1. MEDICAL COMORBIDITIES OF SUBSTANCE USE DISORDERS Oregon Psychiatric Association March 4, 2006

2. Objectives Review epidemiology of alcohol/substance use disorders Review epidemiology of alcohol/substance use disorders Review importance of these disorders in medicine Review importance of these disorders in medicine General overview of medical complications of alcohol/substance use disorders General overview of medical complications of alcohol/substance use disorders Discuss specific complications Discuss specific complications Methamphetamines Methamphetamines Alcohol Alcohol Others Others

3. Epidemiology 2/3 ever consumed alcohol 2/3 ever consumed alcohol ~40% ever used illicit drugs ~40% ever used illicit drugs 20% use tobacco 20% use tobacco Lifetime prevalence Lifetime prevalence Alcohol use disorders Alcohol use disorders Men - 15-20% Men - 15-20% Women - 8% Women - 8% Drug use disorders Drug use disorders Men – 8% Men – 8% Women – 5% Women – 5%

4. Importance 20-40% of general hospital admissions 20-40% of general hospital admissions 20% of primary care visits 20% of primary care visits One million ER visits per year One million ER visits per year Drug use primary problem Drug use primary problem 50-75% of trauma visits 50-75% of trauma visits Up to 200,000 deaths per year Up to 200,000 deaths per year Alcohol decreases life expectancy by 15 yrs Alcohol decreases life expectancy by 15 yrs ~40% of suicides involve drugs/alcohol ~40% of suicides involve drugs/alcohol

5. Societal Costs – Alcohol Use Disorders Total: ~$185 Billion Source: Harwood, H. Report prepared by the Lewin Group for the National Institute on Alcohol Abuse and Alcoholism; 2000. National Institutes of Health, NIH Publication No. 98-4327. Rockville, MD. http://www.niaaa.nih.gov † FAS = fetal alcohol syndrome. 47% 20% 2% 9% 4% 13% 5% 1% Specialty Alcohol Services* Medical Consequences (except FAS † ) Medical Consequences of FAS Lost Future Earnings Due to Premature Deaths Lost Earnings Due to Alcohol-Related Illness Lost Earnings Due to FAS Lost Earnings Due to Crime/Victims Crashes, Fires, Criminal Justice, etc

6. Medical Consequences Direct Effects Direct Effects Toxicity of substance of abuse Toxicity of substance of abuse Toxicity of contaminants Toxicity of contaminants Indirect Effects Indirect Effects Infectious diseases Infectious diseases Trauma Trauma Nutritional deficiencies Nutritional deficiencies Consequences of intoxication/withdrawal states Consequences of intoxication/withdrawal states

7. Case #1 43 yo woman c/o dyspepsia, epigastric burning and anxiety 43 yo woman c/o dyspepsia, epigastric burning and anxiety PMH – hypertension PMH – hypertension Meds: Atenolol 25mg qd Meds: Atenolol 25mg qd HPI, ROS – unremarkable HPI, ROS – unremarkable Labs in past year – all WNL Labs in past year – all WNL

8. Case #1 PE: PE: Looks anxious Looks anxious Hands are cold,clammy, slightly shaky Hands are cold,clammy, slightly shaky Wearing strong perfume Wearing strong perfume P: 102 regular P: 102 regular BP: 155/101 BP: 155/101 Temp, respirations – normal Temp, respirations – normal Remainder of PE only remarkable for mild tachycardia Remainder of PE only remarkable for mild tachycardia

9. What’s Your Diagnosis? Differential – substance use disorders Differential – substance use disorders Mild intoxication – stimulants Mild intoxication – stimulants Withdrawal – alcohol, opioids, sedative/hypnotics Withdrawal – alcohol, opioids, sedative/hypnotics Clues Clues GI symptoms – gastritis GI symptoms – gastritis Hypertension Hypertension Symptoms of alcohol withdrawal Symptoms of alcohol withdrawal Use of perfume, aftershave, mouthwash to cover smell of alcohol Use of perfume, aftershave, mouthwash to cover smell of alcohol

