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 ProgramsUCLA Integrated Substance Abuse Programs www.uclaisap.orgwww.uclaisap.org

Third Annual Statewide Co-Occurring Disorders Third Annual Statewide Co-Occurring Disorders ConferenceConference

June 21-22, 2004June 21-22, 2004Long Beach, CALong Beach, CA

Identifying Substance Abuse in the General Medical Population

PART 1PART 1

National Household Survey on Drug Abuse (NHSDA)

2001

In 2001 an estimated 15.9 million Americans age 12 In 2001 an estimated 15.9 million Americans age 12 years or older used an illicit drug during the month years or older used an illicit drug during the month immediately prior to the survey interview.immediately prior to the survey interview.

7.1 % of the population 12 years or older; up from 7.1 % of the population 12 years or older; up from 6.3 % of this population in 2000.6.3 % of this population in 2000.

National Household Survey on Drug Abuse (NHSDA)

2001 (cont.)

The survey also found statistically significant increases The survey also found statistically significant increases between 2000 and 2001 in the use of particular drugs or between 2000 and 2001 in the use of particular drugs or groups of illicit drugsgroups of illicit drugs

marijuana (from 4.8 to 5.4 %) marijuana (from 4.8 to 5.4 %)

cocaine (0.5 to 0.7 %)cocaine (0.5 to 0.7 %)

the nonmedical use of pain relievers (1.2 to 1.6 %)the nonmedical use of pain relievers (1.2 to 1.6 %)

tranquilizers (0.4 to 0.6 %)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.

Identifying Patients at Risk

Screening instruments: Screening instruments: HistoryHistory: personal history & family : personal history & family

historyhistory Behavioral check listsBehavioral check lists Therapeutic maneuverTherapeutic maneuver

History

What predicts addiction?What predicts addiction? Personal history of drug abusePersonal history of drug abuse Family history of drug abuseFamily history of drug abuse Current addiction to alcohol or Current addiction to alcohol or

cigarettescigarettes History of problems with prescriptionsHistory of problems with prescriptions Co-morbid psychiatric disordersCo-morbid psychiatric disorders

Behavior Suggestive of Addiction

Buying, selling, and forging prescriptionsBuying, selling, and forging prescriptions

Stealing drugsStealing drugs

Injecting oral formulationsInjecting oral formulations

Abusing alcohol and other drugsAbusing alcohol and other drugs

Persistent non-compliance Persistent non-compliance

““Dr. and ER shopping”Dr. and ER shopping”

Drug-related functional deteriorationDrug-related functional deterioration

Resistance to change despite adverse effectsResistance to change despite adverse effects

Substance-related Disorders

Intoxication Intoxication use of substance resulting in maladaptive behavioruse of substance resulting in maladaptive behavior

Acute WithdrawalAcute Withdrawal negative reactions that occur when use is negative reactions that occur when use is

discontinued or drastically reduced can include:discontinued or drastically reduced can include: Delirium, Psychosis, Physical Discomfort, Delirium, Psychosis, Physical Discomfort,

Seizures, Seizures, Death (with some types of withdrawalDeath (with some types of withdrawal

Substance-related Disorders

Protracted Withdrawal (can include)Protracted Withdrawal (can include) Mood disorderMood disorder AnxietyAnxiety Sexual dysfunctionSexual dysfunction Sleep disorderSleep disorder AnhedoniaAnhedonia Memory and Concentration ProblemsMemory and Concentration Problems

DSM IV Criteria for Substance Abuse

Significant impairment or distress resulting Significant impairment or distress resulting from use from use

Failure to fulfill roles at work, home, or school Failure to fulfill roles at work, home, or school

Persistent use in physically hazardous Persistent use in physically hazardous situations situations

Recurrent legal problems related to use Recurrent legal problems related to use

Continued use despite interpersonal problems Continued use despite interpersonal problems

DSM IV criteria for Substance Depend.≥ 3 of the following occurring in the

same 12- month period1. 1. Desire or unsuccessful efforts to cut down on useDesire or unsuccessful efforts to cut down on use

