Recognizing and Managing Substance Use Disorders Katherine Julian, - PDF document

4/9/15 Recognizing and Managing Substance Use Disorders Katherine Julian, M.D. UCSF Division of General Internal Medicine April 9, 2015 Disclosures n None 1

4/9/15 Quiz…Your Clinic Panel n In your clinic panel, what percentage of your current clinic patients would be classified with alcohol abuse or dependence*? A. <1% B. 2-5% C. 6-9% D. 10% E. 20% Substance Use Issues are Highly Prevalent in Americans At Risk Drinking* 23% Illicit Drug Use 8% Substance Abuse/Dependence 9% Alcohol 7% Illicit Drugs 3% SAMHSA, National Survey on Drug Use and Health, 2008 Ages 12+ in the United States 2

4/9/15 Alcohol Use Disorders in Older Adults n 3% met full criteria for an alcohol use disorder n At-risk drinking was reported in: n 17% of men, 11% of women ages 50+ n 19% of all respondents ages 50-64 n 13% of all respondents ages 65+ n Binge drinking was reported in: n 20% of men, 6% of women ages 50+ n 23% of all respondents ages 50-64 n 15% of all respondents ages 65+ NSDUH, 2009 Blazer D, Wu L. Am J Psychiatry, 2009 Outline § Substance Use Disorders - Definitions § SBIRT § Screening § Brief Intervention § Referral to Treatment § ETOH Substance Use Pharmacotherapy § Treatment of Non-Cancer Pain: Balance risks/benefits § Opiate Substance Use Pharmacotherapy 3

4/9/15 Quiz… n Which of the following is NOT considered to be “at risk” drinking? A. 45 yo woman who drinks 1-2 glasses of wine each night B. 70 yo man who drinks 1-2 beers each night C. 25 yo woman who drinks 4-5 drinks once a week when she goes out with friends D. 40 yo man who drinks 1-2 glasses of wine each night Definition – At Risk Drinking n Men • >4 drinks/day or • >14 drinks/week n Women (and > than 65 yrs) • >3 drinks/day or • >7 drinks/week n Increased risk of alcohol-related problems 4

4/9/15 What is a Drink? A standard drink is any drink that contains about 14 grams of pure alcohol (about 0.6 fluid ounces or 1.2 tablespoons) DSM5 - Substance Use Disorder n No longer need to differentiate between substance abuse and substance dependence n Each substance can be categorized as a disorder n Ex: Alcohol use disorder, stimulant use disorder, etc n Grade Severity: Mild, Moderate, Severe 5

4/9/15 New DSM5 - Substance Use Disorder n “Maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 2 (or more) of the following, occurring within a 12-month period:” n Failure to fulfill role obligations n Recurrent substance use in situations that are physically hazardous n Persistent use despite social/interpersonal problems Criteria for Substance Use Disorder (contd) n Tolerance n Withdrawal n Using more than originally intended n Persistent desire or unsuccessful efforts to cut-down n Time spent obtaining/using substance or recovering from side effects n Reduction of social/occupational activities n Use despite physical/psychological problems n Craving n Need 2 criteria for SUD n 2-3 criteria =mild n 4-5 = moderate n >6 = severe 6

4/9/15 Screening U.S Preventive Services Task Force now recommends screening all adult patients for alcohol misuse How to Screen? § Ask permission: “Would it be ok to spend the next few minutes talking about alcohol?” § Pre-screen: Do you sometimes drink beer, wine, or other alcoholic beverages? § Single Alcohol Screen Question: § Men: How many times in the past year have you had 5 or more drinks in one day? § Women (or >65 yo): How many times in the past year have you had 4 or more drinks in one day? § Positive Screen=1 or more Smith PC, et al. J Gen Intern Med 2009;24(7); NIAAA Guidelines 2005 7

4/9/15 How to Screen? § Single Drug Use Screen Question: § How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons? § Positive Screen=1 or more Smith PC, et al. J Gen Intern Med 2009;24(7); NIAAA Guidelines 2005 Evidence for the Single Screen § Single Question Screen § Sensitivity/specificity: 88%/ 67% for alcohol use d/o § Sensitivity/specificity: 82%/79% for unhealthy use § CAGE: § Sensitivity/specificity: 92%/ 48% for alcohol dependence § AUDIT § Sensitivity/specificity: 96%/ 57% for unhealthy use § Sensitivity/specificity: 90%/ 61% for alcohol use d/o § Single Drug Screen § Sensitivity/ specificity: 100%/ 74% for drug disorder § Sensitivity/specificity: 71%/ 95% for use with consequences Smith PC, JGIM 2009; Smith PC, Arch Intern Med 2010 8