10. Defining the “Standard Drink” 10-15g ethanol 10-15g ethanol 12 oz of regular beer or cooler (5% alcohol) 12 oz of regular beer or cooler (5% alcohol) 5 oz of table wine (12% alcohol) 5 oz of table wine (12% alcohol) 1.5 oz of hard liquor (40% alcohol, 80 proof) 1.5 oz of hard liquor (40% alcohol, 80 proof) The average person metabolizes about 1 standard drink per hour The average person metabolizes about 1 standard drink per hour 12 oz 8.5 oz 5 oz 3.5 oz 2.5 oz 1.5 oz 12 oz beer or cooler 8-9 oz malt liquor 5 oz wine 3-4 oz fortified wine 2-3 oz cordial, liqueur, or aperitif 1.5 oz brandy 1.5 oz hard liquor Source: National Institute on Alcohol Abuse and Alcoholism. Bethesda, Md: NIAAA; 2004. NIH Publication No. 04-3769.

11. Chronic Alcohol Use Liver Disease Cirrhosis Coronary Artery Disease Cardiomyopathy Arrhythmias Hypertension Stroke Duodenal ulcers Cognitive disorders CVA Psychosis PancreatitisDiabetes Head, Neck, GI cancers Stomach ulcers Gastritis Adapted from: Schuckit MA. In: Harrison’s Principles of Internal Medicine. New York: McGraw-Hill; 2001:2561-2566.. NeuropathiesAnemias Nutritional Deficiencies

12. Diseases Associated with Chronic Alcohol Use Cardiomyopathy Cardiomyopathy Gastritis, other GI complications Gastritis, other GI complications Liver disease Liver disease Dementia Dementia Neuropathy Neuropathy Pancreatitis Pancreatitis Anemias Anemias Head, Neck, GI cancers Head, Neck, GI cancers Diabetes Diabetes Coronary artery disease Coronary artery disease CVA CVA Nutritional deficiencies Nutritional deficiencies Hypertension Hypertension Sources: Schuckit MA. In: Harrison’s Principles of Internal Medicine. New York: McGraw-Hill; 2001:2561-2566. American Psychiatric Association. DSM-IV-TR. American Psychiatric Association: Washington, DC; 2000.

13. Nutritional Consequences Heavy drinkers – up to 50% of daily caloric intake Heavy drinkers – up to 50% of daily caloric intake >25% -  significant decrease in necessary nutrients >25% -  significant decrease in necessary nutrients Malnutrition Malnutrition Vitamin deficiencies Vitamin deficiencies Impairs activation and utilization of nutrients Impairs activation and utilization of nutrients Maldigestion (GI complications) Maldigestion (GI complications)

14. Specific Deficiencies Thiamine Thiamine Wernicke-Korsakoff’s Wernicke-Korsakoff’s Neuropathies Neuropathies Folate Folate Megaloblastic anemia Megaloblastic anemia Vitamin C – with high alcohol intake Vitamin C – with high alcohol intake Vitamin D Vitamin D Decreased intake, poor absorption, insufficient sunlight Decreased intake, poor absorption, insufficient sunlight Decreased bone mass, density Decreased bone mass, density Increased osteoporosis, bone fractures Increased osteoporosis, bone fractures

15. GI Complications Liver Liver ETOH toxic to hepatocytes ETOH toxic to hepatocytes AST>ALT AST>ALT Accelerates liver damage in hepatitis C infection Accelerates liver damage in hepatitis C infection Increases risk of acetaminophen toxicity Increases risk of acetaminophen toxicity Range of disease Range of disease Fatty liver Fatty liver Alcoholic hepatitis Alcoholic hepatitis Fibrosis Fibrosis Cirrhosis Cirrhosis