2. Large amount of time spent obtaining drug, using drug, 2. Large amount of time spent obtaining drug, using drug, or recovering from drug effectsor recovering from drug effects

3. Social, occupational, or recreational activities reduced 3. Social, occupational, or recreational activities reduced because of drug usebecause of drug use

4. Opiate use continued despite knowledge that a physical 4. Opiate use continued despite knowledge that a physical or psychological problem is being caused or or psychological problem is being caused or exacerbated by useexacerbated by use

5. Tolerance to drug5. Tolerance to drug

6. Withdrawal upon cessation of use6. Withdrawal upon cessation of use

EtOH StatsU.S. Department of Justice Bureau of Justice Statistics

48.3 % or 109 million 48.3 % or 109 million persons were current persons were current drinkers in the 2001 drinkers in the 2001 surveysurvey

Almost half of all Almost half of all Americans age 12 or Americans age 12 or olderolder

EtOH Stats ContinuedU.S. Department of Justice Bureau of Justice Statistics

About 10.1 million About 10.1 million persons age 12 to 20 years persons age 12 to 20 years reported current use of reported current use of alcohol in 2001.alcohol in 2001. 28.5 % of this age 28.5 % of this age

group for whom group for whom alcohol is an illicit alcohol is an illicit substance. substance.

Of this number, nearly Of this number, nearly 6.8 million or 19.0 % 6.8 million or 19.0 % were binge drinkers and were binge drinkers and 2.1 million or 6.0 % 2.1 million or 6.0 % were heavy drinkers.were heavy drinkers.

Drinking and Driving In 2001, more than 1 in 10 In 2001, more than 1 in 10

Americans or 25.1 million Americans or 25.1 million persons reported driving under persons reported driving under the influence of alcohol at the influence of alcohol at least once in the 12 months least once in the 12 months prior to the interview.prior to the interview.

The rate of driving under the The rate of driving under the influence of alcohol increased influence of alcohol increased from 10.0 to 11.1 % between from 10.0 to 11.1 % between 2000 and 2001. 2000 and 2001.

Among young adults age 18 to Among young adults age 18 to 25 years, 22.8 % drove under 25 years, 22.8 % drove under the influence of alcohol.the influence of alcohol.

EtOH Effects SPEED OF DRINKING - The SPEED OF DRINKING - The

liver metabolizes ≈1/2 ounce of liver metabolizes ≈1/2 ounce of alcohol per hour.alcohol per hour.

PRESENCE OF FOOD IN THE PRESENCE OF FOOD IN THE STOMACH – STOMACH –

When alcoholic beverages are When alcoholic beverages are taken with a substantial meal, taken with a substantial meal, peak BAC may be reduced by as peak BAC may be reduced by as

much as 50%.much as 50%.

BODY WEIGHT BODY WEIGHT

DRINKINGDRINKING HISTORY/TOLERANCE –HISTORY/TOLERANCE – ENVIRONMENTENVIRONMENT

EtOH Effects THE DRINKER'S THE DRINKER'S EXPECTATIONSEXPECTATIONS GENERAL STATE OFGENERAL STATE OF EMOTIONAL ANDEMOTIONAL AND PHYSICAL HEALTHPHYSICAL HEALTH - - SEX DIFFERENCESSEX DIFFERENCES

Females will generally Females will generally have a higher BAC than their have a higher BAC than their male counterparts, due to less male counterparts, due to less body fluids to dilute the body fluids to dilute the alcohol and to more body fat.alcohol and to more body fat.

Females are generally Females are generally more affected by alcohol just more affected by alcohol just prior to menstruation.prior to menstruation.

