF  EMOTIONAL AND  PHYSICAL HEALTH -  SEX DIFFERENCES Females will generally have a higher BAC than their male counterparts, due to less body fluids to dilute the alcohol and to more body fat. Females are generally more affected by alcohol just prior to menstruation.  OTHER DRUGS- p450, etc

17. Physiological Markers of Alcoholism  Uric acid  Triglycerides  Gamma-glutamyl transferase  Aspirate aminotransferase  Alanine aminotransferase  Mean corpuscular volume

18. Laboratory Tests Red blood cells indices: INCREASED MCV Red blood cells indices: INCREASED MCV Liver function tests: Liver function tests:  INCREASED: AST (SGOT), ALT (SGPT), GGT INCREASED Serum uric acid INCREASED Serum uric acid INCREASED Carbohydrate-deficient transferrin (CDT) INCREASED Carbohydrate-deficient transferrin (CDT)

19. Cocaine  Blow  Nose candy  Snowball  Tornado  Wicky stick

20. Cocaine  Principal routes of cocaine administration  Oral  "chewing"  Intranasal  "snorting"  Intravenous  "mainlining,"  "injecting"  Inhalation  "smoking” Cocaine + Heroin = Speedball

21. Cocaine Blocks the Removal of Dopamine From the Synapse of Neurons in the Nucleus Accumbens. These Neurons Originate From the Ventral Tegmental Area

22. Cocaine Effects  Short term Effects  Increased energy  Decreased appetite  Mental alertness  Increased heart rate and blood pressure  Constricted blood vessels  Increased temperature  Dilated pupils

23. Cocaine Effects  Long Term Effects   Addiction  Irritability and mood disturbance   Restlessness   Paranoia   Auditory hallucinations

24. Cocaine Medical Complications  Cardiovascular effects  disturbances in heart rhythm heart rhythm  heart attacks  Respiratory effects  chest pain  respiratory failure  Neurological effects  strokes  Seizures  headaches  Gastrointestinal complications  abdominal pain  nausea

25. Cocaethylene  Human liver combines cocaine and alcohol and manufactures a third substance, cocaethylene, that intensifies cocaine's euphoric effects, while possibly increasing the risk of sudden death.

26. Methamphetamine  Street methamphetamine is referred to by many names "speed"meth”"chalk”  Methamphetamine hydrochloride, clear chunky crystals resembling ice, which can be inhaled by smoking, is referred to as "ice”"crystal”"glass"

27. How Does Methamphetamine Act?  Methamphetamine releases high levels of dopamine, which stimulates brain cells,  Enhancing mood and body movement.  Methamphetamine appears to have a neurotoxic effect, damaging brain cells that contain dopamine and serotonin,  Methamphetamine appears to cause reduced levels of dopamine, which can result in symptoms like those of Parkinson's disease

28. Methamphetamine  Increased wakefulness  Increased physical activity  Decreased appetite  Increased respiration  Hyperthermia  Euphoria.  Other CNS effects:  irritability, insomnia, confusion, tremors, convulsions, anxiety, paranoia, and aggressiveness. What does it do?

29. Methamphetamine Effects  Increased heart rate and blood pressure  Irreversible damage to blood vessels in the brain, producing strokes  Respiratory problems, irregular heartbeat, extreme anorexia.  Cardiovascular collapse and death.  Hyperthermia and convulsions can result in death.

30. What Are Opiates?  a.) Inducing sleep; somniferous; narcotic; hence, anodyne; causing rest, dullness, or inaction; as, the opiate rod of Hermes.  (n.) Originally, a medicine of a thicker consistence than syrup, prepared with opium.  (n.) Any medicine that contains opium, and has the quality of inducing sleep or repose; a narcotic.  (n.) Anything which induces rest or inaction; that which quiets uneasiness.

31. Opiates  Oxycodone  (oxycontin)  Propoxyphene  (Darvon)  Hydrocodone  (Vicodin)  Hydromorphone  (Dilaudid)  Meperidine  (Demerol),  Diphenoxylate (Lomotil)  Codeine

32. Heroin  Heroin is processed from morphine (diacetylmorphine)  Morphine is a naturally occurring substance extracted from the seedpod of the Asian poppy plant.  Heroin usually appears as a white or brown powder.  Street names "smack,“ "H," "H,"“horse,”"skag,“"junk" "Mexican black tar,” “China White”  Originally produced by Bayer as a “non addictive” analgesic

33. Opiate Effects Desirable Desirable  Pain relief  Euphoria - heroin produces greater ‘rush’ than morphine due to ↑ lipophilicity  Prolonged sense of contentment and well-being Undesirable Undesirable  Nausea and vomiting  Respiratory depression – ↓ in sensitivity of respiratory center to PCO 2  Constipation - ↑ tone + ↓ motility in GI tract  DON’T RX OPIATES WITHOUT CONSIDERING THIS  Pupillary constriction - stimulation of oculomotor nucleus

34. Brief Intervention for Hazardous and Harmful Drinking  Thomas Babor and J. C. Higgins-Biddle  WHO standard, published in 2001  Low in cost and proven effective across a spectrum of EtOH problems  SBI : Screening Brief Intervention

35. Categorize USE USE  Any ingestion of alcohol LOW RISK LOW RISK  Drinking that is within legal and medical guidelines and is not likely to result in alcohol related problems MISUSE MISUSE  Any level of risk ranging form hazardous drinking to alcohol dependence