4/9/15 A Positive Screen… n 1 or more heavy drinking days n Any positive drug screen n What to do next? Assess… n Determine how many drinks/day in a week n Ask which drugs the patient has been using n Ask about negative impacts The follow-up questions are to assess impact and whether or not use is serious enough to warrant a substance use disorder diagnosis. Determining “At Risk” vs. “Substance Use Disorder” n Pts who meet criteria for “at-risk” should get a brief intervention n Patients who meet substance use disorder criteria abuse should get a Brief intervention n AND A referral to specialty care (if they are willing) n AND Be considered for pharmacotherapy n 9

4/9/15 What is a Brief Intervention? n Advise and Assist the patient n Short, 3-5 minute motivational interviews that encourage patients to create a plan of action (ex: reduce drinking) that is based on their willingness to change their behavior n Feedback and recommendations are given respectfully in the form of useful information. Brief Intervention n Non-judgmental but give direct, honest feedback n Provide advice on what a patient should do n Negotiate a concrete, realistic plan for behavioral change n If not ready to change → harm reduction n Plan for follow-up 10

4/9/15 HOW TO HELP PATIENTS: A CLINICAL APPROACH: NIAAA 2005 Resource for Clinicians AT-RISK DRINKING Advise and Assist § State your conclusion and recommendation clearly “You are drinking more than is medically safe.” image credit: Comstock HOW TO HELP PATIENTS: A CLINICAL APPROACH AT-RISK DRINKING Advise and Assist § State your conclusion and recommendation clearly “I strongly recommend that you cut down (or quit) and I’m willing to help.” image credit: Comstock 11

4/9/15 HOW TO HELP PATIENTS: A CLINICAL APPROACH AT-RISK DRINKING Advise and Assist § State your conclusion and recommendation clearly § Gauge readiness to change drinking habits “Are you willing to consider making changes in your drinking?” image credit: Comstock Stages of Change from Transtheoretical Model Lapse Maintenance Precontemplation Contemplation Action Preparation 12

4/9/15 Motivational Interviewing n Specialized skill set designed to help patients become ready and motivated to change health-related behaviors n Express empathy, develop discrepancy, support self-efficacy MI: Assess Readiness to Change n Readiness Ruler n “On a scale of 0-10, how ready are you to stop drinking?” n “I would say about a 3” n “So it sounds like you aren’t too interested right now. But I’m curious why you said ‘3’ rather than ‘0’.” OR “What would it take to move you to a 5?” n “Well, I know I should stop at some point.” n “Can you say a bit more about why you think that you should stop?” 13

4/9/15 MI: Enhance Motivation n Listen for “change talk” n Small verbal cues that the patient has thought about changing/need to change or health consequences of their behavior n “I was worried there at first, but I don’t really think I have a problem.” n “I don’t see why everyone is making such a fuss about this. I can handle it.” MI: Enhance Motivation n When you hear “change talk”, use MI skills (OARS) to respond n Open-ended questions n “Why do you think everyone is making such a fuss?” n Affirmations n “I can see you really care a lot about your health” n Reflections n “You are really considering whether you should cut down” n Summary statements: tie together multiple points n “I hear you saying that you don’t drink more than most people but everyone is making a fuss about your drinking” 14

4/9/15 MI n Ask Importance/Confidence Questions n “On a scale of 1-10, how important is it to you to stop drinking (or cut back)? On a scale of 1-10, how confident are you that you can stop drinking (or cut back)?” n This will help guide your next steps n Ask about pros/cons of the behavior Pharmacotherapy 15

4/9/15 Addiction Treatment Model: Treating Limbic Drive and Cortical Thinking Structures Decision Making (Counseling) Limbic Drive (Pharmacotherapy) From Pettinati, NIH 2006 Substances for which Substances for which Pharmacotherapy Pharmacotherapy is Not Available is Available n Cocaine n Opioids n Methamphetamine n Alcohol n Hallucinogens n Tobacco (nicotine n Cannabis dependence) n Solvents/Inhalants 16