OTHER DRUGS- OTHER DRUGS- p450, etcp450, etc

Physiological Markers of Alcoholism

Uric acidUric acid TriglyceridesTriglycerides Gamma-glutamyl transferaseGamma-glutamyl transferase Aspirate aminotransferaseAspirate aminotransferase Alanine aminotransferaseAlanine aminotransferase Mean corpuscular volumeMean corpuscular volume

Laboratory Tests

Red blood cells indices: INCREASED Red blood cells indices: INCREASED MCVMCV

Liver function tests: Liver function tests: INCREASED: AST (SGOT), ALT (SGPT), GGTINCREASED: AST (SGOT), ALT (SGPT), GGT

INCREASED Serum uric acidINCREASED Serum uric acid INCREASED Carbohydrate-deficient INCREASED Carbohydrate-deficient

transferrin (CDT)transferrin (CDT)

Cocaine

BlowBlow Nose candyNose candy SnowballSnowball TornadoTornado Wicky stickWicky stick

Cocaine

Principal routes of cocaine administrationPrincipal routes of cocaine administration

OralOral "chewing" "chewing"

IntranasalIntranasal "snorting""snorting"

IntravenousIntravenous "mainlining," "mainlining," "injecting""injecting"

InhalationInhalation "smoking”"smoking”

Cocaine + Heroin = SpeedballCocaine + Heroin = Speedball

Cocaine Blocks the Removal of Dopamine From the Synapse of Neurons in the Nucleus Accumbens. These Neurons

Originate From the Ventral Tegmental Area

Cocaine Effects

Short term EffectsShort term Effects

Increased energyIncreased energy Decreased appetiteDecreased appetite Mental alertnessMental alertness Increased heart rate and blood pressureIncreased heart rate and blood pressure Constricted blood vesselsConstricted blood vessels Increased temperatureIncreased temperature Dilated pupilsDilated pupils

Cocaine Effects

Long Term EffectsLong Term Effects

Addiction

Irritability and mood disturbanceIrritability and mood disturbance

Restlessness

Paranoia

Auditory hallucinations

Cocaine Medical Complications Cardiovascular effectsCardiovascular effects

disturbances in disturbances in heart rhythmheart rhythm heart attacksheart attacks

Respiratory effectsRespiratory effects chest painchest pain respiratory failurerespiratory failure

Neurological effectsNeurological effects strokesstrokes SeizuresSeizures headachesheadaches

Gastrointestinal Gastrointestinal complicationscomplications abdominal painabdominal pain nauseanausea

Cocaethylene

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

Methamphetamine Street methamphetamine is Street methamphetamine is

referred to by many namesreferred to by many names

"speed"speed

"meth”"meth”

"chalk”"chalk”

Methamphetamine Methamphetamine hydrochloride, clear chunky hydrochloride, clear chunky crystals resembling ice, crystals resembling ice, which can be inhaled by which can be inhaled by smoking, is referred to as smoking, is referred to as

"ice”"ice”

"crystal”"crystal”

"glass""glass"

How Does Methamphetamine Act?

Methamphetamine releases Methamphetamine releases high levels of dopamine, high levels of dopamine, which stimulates brain cells, which stimulates brain cells,

Enhancing mood and body Enhancing mood and body movement. movement.

Methamphetamine appears Methamphetamine appears to have a neurotoxic effect, to have a neurotoxic effect, damaging brain cells that damaging brain cells that contain dopamine and contain dopamine and serotonin, serotonin,

Methamphetamine appears Methamphetamine appears to cause reduced levels of to cause reduced levels of dopamine, which can result dopamine, which can result in symptoms like those of in symptoms like those of Parkinson's diseaseParkinson's disease

Methamphetamine

Increased wakefulnessIncreased wakefulness Increased physical Increased physical

activityactivity Decreased appetiteDecreased appetite Increased respirationIncreased respiration HyperthermiaHyperthermia Euphoria. Euphoria. Other CNS effects:Other CNS effects:

irritability, irritability, insomnia, confusion, insomnia, confusion, tremors, tremors, convulsions, anxiety, convulsions, anxiety, paranoia, and paranoia, and aggressiveness. aggressiveness.

What does it do?

