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How Substance Use
Disorders Affect
Physical Health
1
Learning Objectives
• Define the continuum of Substance Use Disorders
• Understand the risk levels associated with various stages of
use
• Examine the general and specific health concerns related to
Substance Use Disorders for users and others
• Identify special problems experienced by substance
using/abusing pregnant women and their babies
• Demonstrate how behavioral and primary healthcare
workers can intervene more effectively to reduce risks
associated with substance use
Stigma
.
3
4
Stereotype
Substance Use Disorders
• Use
• Abuse
• Addiction
Use
7
The Drinkers’
Pyramid
3-7 % alcohol dependent or
harmful users
40% abstainers
35- 40% low-risk
drinkers
10- 15% hazardous,
at-risk users
What is a Low-Risk Limit?
8
What is a Low-Risk Limit?
• No more than two
standard drinks a
day for men, one
per day for women
(for daily drinkers)
• Do not drink at least
two days of the
week
9
10
Definitions: Standard Drink
There are times when even one or two drinks can be too much:
• When operating machinery
• When driving
• When taking certain medicines
• If you have certain medical conditions
• If you cannot control your drinking
• If you are pregnant
11
What is a Low-Risk Limit?
Abuse
13
Substance Abuse vs. Substance
Dependence
Substance Abuse: the misuse of alcohol, an illicit
drug, prescription drug or over-the-counter
medication.
Substance abuse often involves a pattern of
harmful alcohol and/or drug use for mood altering
purposes.
A person diagnosed with substance abuse is not
considered to be addicted or dependent (otherwise
the diagnosis would be substance dependence).
• Substance abuse/dependence is strongly associated with health problems, disability, death, accident, injury, social disruption, crime and violence
• Alcohol abuse/dependence alone generates nearly $185 billion in annual economic costs (NIAAA)
• Drug abuse/dependence generates an estimated $98 billion annually in annual economic costs (NIDA)
14
Scope of the Problem
Addiction
Lincoln on Addiction
“In my judgment such of us who have
never fallen victims (of alcoholism)
have been spared more by the
absence of appetite than from any
mental or moral superiority over those
who have.” (remarks to the Springfield, Illinois
Washingtonian Society, February, 1842)
21
Addiction is Manageable
Recovery Happens
Addiction is Manageable and, with treatment, has good
outcomes.
….all this bad news!
Is there no hope?
Of course there is hope! Recovery is all
around us.
“No known cure” doesn’t mean not “untreatable.” We
don’t cure diabetes, we manage it with proper diet, blood
sugar monitoring and other acts of discipline.
Recovery
• Recovery from alcoholism and drug addiction is a
process of change through which an individual
achieves abstinence and improved health,
wellness, and quality of life. (SAMHSA/CSAT)
General Health Concerns for the
Abuser
• Cardiovascular disease
• Stroke
• Cancer
• HIV/AIDS
• Hepatitis B and C
• Liver disease
• Lung disease
• Mental disorders
• Neurological disorders
According to the American Cancer Society (ACS) the greater a person’s alcohol consumption
is the greater the chances are that he or she will get certain
kinds of cancer
General Health Concerns for Others
• Prenatal exposure
• Negative effects of second-hand smoke
• Increased spread of infectious diseases
• Automobile crashes and other accidents
Alcohol
• Cardiovascular system
– High blood pressure
• Neurological system
– Damage to
• Cerebral cortex
• Hippocampus
• Cerebellum
– Stroke
• Endocrine system
– Cirrhosis
– Liver Cancer
– Diabetes
Alcohol dependence is the leading cause of cirrhosis, which
is the eighth leading cause of death in the U.S. and kills about
25,000 people a year
National Institute of Health, 2000; Stinson, Grant, and Dufour, 2001
• Alcohol is a factor in:
– 60-70% of homicides
– 40% of suicides
– 40-50% of fatal motor vehicle accidents
– 60% of fatal burn injuries
– 60% of drownings
– 40% of fatal falls
29
Scope of the Problem
Alcohol
Prenatal Exposure
• Children with fetal alcohol spectrum disorder may:
– Be born small
– Have problems eating and sleeping
– Have problems seeing and hearing
– Have trouble following directions and learning how to do
simple things
– Have trouble paying attention and learning in school
– Need special teachers and schools
– Have trouble getting along with others and controlling
their behavior
– Need medical care all their lives
Tobacco
• Smoking harms nearly every organ in the body
• Adverse health effects from smoking account for about 443,000 deaths (or nearly one of every 5 deaths) each year in the US
• Smoking causes coronary heart disease, the leading cause of
death in the US
• Smoking causes abdominal aortic aneurysm
• Smoking causes cancers, including acute myeloid leukemia,
bladder cancer, cancer of the cervix, cancer of the esophagus,
kidney cancer, cancer of the larynx, lung cancer
• More deaths are caused each year by tobacco than by all
deaths from HIV, illegal drug use, alcohol use, motor vehicle
injuries, suicides and murders combined (Centers for Disease Control and Prevention)
Tobacco and Pregnancy
• Fetus exposed to dangerous chemicals like nicotine, carbon
monoxide and tar. These chemicals lessen the amount of oxygen
available for the developing fetus
• For the mother, smoking can lead to an ectopic pregnancy,
vaginal bleeding, placental abruption, placenta previa
• Babies can born prematurely, with low birth weight
• Birth defects can occur, such as cleft lip or palate
Second Hand Smoke
• Sidestream v. Mainstream
• 3,400 lung cancer deaths in non-smoking adults (est.)