36. Hhhh ADVISE APPROPRIATE ACTION FOLLOW UP - Supportive Care ASK Quantity/Frequency Binge CAGE AUDIT Brief Intervention Motivational Interview Referral Step 1 Step 2 Step 3 Step 4 3-2 ASSESS Academic Social Behavioral Medical

37. Methods of Screening  CAGE  MAST/DAST  AUDIT  OTHERS

38. The Audit: A Demonstration How it works

39. Public Health Paradigm The primary goal of brief intervention is to:  Reduce alcohol use to low-risk levels  Encourage abstinence in persons who are alcohol-dependent

40. Brief Intervention or Brief Talk Therapy  Commonly used by clinicians to talk to patients about health issues or medication compliance  Not unique to the alcohol field  Designed for use in busy clinical settings  Generally 5-10 minute duration

41. Brief Intervention or Brief Talk Therapy (Continued)  Includes motivational interviewing and Cognitive Behavioral Therapy (CBT) techniques  More clinician-centered than client-centered therapy  Clinician shares concerns with student and tries to convince student to decrease alcohol use

42. Brief Intervention or Brief Talk Therapy (Continued)  Uses an empathic, non-confrontational style  Offers patient choices  Emphasizes patient responsibility  Conveys confidence in patient's ability to change

43.  Conduct an assessment: “ Tell me about your drinking.” “What do you think about your drinking ?” “ Tell me about your drinking.” “What do you think about your drinking ?”  Consider Screening measures: AUDIT  Provide direct clear feedback: "As your doctor/therapist, I am concerned about how much you drink and how it is affecting your health." Brief Intervention or Brief Talk Therapy (Continued)

44.  Establish a treatment contract through negotiation and goal setting: "You need to reduce your drinking. What do you think about cutting down to three drinks 2-3 times per week?“  Apply behavioral modification techniques: "Here is a list of situations when students drink and sometimes lose control of their drinking.” "Here is a list of situations when students drink and sometimes lose control of their drinking.” Brief Intervention or Brief Talk Therapy (Continued)

45.  Ask patients to review a self-help booklet and complete diary cards: “I would like you to review this booklet and bring it with you at your next visit. I’d also like you to write down how much you drink on these diary cards.” “I would like you to review this booklet and bring it with you at your next visit. I’d also like you to write down how much you drink on these diary cards.”  Set up a continuing care plan for nurse reinforcement phone calls and clinic visits. Brief Intervention or Brief Talk Therapy (Continued)

46. Brief Intervention Studies in College Students Marlatt Et. Al. 1998  348 heavy drinking college freshmen recruited at the University of Washington  Recruitment occurred via self-report questionnaire completed by incoming students  Intervention delivered by research staff  No involvement of primary care clinicians  Follow up at 6, 12 and 24 months

47. Brief Intervention Studies in College Students Marlatt Et. Al. 1998 (Continued)  Intervention consisted of  self-monitoring  personalized feedback at year 1  mail feedback at year 2  Experimental group drank significantly less and had fewer self-reported consequences than the control group

48. Brief Intervention Trials Conducted in Young Adults Monte Et. Al. 1999 94 persons age 18 -19 recruited from hospital emergency departments based on an alcohol-related accident 94 persons age 18 -19 recruited from hospital emergency departments based on an alcohol-related accident Subjects randomized to brief motivational interview or standard care Subjects randomized to brief motivational interview or standard care Intervention consisted of a 30-60 minute motivational interviewing session with a counselor Intervention consisted of a 30-60 minute motivational interviewing session with a counselor Outcome - subjects randomized to the intervention group had fewer negative consequences, reduced drunk driving arrests, and fewer traffic violations Outcome - subjects randomized to the intervention group had fewer negative consequences, reduced drunk driving arrests, and fewer traffic violations

49. Project TrEAT Fleming, 2002 Trial of Early Alcohol Treatment  64 physicians, 17 sites  17,695 screened  1,705 assessed  774 enrolled (n=225 persons 18-30 years old)  392 experimental  382 control  Follow-up:  12 months 723 (93.4%)  48 months 643 (83.1%)

50. Project TrEAT (continued) 3-14

51. Project TrEAT (continued) 3-15

52. Project TrEAT (continued) 3-16

53. Project TrEAT (continued) 3-17

54. 48-Month TrEAT Data: Benefit-Cost Analysis TreatmentControl (n=392)(n=382) Medical Use Emergency department visits302376* Days of hospitalization420664 * Motor Vehicle Events Crash with fatalities 0 2 Crash with non-fatal injuries 2031 Crash with property damage only 6772 Operating while intoxicated 2525 Other moving violations169 177 * Adjusted to equate patient-years

55. 48-Month TrEAT Data: Benefit-Cost Analysis TreatmentControl (n=392) (n=382) Legal Events Assault/battery/child abuse 8 11 Resist/obstruct officer/disorderly 8 6 Controlled substance/liquor violation 2 11 Criminal damage/property damage 2 1 Theft/robbery 3 3 Other arrests 5 9

56. What We Know  Brief Intervention can reduce alcohol use for at least 12 months  Effect size is similar for men and women  Effects are similar for persons over age 18

57. What We Know (continued)  Reduction in utilization events  Cost savings  Improved health status

58. BI appears to reduce alcohol-related harm  Decreased GGT levels (Kristenson, 1983; Wallace, 1988; Israel, 1996)  Decreased sick days (Kristenson, 1983)  Decreased drinking and driving (Monti, 1999)  Decreased scores on questionnaires regarding alcohol-related problems (Marlatt, 1998) What We Know (continued)