Methamphetamine Effects Increased heart rate Increased heart rate

and blood pressure and blood pressure Irreversible damage to Irreversible damage to

blood vessels in the blood vessels in the brain, producing brain, producing strokesstrokes

Respiratory problems, Respiratory problems, irregular heartbeat, irregular heartbeat, extreme anorexia. extreme anorexia.

Cardiovascular collapse Cardiovascular collapse and death.and death.

Hyperthermia and Hyperthermia and convulsions can result convulsions can result in death.in death.

What Are Opiates? a.) a.) Inducing sleep; somniferous; narcotic; Inducing sleep; somniferous; narcotic;

hence, anodyne; causing rest, dullness, or hence, anodyne; causing rest, dullness, or inaction; as, the opiate rod of Hermes. inaction; as, the opiate rod of Hermes.

(n.) (n.) Originally, a medicine of a thicker Originally, a medicine of a thicker consistence than syrup, prepared with opium.consistence than syrup, prepared with opium.

(n.) (n.) Any medicine that contains opium, and Any medicine that contains opium, and has the quality of inducing sleep or repose; a has the quality of inducing sleep or repose; a narcotic. narcotic.

(n.) (n.) Anything which induces rest or inaction; Anything which induces rest or inaction; that which quiets uneasiness. that which quiets uneasiness.

Opiates OxycodoneOxycodone

(oxycontin)(oxycontin) PropoxyphenePropoxyphene

(Darvon)(Darvon) HydrocodoneHydrocodone

(Vicodin)(Vicodin) HydromorphoneHydromorphone

(Dilaudid)(Dilaudid) MeperidineMeperidine

(Demerol), (Demerol), Diphenoxylate Diphenoxylate

(Lomotil)(Lomotil) CodeineCodeine

Heroin Heroin is processed from Heroin is processed from

morphine morphine (diacetylmorphine)(diacetylmorphine)

Morphine is a naturally Morphine is a naturally occurring substance occurring substance extracted from the seedpod extracted from the seedpod of the Asian poppy plant. of the Asian poppy plant.

Heroin usually appears as a Heroin usually appears as a white or brown powder. white or brown powder.

Street names Street names

"smack,“"smack,“

"H," "H,"

““horse,” horse,”

"skag,“"skag,“

"junk" "junk"

"Mexican black tar,”"Mexican black tar,”

““China White”China White” Originally produced by Originally produced by

Bayer as a “non addictive” Bayer as a “non addictive” analgesicanalgesic

Opiate Effects DesirableDesirable

Pain reliefPain relief Euphoria - heroin produces greater ‘rush’ than Euphoria - heroin produces greater ‘rush’ than

morphine due to morphine due to ↑↑ lipophilicity lipophilicity Prolonged sense of contentment and well-beingProlonged sense of contentment and well-being

UndesirableUndesirable Nausea and vomiting Nausea and vomiting Respiratory depression – Respiratory depression – ↓↓ in sensitivity of respiratory in sensitivity of respiratory

center to PCOcenter to PCO22 Constipation - Constipation - ↑↑ tone + tone + ↓↓ motility in GI tract motility in GI tract

DON’T RX OPIATES WITHOUT DON’T RX OPIATES WITHOUT CONSIDERING THISCONSIDERING THIS

Pupillary constriction - stimulation of oculomotor Pupillary constriction - stimulation of oculomotor nucleusnucleus

Brief Intervention for Hazardous and Harmful

Drinking

Thomas Babor and J. C. Higgins-BiddleThomas Babor and J. C. Higgins-Biddle WHO standard, published in 2001WHO standard, published in 2001 Low in cost and proven effective across a Low in cost and proven effective across a

spectrum of EtOH problemsspectrum of EtOH problems SBISBI : Screening Brief Intervention : Screening Brief Intervention

Categorize

USEUSE

Any ingestion of alcoholAny ingestion of alcohol

LOW RISKLOW RISK

Drinking that is within legal and medical guidelines Drinking that is within legal and medical guidelines and is not likely to result in alcohol related and is not likely to result in alcohol related problemsproblems