16. GI Complications Pancreatitis Pancreatitis Generally after 10-15 years of heavy ETOH Generally after 10-15 years of heavy ETOH GI bleeding GI bleeding Gastritis Gastritis Peptic ulcer disease Peptic ulcer disease Esophageal varices Esophageal varices Duodenitis Duodenitis Esophagitis Esophagitis

17. Neurologic Complications Wernicke’s encephalopathy Wernicke’s encephalopathy Delirium, ataxia, ophthalmoplegia Delirium, ataxia, ophthalmoplegia Thiamine deficiency Thiamine deficiency Necrosis of mammillary bodies and thalamus Necrosis of mammillary bodies and thalamus 50-85%  Korsakoff’s psychosis 50-85%  Korsakoff’s psychosis Few regain cognitive function Few regain cognitive function

18. Korsakoff’s Psychosis Common pathology and etiology as Wernicke’s Common pathology and etiology as Wernicke’s Severe memory impairment Severe memory impairment Recent and ongoing events Recent and ongoing events Confabulation, lack of insight Confabulation, lack of insight Other intellectual functions may be intact Other intellectual functions may be intact Treat with thiamine Treat with thiamine

19. Alcoholic Dementia Prominent effects – frontal cortex, putamen Prominent effects – frontal cortex, putamen Extreme variability Extreme variability Etiology Etiology Neurotoxic Neurotoxic Effects on neurotransmitters Effects on neurotransmitters Decreased cerebral blood flow Decreased cerebral blood flow Vitamin deficiencies Vitamin deficiencies

20. Alcoholic Dementia Impairments Impairments Abstract thinking Abstract thinking Problem solving Problem solving Visual, spatial, motor abilities Visual, spatial, motor abilities New learning New learning Remote memory Remote memory Personal care Personal care

21. Other Neurologic Complications “Blackouts” – transient anterograde amnesia “Blackouts” – transient anterograde amnesia ↑risk of CVA ↑risk of CVA ↑risk of cerebral trauma ↑risk of cerebral trauma Cerebellar degeneration Cerebellar degeneration Metabolic encephalopathies Metabolic encephalopathies Peripheral neuropathies Peripheral neuropathies Sensory, motor or autonomic Sensory, motor or autonomic “Stocking-glove” distribution “Stocking-glove” distribution

22. Other Organ Systems Hematologic Hematologic Anemias – Fe deficiency, folate deficiency Anemias – Fe deficiency, folate deficiency Pancytopenia – alcohol toxic to bone marrow Pancytopenia – alcohol toxic to bone marrow Musculoskeletal Musculoskeletal Rhabdomyolysis Rhabdomyolysis Osteopenia/osteoporosis, fractures Osteopenia/osteoporosis, fractures Myopathy Myopathy Cardiovascular Cardiovascular Cardiomyopathy Cardiomyopathy Hypertension Hypertension Dermatologic Dermatologic Facial edema, rosacea, rhinophyma Facial edema, rosacea, rhinophyma Metabolic/endocrine Metabolic/endocrine Gout Gout Decreased testosterone Decreased testosterone Menstrual abnormalities Menstrual abnormalities

23. Marijuana Pulmonary toxicity Pulmonary toxicity COPD COPD Head, neck cancers Head, neck cancers Cognitive deficits Cognitive deficits Attention, short term memory Attention, short term memory Information processing Information processing Motor impairment Motor impairment ↓ Immune response ↓ Immune response ↓ Testosterone levels ↓ Testosterone levels Menstrual abnormalities Menstrual abnormalities

24. Summary Common disorders Common disorders Many medical complications Many medical complications Patients frequently present to ERs, general medical settings Patients frequently present to ERs, general medical settings Important to assess all patients for alcohol, tobacco, other substance use Important to assess all patients for alcohol, tobacco, other substance use Complaints may caused/exacerbated by substance use Complaints may caused/exacerbated by substance use