Title: Maine's Addiction Crisis, It's Effects on Maine Families and the Role of the Nurse Practitioner
1Maine's Addiction Crisis, It's Effects on Maine
Families and the Role of the Nurse Practitioner
- Mark Publicker, MD FASAM
- Medical Director
- Mercy Recovery Center
2Talk objectives
- Describe
- the epidemiology of Maines drug problems
- the effects of addiction on families and of abuse
on addiction - availability and barriers to treatment
- the role of nurse practitioners in advancing
treatment - Be kind, for everyone you meet is fighting a
great battle. - Philo of Alexandria
3Maine substance abuse
- High rates of opiate, cocaine, alcohol, cannabis
and benzodiazepine addiction - Methamphetamine increasing across the state
- Trend towards opiate dependence plus
methamphetamine - Younger onset, more severe alcohol problems,
greater female abuse
4Alcoholism epidemiology
- 14 lifetime prevalence
- 5-8 12 month prevalence
- Up to 20 of outpatient medical visits
- 20-40 of hospitalizations
- 40-60 of trauma admissions
5Substance abuse
- For this talk, focus on Addiction
- Addiction is
- A brain disorder
- A behavioral disorder
- Tolerance
- Dependence
- Compulsive use
- Loss of control
- Use despite known consequences
6Opiate dependence in Maine
- Continued exponential growth in prescription
opiate and heroin since 1990s - Opiate addiction as a pediatric disease
7Maine adolescent 30-day prescription drug abuse
- 7th Grade 3.7
- 8th Grade 6.1
- 9th Grade 8.9
- 10th Grade 11.0
- 11th Grade 11.6
- 12th Grade 10.3
8Maine opiate epidemic
- Buprenorphine maintenance 900
- Methadone maintenance 2200
- OSA estimate of untreated population 30000
9Methamphetamine
- Powerfully addictive stimulant
- Injected, snorted, smoked or ingested
- High rates of neglect, physical and sexual abuse
- Environmental toxicity from exposure to meth lab
fumes - Burns in mouth and throat
- Asthma
10Family effects of addiction
- Emotional
- Social
- Financial
- Legal
Happy families are all alike every unhappy
family is unhappy in its own way. - Leo
Tolstoy
11Parenting and substance abuse
- Substance abuse as a cause of child abuse
- Child abuse as a cause of substance abuse
- What factors increase of mitigate the effects of
abuse on the development of addiction? - Most information from indirect sources
12Parenting and Substance abuse
- Substance abuse is both a cause and a consequence
of child abuse - Necessary to treat both the substance abuse
disorder and the trauma to promote optimal
outcomes - While common, relapse need not be seen as a
disaster - Pharmacotherapy and behavioral therapies can
improve outcomes for parents and children
13Parenting and substance abuse
- Are people with substance abuse disorders more
likely to have been abused or neglected as
children? - Are those with history of abuse or neglect more
likely to develop substance abuse disorders?