MISUSEMISUSE

Any level of risk ranging form hazardous drinking Any level of risk ranging form hazardous drinking to alcohol dependenceto alcohol dependence

Hhhh

ADVISE APPROPRIATE ACTION

FOLLOW UP - Supportive Care

ASK

Quantity/Frequency Binge CAGE AUDIT

BriefIntervention

Motivational Interview

Referral

Step 1

Step 2

Step 3

Step 4

3-2

ASSESS

Academic Social Behavioral Medical

Methods of Screening

CAGECAGE MAST/DASTMAST/DAST AUDITAUDIT OTHERSOTHERS

The Audit: A Demonstration

How it worksHow it works

Public Health Paradigm

The primary goal of brief intervention The primary goal of brief intervention is to:is to: Reduce alcohol use to low-risk levels Reduce alcohol use to low-risk levels Encourage abstinence in persons who Encourage abstinence in persons who

are alcohol-dependent are alcohol-dependent

Brief Intervention or Brief Talk Therapy

Commonly used by clinicians to talk to Commonly used by clinicians to talk to patients about health issues or medication patients about health issues or medication compliancecompliance

Not unique to the alcohol fieldNot unique to the alcohol field Designed for use in busy clinical settingsDesigned for use in busy clinical settings Generally 5-10 minute durationGenerally 5-10 minute duration

Brief Intervention or Brief Talk Therapy (Continued)

Includes motivational interviewing and Includes motivational interviewing and Cognitive Behavioral Therapy (CBT) Cognitive Behavioral Therapy (CBT) techniquestechniques

More clinician-centered than client-centered More clinician-centered than client-centered therapytherapy

Clinician shares concerns with student and Clinician shares concerns with student and tries to convince student to decrease alcohol tries to convince student to decrease alcohol useuse

Brief Intervention or Brief Talk Therapy (Continued)

Uses an empathic, non-confrontational styleUses an empathic, non-confrontational style Offers patient choicesOffers patient choices Emphasizes patient responsibilityEmphasizes patient responsibility Conveys confidence in patient's ability to Conveys confidence in patient's ability to

changechange

Conduct an assessment: Conduct an assessment:

““Tell me about your drinking.” “What do you Tell me about your drinking.” “What do you think think

about your drinkingabout your drinking?”?”

Consider Screening measures: AUDITConsider Screening measures: AUDIT

Provide direct clear feedback: Provide direct clear feedback:

"As your doctor/therapist, I am concerned "As your doctor/therapist, I am concerned

about how much you drink and how it is about how much you drink and how it is

affecting your health."affecting your health."

Brief Intervention or Brief Talk Therapy (Continued)

Establish a treatment contract through negotiation and Establish a treatment contract through negotiation and goal setting:goal setting:

"You need to reduce your drinking. What do you "You need to reduce your drinking. What do you think about cutting down to three drinks 2-3 times per think about cutting down to three drinks 2-3 times per

week?“week?“

Apply behavioral modification techniques: Apply behavioral modification techniques:

"Here is a list of situations when students drink and "Here is a list of situations when students drink and

sometimes lose control of their drinking.”sometimes lose control of their drinking.”

Brief Intervention or Brief Talk Therapy (Continued)

Ask patients to review a self-help booklet and Ask patients to review a self-help booklet and complete diary cards:complete diary cards:

““I would like you to review this booklet and bring it I would like you to review this booklet and bring it with you at your next visit. I’d also like you to write with you at your next visit. I’d also like you to write down how much you drink on these diary cards.” down how much you drink on these diary cards.”

Set up a continuing care plan for nurse reinforcement Set up a continuing care plan for nurse reinforcement

phone calls and clinic visits.phone calls and clinic visits.