• 46,000 deaths from heart disease in non-smokers who live
with smokers (est.)
• Increases the number and severity of asthma attacks in
children
• More than 750,000 middle ear infections in children
• Increased risk of low birth weight in babies born to pregnant
women exposed to second hand smoke
(American Cancer Society)
Marijuana
• Cardiovascular
– Increased heart rate
• Respiratory system
– Lung damage
– Cancer
• Reproductive system
– Delay in development
– Possible infertility
Marijuana users have a 4.8-fold increase in the risk of
heart attack in the first hour after smoking the drug
Mittleman, M.A., Lewis, R.A., Maclure, M., Sherwood, J.B., Muller, J.E.
Triggering myocardial infarction by marijuana.
Circulation, 103(23), 2805–2809, 2001.
Marijuana smoke contains 50–70% more carcinogenic hydrocarbons than tobacco smoke.
Hashibe, M., Morgenstern, et al 2006
Heroin (and other opiates)
• Cardiovascular system
– Infection of the heart lining
• Respiratory system
– Chest pains
– Respiratory failure
– pneumonia
• Digestive system
– Abdominal pain
– Nausea
– Constipation
– Weight loss and malnutrition
• Kidney disease
Estimated annual dialysis cost for just one person who has wrecked
his own kidneys by shooting heroin ("heroin nephropathy")
$50,000
AMERICAN JOURNAL OF KIDNEY DISEASES,
40(3):611-622, Lee H © 2002 National Kidney Foundation.
Heroin (and other Opiates)
Prenatal Exposure
• Physical issues
– Low birth weight
– Born physically dependent
– Need to be tapered from opiates
– Need for long-term hospitalization
• Cognitive issues
– Cognitive performance
– Developmental delay
Heroin (and other Opiates)
Route of Use
• Snorting
– Nose bleeds
– Hole in septum
• Injection
– HIV/AIDS
– Hepatitis C
– Allergic reaction to additives
– Collapsed veins.
Injection Drug Use
• Transmission of bloodborne infections
– Human immunodeficiency virus (HIV)
– Hepatitis B (HBV) and hepatitis C (HCV) infections
• Collapsed veins
– Difficult to find veins for medical treatment
• Soft-tissue infections
– Abscesses
– Cellulitis
In the U.S., approximately one third of AIDS cases and one half of
new HCV cases are associated with injection drug use
Cocaine
• Cardiovascular
– Disturbances in heart rate
– Sudden heart attacks
• Respiratory system
– Chest pains
– Respiratory failure
• Digestive system
– Abdominal pain
– Nausea
– Weight loss and malnutrition
• Neurological system
– Strokes
– seizures
Cocaine-related deaths are often a result of cardiac arrest or seizures
followed by respiratory arrest.
