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Monitoring Abstinence
Martin H. Plawecki MD, PhD
Indiana University School of MedicineDepartment of Psychiatry
Alcohol Medical Scholars Program
Introduction• Many diseases: chronic, relapsing, remitting
• Controlled, not cured
• Examples
• Type I diabetes: 30-50% relapse rate
• High blood pressure: 50-70% relapse rate
• Substance use disorders (SUDs): 40-60% relapse rate
© Alcohol Medical Scholars Program 2
Goals of SUD Treatment
• Harm reduction
• Abstinence
• Abstinence monitoring has a role in both
© Alcohol Medical Scholars Program 3
This Lecture Covers
• Definition/course of Substance Use Disorders (SUDs)
• Goals of monitoring abstinence and detection
• Abstinence monitoring substance examples
• Efficacy of monitored abstinence
© Alcohol Medical Scholars Program 4
This Lecture Covers
• Definition/course of Substance Use Disorders (SUDs)Definition/course of Substance Use Disorders (SUDs)
• Goals of monitoring abstinence and detection
• Abstinence monitoring substance examples
• Efficacy of monitored abstinence
© Alcohol Medical Scholars Program 5
Substance Use DisorderIn Same Year, ≥2 of:
• Tolerance• Withdrawal• Use longer/more• Unable to ↓• Lots time use• ↓ Activities• Use despite probs• Craving
© Alcohol Medical Scholars Program 6
• Failed roles• Hazardous use• Social problems
Substance Use Disorder II
© Alcohol Medical Scholars Program 7
This Lecture Covers
• Definition/course of Substance Use Disorders (SUDs)
• Goals of monitoring abstinence and detectionGoals of monitoring abstinence and detection
• Abstinence monitoring substance examples
• Efficacy of monitored abstinence
© Alcohol Medical Scholars Program 8
Goals of Monitoring Abstinence• Improve treatment outcomes by:
• Improving treatment compliance
• Verifying prescribed substance usage
• Detecting problematic usage
• Safety
• Objective is NOT punitive
© Alcohol Medical Scholars Program 9
Detection• When and how are dependent on what
• Both are determined by drug
• Absorption – how and how much drug enters
• Distribution – where drug goes in body
• Metabolism – what body does to drug
• Elimination – how drug is eliminated
© Alcohol Medical Scholars Program 10
Detection II• Strategies• Detect chemical itself• Detect metabolites• Detect secondary effects
• Detection can be chemical or electrical within• Blood• Breath• Sweat• Hair• Urine
© Alcohol Medical Scholars Program 11
This Lecture Covers
• Definition/course of Substance Use Disorders (SUDs)
• Goals of monitoring abstinence and detection
• Abstinence monitoring substance examplesAbstinence monitoring substance examples
• Efficacy of monitored abstinence
© Alcohol Medical Scholars Program 12
Monitoring Abstinence - Breath• Advantages
• Easy, non-invasive
• Cost – reusable device
• Disadvantages
• Must be done properly
• Possibly non-specific
© Alcohol Medical Scholars Program 13
Draeger Alcotest
Monitoring Breath - Alcohol• Alcohol is water soluble & appears in breath
• Electrochemical detection (burns alcohol)
• Deep breath is proportional to blood level
• Detects low [alcohol] (1 drink in past hour)
© Alcohol Medical Scholars Program 14
Monitoring Breath - Nicotine• CO from burning tobacco in breath
• Electrochemical detection (burns CO)
• Detected up to 2 dys; “smoker” sensitivity < 10 hrs
© Alcohol Medical Scholars Program 15
Monitoring Abstinence - Urine• Advantages• Easy to obtain/non-invasive
• Detection via specific antibodies
• Common and inexpensive
• Disadvantages• Positive test → expensive replication
• Replication takes weeks to get results
• Specific drugs detected for different time lengths
• Cheating
© Alcohol Medical Scholars Program 16
Monitoring Abstinence – Urine II• Urine drug screen• Specific antibody screening for substances/byproducts• Many substances can be screened in a single test
© Alcohol Medical Scholars Program 17
Times for Useful Urine Monitoring
• Opioids – 1-3 days
• Cannabinoids
• Single use – 3 days
• Daily – 10-15 days
• Heavy – >30 days
• Amphetamines – 2 days
Detection Times
• Cocaine – 2-4 days
• PCP – 8 days
• Alcohol – ¼ - ½ day
• Sedatives
• Short-acting – 3 days
• Long-acting – 30 days
© Alcohol Medical Scholars Program 18
A Problem With Urine Monitoring• Cheating• Adulterants - substances added to urine sample• Dilution - intentional fluid over-ingestion• Substitution - use of another’s, old, or synthetic urine• False attribution - claimed use of one to hide another
© Alcohol Medical Scholars Program 19
Monitoring Abstinence - Blood• Advantages
• Highly specific → confirm other tests
• Difficult to cheat, low false positives
• Direct and indirect measurements possible
• Disadvantages
• Invasive – requires a blood draw
• Expensive – includes testing and procedure fees
© Alcohol Medical Scholars Program 20
Monitoring Blood - Alcohol• Alcohol: Blood Alcohol Concentration
• Direct detection of alcohol
• Limited to recent consumption only
• Alcohol: Carbohydrate deficient transferrin (CDT)