Brief Intervention or Brief Talk Therapy (Continued)

Brief Intervention Studies in College Students Marlatt Et. Al. 1998

348 heavy drinking college freshmen recruited at 348 heavy drinking college freshmen recruited at the University of Washingtonthe University of Washington

Recruitment occurred via self-report Recruitment occurred via self-report questionnaire completed by incoming students questionnaire completed by incoming students

Intervention delivered by research staffIntervention delivered by research staff No involvement of primary care cliniciansNo involvement of primary care clinicians Follow up at 6, 12 and 24 monthsFollow up at 6, 12 and 24 months

Brief Intervention Studies in College Students Marlatt Et. Al. 1998

(Continued) Intervention consisted ofIntervention consisted of

self-monitoringself-monitoring personalized feedback at year 1personalized feedback at year 1 mail feedback at year 2mail feedback at year 2

Experimental group drank significantly less Experimental group drank significantly less and had fewer self-reported consequences and had fewer self-reported consequences than the control groupthan the control group

Brief Intervention Trials Conducted in Young Adults Monte Et. Al. 1999

94 persons age 18 -19 recruited from hospital emergency 94 persons age 18 -19 recruited from hospital emergency departments based on an alcohol-related accidentdepartments based on an alcohol-related accident

Subjects randomized to brief motivational interview or Subjects randomized to brief motivational interview or standard carestandard care

Intervention consisted of a 30-60 minute motivational Intervention consisted of a 30-60 minute motivational interviewing session with a counselorinterviewing session with a counselor

OutcomeOutcome - subjects randomized to the intervention group - subjects randomized to the intervention group had fewer negative consequences, reduced drunk driving had fewer negative consequences, reduced drunk driving arrests, and fewer traffic violationsarrests, and fewer traffic violations

Project TrEAT Fleming, 2002

Trial of Early Alcohol TreatmentTrial of Early Alcohol Treatment

64 physicians, 17 sites64 physicians, 17 sites

17,695 screened17,695 screened

1,705 assessed1,705 assessed

774 enrolled (n=225 persons 18-30 years old)774 enrolled (n=225 persons 18-30 years old) 392 experimental392 experimental 382 control382 control

Follow-up: Follow-up: 12 months 723 (93.4%)12 months 723 (93.4%) 48 months 643 (83.1%)48 months 643 (83.1%)

Project TrEAT (continued)

3-14

Project TrEAT (continued)

3-15

Project TrEAT (continued)

3-16

Project TrEAT (continued)

3-17

48-Month TrEAT Data: Benefit-Cost Analysis

Treatment Control(n=392) (n=382)

Medical UseEmergency department visits 302 376*Days of hospitalization 420 664*

Motor Vehicle EventsCrash with fatalities 0 2Crash with non-fatal injuries 20 31Crash with property damage only 67

72Operating while intoxicated 25 25Other moving violations 169 177

*Adjusted to equate patient-years

48-Month TrEAT Data: Benefit-Cost Analysis

Treatment Control(n=392) (n=382)

Legal EventsAssault/battery/child abuse 8 11Resist/obstruct officer/disorderly 8 6Controlled substance/liquor violation 2 11Criminal damage/property damage 2 1Theft/robbery 3 3Other arrests 5 9

What We Know

Brief Intervention can reduce alcohol use for Brief Intervention can reduce alcohol use for at least 12 monthsat least 12 months

Effect size is similar for men and womenEffect size is similar for men and women

Effects are similar for persons over age 18Effects are similar for persons over age 18

What We Know (continued)

Reduction in utilization eventsReduction in utilization events

Cost savings Cost savings

Improved health statusImproved health status

BI appears to reduce alcohol-related BI appears to reduce alcohol-related harmharm Decreased GGT levels (Kristenson, 1983; Decreased GGT levels (Kristenson, 1983;

Wallace, 1988; Israel, 1996)Wallace, 1988; Israel, 1996) Decreased sick days (Kristenson, 1983)Decreased sick days (Kristenson, 1983) Decreased drinking and driving (Monti, 1999)Decreased drinking and driving (Monti, 1999) Decreased scores on questionnaires regarding Decreased scores on questionnaires regarding

alcohol-related problems (Marlatt, 1998)alcohol-related problems (Marlatt, 1998)

What We Know (continued)