14National estimates
- Survey State child welfare administrators
substance abuse in 70 of cases - Children living with at least one
substance-abusing parent - Illicit drug use in past year - 10.6 million
- Illicit drug use in past month 8.4 million
- Dependent alcoholdrug 7.52 million
15Parenting and substance abuse
- Miller 70 women in treatment for alcohol
dependence reported childhood sexual abuse vs 35
in general population - Parental alcoholism and child abuse were
independent risk factors for problem drinking in
adulthood - Two thirds of incest victims attribute their SA
to the abuse
16Parenting and substance abuse
- Fewer studies of child abuse among boys and men
with substance abuse disorders - A few prospective studies of childhood abuse
among men suggest higher risk - Simpson alcohol abuse disorders more severe in
men sexually abused as children - More overdoses, higher rates of liver disease and
more seizures
17Parenting and substance abuse
- CASA 1999 children of substance abusers three
times more likely to be abused and four times as
likely to be neglected - Substance abuse involved in at least one third of
children in child welfare system
18Parenting and Substance Abuse
- PTSD Harvard meta-analysis 59 of women in
treatment - Three times greater incidence than male patients
- Trauma independent of PTSD
- 55-99 female patients report physical or sexual
trauma before age 18 - Women victims of both types of abuse twice as
likely to abuse drugs as those with one type
19Intergenerational substance abuse
- Increased risk for repetition of troubled parent
child relations, including abuse and neglect and
substance abuse (Sheridan) - Problems more likely to develop at times of
increased stress
20Rape, child abuse and trauma
- Rape victims much more likely to abuse drugs
- S. Carolina study 4008 women 61 rapes by age
17, half of these by age 11 - Three times as likely to have used marijuana
- Six times more likely to have used cocaine
- 10 times as likely to have used drugs other than
cocaine, including heroin and amphetamines
21Relapse
- Higher rates of relapse in men correlate with
higher rates of childhood abuse - Role of chronic stress states in triggering
alcohol and other drug relapse
22Mothers characteristics
- Women seeking treatment
- Function as single parents with little financial
support from fathers - Live in unstable or unsafe environments
- Lack transportation
- Lack child care
- Have special therapeutic needs incest, abuse,
sexuality, relationships
23Prenatal exposure
- Estimate, based on study of 36 hospitals, 11
infants exposed to illegal drugs - Little difference between public and private
clinics or between white and black patients
24Treatment availability and barriers
- Significant advances in pharmacotherapy of
alcohol dependence in combination with
psychosocial treatment - Naltrexone
- Acamprosate (Campral)
25Undertreatment of alcohol dependence
- US data SAMHSA 2003
- Alcohol abuse/dependence
- 17.8 million
- Alcohol dependence 7.9 million
- Seeking treatment 2.2 million
- Treated with medication 100,000
- We are all incurables. -Archbishop Romero, when
asked why he was attending to the sick at a
hospital for incurables
26Treatment availability and barriers
- Barriers
- Little medical provider education on addiction
leading to under diagnosis and under treatment - Too few programs have an evidence-based, medical
model - Beliefs
- Adherence
27Treatment availability and barriers
- Barriers
- Integration
- Patient selection
- Side effects
- Coverage
28Treatment availability and barriers
- Buprenorphine
- Limited availability because of training
requirements and DATA 2000 patient cap - Limited access to intensive outpatient treatment
in many areas of the state
29Nurse practitioners role in addiction treatment
- Apply the tools of chronic disease management
- Screening
- Family interventions by trusted primary care
practitioners - Medication management
- Acamprosate, naltrexone, buprenorphine
- You must be the change you want to see in the
world. Mohandas Gandhi
30Impact of physician warning on alcoholism
treatment outcome
- WalshJAMA 1992 Feb 267(5)663-7
- Two years later, those warned were more likely to
be abstaining, and sober, and were less impaired.
- Fewer than a quarter remembered physician warning
although three quarters had been seen by a
physician
31Nurse practitioners role in addiction treatment
- Careful prescription of controlled substances
- Use the PMP
- Learn Motivational Interviewing
- Learn about community resources
- AA, NA, Alanon, Families Anonymous
- Detoxification and rehabilitation programs in
your area and across the state
32Nurse practitioner role Screening
- Ask all patients about their alcohol and drug use
- Assess for alcohol-related problems
- Advise appropriate actions
- Monitor progress
33Nurse practitioner role BRENDA
- Biopsychosocial assessment
- Report to the patient
- Empathetic understanding
- Needs derived collaboratively
- Direct advice on how to meet the needs
- Assess patient response and adjust
34Nurse practitioners role in addiction treatment
- to ignore a chronic malady as painful to the
individual, as damaging to his health, as
destructive to his family, and as refractory to
willpower, to motivation, and to common sense as
alcoholism for doctors to ignore such a malady
is unconscionable. - George Vaillant
35Nurse practitioners role in addiction treatment
- The future
- MNPA collaboration with the Maine Society of
Addiction Medicine in CME programs
"In order to make an apple pie from scratch, you
must first create the universe." Carl Sagan