NIH Publication Number 99-4342
Cocaine
Prenatal Exposure
• Physical issues
– Low birth weight
– Smaller head circumference
– Shorter length
• Cognitive issues
– Cognitive performance
– Information processing
– Attention to tasks (ADD/ADHD)
Cocaine
Route of Use
• Snorting
– Nose bleeds
– Hole in septum
– Bowel gangrene
• Injection
– HIV/AIDS
– Hepatitis C
– Allergic reaction to additives
• Smoking
– Burns
– Infection
Amphetamines
(including methamphetamine)
• Brain damage
• High body temperature
• Heart problems
• Seizures
• Dental Problems
Ecstasy (MDMA)
• Cardiovascular
– Increased heart rate
– High blood pressure
– Heart wall stress
• Nerve cell toxicity
• Confusion, depression, sleep problems,
severe anxiety
Bath Salts
• Ivory Wave, Bliss, White Lightning, Hurricane Charlie
• Readily available over the Internet and in some convenience
stores
• Effects similar to other stimulants
• Most contain MDPV (methylenedioxypyrovalerone)
• Physical effects include: tachycardia, hypertension, stomach
cramps and digestive problems, bruxism, kidney pain, tinnitus,
dizziness, difficulty breathing
• Prolonged panic attacks, possible psychosis
• Users have reported a compulsive desire to continuously re-dose
• Routes of use include: oral, smoking, snorting, intravenous use
Inhalants
• Neurological system
– Effect the myelin sheath around the neuron
– Personality change, memory loss, hallucinations, tremors
– Vision problems
• Cardiovascular system
– Disturbances in heart rate
– Sudden heart attacks
• Respiratory system
– Lung damage
– Difficulty breathing (due to lack of oxygen in the blood)
• Kidneys
– Kidney stones
Inhalants
• More 12 and 13 year olds use inhalants than marijuana
• 1.1 million adults (over 18) used inhalants in the past year-
more than the number of adults who used crack cocaine,
LSD, heroin or PCP
• 54% of the 3,273 people treated for inhalants in 2008 were
18 or older; 1 in 3 adults were between 30-44; 1 in 6 were
45 or older; 72% were non-Hispanic whites
(NSDUH)
LSD (and other Hallucinogens)
• Cardiovascular system
– Increased heart rate
– High blood pressure
• Neurological system
– Tremors
– sleeplessness
• Digestive system
– Loss of appetite
• Mental health
– Traumatic experiences
– Emotional instability
Mescaline has been associated to fetal abnormalities
Gilmore HT. Peyote use during pregnancy.
S D J Med 54(1):27–29, 2001.
Steroids
• Cardiovascular
• Liver problems
• Stroke
• Infectious disease
• Depression and suicide
Drug combinations
• Cocaine and alcohol
– Greater risk of sudden death
• Alcohol and depressants
– Loss of coordination
– Coma
– Slowing of CNS
• Fentanyl and heroin or cocaine
– Irregular heartbeat
– Breathing difficulties
Researchers have found that the human liver combines
cocaine and alcohol to produce Cocaethylene which is associated with a greater risk of sudden death than
cocaine alone. Harris DS, et al
1. Identification of use, misuse, and problematic use; screen with simple direct methods
2. Connection of use/misuse to health related issues
3. Consumption reduction
4. Brief Intervention
5. Referral for formal assessment
63
Role of Behavioral and Primary Healthcare
Workers in Drug and Alcohol Use–
What Can We Do To Help?
64
SBIRT
An Effective Approach
»Screening
»Brief
Intervention
»Referral
»Treatment
65
SBIRT
• “alcohol screening and counseling (is)
one of the highest-ranking preventive
services among the 25 effective services
evaluated using standardized methods.
Since current levels of delivery are the
lowest of comparably ranked services,
this service deserves special attention by
clinicians and care delivery systems. --
American Journal of Preventive Medicine
66
Screening
• Involves the use of …
• Alcohol and/or drug abuse screening tools,
like the Alcohol Use Disorders
Identification Test (AUDIT) or the Drug
Abuse Screening Test (DAST)
Screening vs.
Assessment
• Screening: determining the possibility
that a condition exists
• Assessment: confirming the existence
of a condition and its severity.
68
Early and Brief Intervention
• For those not ready to change, may
increase their motivation
• For those ready to change
– Provides advice on appropriate goals and
strategies
– Provides support
69
The Brief Intervention:
• Short dialogues between the healthcare provider and the patient that typically involve:
– Feedback
– Client engagement
– Simple advice or brief counseling
– Goal-setting
– Follow-up
Spirit of Motivational Interviewing
• Collaboration (vs. Confrontation)
– Meeting of aspirations
– Neither exhortation nor persuasion
• Evocation (vs. Education)
– Drawing out
– Neither instilling nor installing
• Autonomy (vs. Authority)
– Personal responsibility
– Neither imposition nor coercion
71
A Good Outcome from BI
• Reduction or cessation of
use (even temporary)
• Starting to think about
reducing
• Agreeing to accept referral
“A cross-national trial of brief interventions with heavy drinkers”
• Multinational study in 10 countries (n=1,260)
• Interventions included simple advice, brief and extended counseling compared to control group
• Results: Consumption decreased
–21% with 5 minutes advice, 27% with 15 minutes
compared to 7% controls
–Significant effect for all interventions
72
World Health Organization (Am J Pub Health 1996)
Thank you for your time and attention!
References
• www.drug abuse.gov
• www.niaaa.nih.gov
• www.cdc.gov/ncbddd/fasd/training.html
• www.nida.nih.gov/infofacts
• NIDA Research Report Series: Cocaine Abuse and Addiction, NIH
Publication Number 99-4342, May, 1999, Revised November
2004
• NIDA Monograph 44. Marijuana Effects on the Endocrine and
Reproductive Systems
• Drinking and Your Pregnancy, NIH Publication No. 05–5610
Revised 2009
• www.sbirtoregon.org
• http://sbirt.ireta.org/sbirt/