• Indirect marker - ↑ alcohol > 2 wks → ↑ CDT
• Timing: abstinence → ↓ CDT in 2-5 weeks
© Alcohol Medical Scholars Program 21
Monitoring Blood - Cannabis• Direct detection of cannabinoids
• Acute use: peaks in min, ↓ <1 hr but > 0 for 1 day
• Chronic: detectable up to 30 days
© Alcohol Medical Scholars Program 22
Monitoring Abstinence - Sweat• Advantages
• Largely non-invasive
• Relatively tamper resistant
• Can be done chemically and electronically
• Wide variety of substances can be detected
• Disadvantages• Positive test → expensive replication
• Difficult to quantify
• Unclear effects of exercise → ↑sweat
© Alcohol Medical Scholars Program 23
Monitoring Sweat - Chemical• Swab collection
• Primarily to verify intoxication
• Detects recent usage only (<24 hours)
• Patch collection
• Detection over longer time window (1-2 wks)
• May provide a cumulative measure of the interval
• Possible for drugs to be re-absorbed
© Alcohol Medical Scholars Program 24
PharmaChem Patch
Monitoring Sweat - Electronic• Advantages
• Continuous monitoring
• Data can be monitored remotely
• Disadvantages
• Intrusive and highly visible
• Expensive
• Optimized for forensics
© Alcohol Medical Scholars Program 25
Sweat Monitoring - Alcohol
• Alcohol → sweat
• Samples every 30 minutes
• Automatic alerts
• Tamper Resistant
• Cost
• Lease: $6-8/day lease
• Purchase: $1,400-1,800 + $5/day
© Alcohol Medical Scholars Program 26
Monitoring Abstinence - Other Hair• Advantages• Chemical detection• Long-term use patterns• Non-invasive• Limited cheating
• Disadvantages• Limited substances• No acute intoxication• 1 week until detection• + → $$$ confirmation
Saliva• Advantages• Chemical detection• Acute intoxication• Non-invasive• Limited Cheating• Sensitive
• Disadvantages• Short detection time• + → $$$ confirmation
© Alcohol Medical Scholars Program 27
Monitoring Other - ExamplesHair
• Drug → follicles → hair• ~100 hairs cut by scalp• Detects• Cocaine• Amphetamines• Opiates• PCP• THC• Ecstacy
Saliva
• Drug → blood → saliva• Pad placed in cheek• Detects• Cocaine• Amphetamines• Opiates• PCP• THC• Sedatives
© Alcohol Medical Scholars Program 28
This Lecture Covers
• Definition/course of Substance Use Disorders (SUDs)
• Goals of monitoring abstinence and detection
• Abstinence monitoring substance examples
• Efficacy of monitored abstinenceEfficacy of monitored abstinence
© Alcohol Medical Scholars Program 29
Methadone Maintenance• Goal: ↓ health risk, ↓ crime, ↑ family/job
• Replacement: methadone vs heroin• Lasts >24hours → 1x/day dosing
• Allows work; avoids withdrawal and prevent “high”
• Cheaper & from clinic → ↓ risky acts, ↓crimes
• Highly structured and federally regulated• Administer methadone daily, usually at clinic
• Monitor for abstinence – urine drug screens
• Requires counselling
© Alcohol Medical Scholars Program 30
Methadone Maintenance Efficacy• 3x ↑ Remain in Rx vs no opiate replacement
• 2/3x ↓ Positive opioid hair/urine samples
• 2 ½x ↓ Crime involvement
© Alcohol Medical Scholars Program 31
Chronic Pain Management• Goal: control pain, minimize substance misuse• Adherence monitoring and risk minimization• Explicit behavior agreements
• Estimate risk
• Use difficult-to-misuse medications
• Rx drug monitoring programs• Urine drug screens
• Success → continue in program
• Failure → lose access to prescription opioids
© Alcohol Medical Scholars Program 32
Chronic Pain Management Efficacy
• Urine drug testing → ↓ illicit drug usage
• ↑ Urine drug tests → ↑ prescription adherence
↓ non-Rx medications
© Alcohol Medical Scholars Program 33
Court Mandated Rx• Goal: ↓ drug use → ↓ crime
• Links highly structured Rx to legal system• Residential and outpatient treatment
• Random urine drug screens
• Routine judicial interaction and progress monitoring
• Success → avoid jail
• Failure→
• ↑ Monitoring frequency/intensity
• ↑ Punishment up to jail© Alcohol Medical Scholars Program 34
Court Mandated Rx Efficacy• 12% ↓ Criminal relapse
• No clear effect on SUD outcomes
• Difficult to quantify
• Highly variable population
• Different Rx approaches/referral networks
© Alcohol Medical Scholars Program 35
Physician Health Programs• Goal: ↓ patient harm• Links highly structured Rx to medical license• Residential and outpatient treatment• Random urine drug screens• +/- Random office visit• ≥5 Yr follow-up • Success → practice medicine, keep job• Failure →• Treatment, ↑monitoring frequency/intensity• Referral to medical licensing board
© Alcohol Medical Scholars Program 36
Soberlink Blue Device System
© Alcohol Medical Scholars Program 37
Physicians Health Programs Efficacy
• Only ~20% w/ +UDS at any time during 5 yrs
• 70-80% Physicians still licensed/employed at 5 yrs
© Alcohol Medical Scholars Program 38
Summary
• SUDs are chronic relapsing/remitting conditions
• Abstinence monitoring is therapeutic
• Monitoring can be chemical and electronic
• Monitored abstinence → better outcomes
© Alcohol Medical Scholars Program 39
Questions
© Alcohol Medical Scholars Program 40