Maine's Addiction Crisis, It's Effects on Maine Families and the Role of the Nurse Practitioner

1
Maine'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

2
Talk 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

3
Maine 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

4
Alcoholism 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

5
Substance 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

6
Opiate dependence in Maine

• Continued exponential growth in prescription
  opiate and heroin since 1990s
• Opiate addiction as a pediatric disease

7
Maine 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

8
Maine opiate epidemic

• Buprenorphine maintenance 900
• Methadone maintenance 2200
• OSA estimate of untreated population 30000

9
Methamphetamine

• 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

10
Family effects of addiction

• Emotional
• Social
• Financial
• Legal

Happy families are all alike every unhappy
family is unhappy in its own way. - Leo
Tolstoy
11
Parenting 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

12
Parenting 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

13
Parenting 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?

14
National 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

15
Parenting 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

16
Parenting 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

17
Parenting 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

18
Parenting 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

19
Intergenerational 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

20
Rape, 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

21
Relapse

• 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

22
Mothers 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

23
Prenatal 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

24
Treatment availability and barriers

• Significant advances in pharmacotherapy of
  alcohol dependence in combination with
  psychosocial treatment
• Naltrexone
• Acamprosate (Campral)

25
Undertreatment 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

26
Treatment 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

27
Treatment availability and barriers

• Barriers
• Integration
• Patient selection
• Side effects
• Coverage

28
Treatment 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

29
Nurse 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

30
Impact 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

31
Nurse 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

32
Nurse practitioner role Screening

• Ask all patients about their alcohol and drug use
• Assess for alcohol-related problems
• Advise appropriate actions
• Monitor progress

33
Nurse 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

34
Nurse 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

35
Nurse 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