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


the epidemiology of Maine's drug problems ... Maine substance abuse ... Opiate dependence in Maine ... – PowerPoint PPT presentation

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

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

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
  • Be kind, for everyone you meet is fighting a
    great battle.
  • Philo of Alexandria

Maine substance abuse
  • High rates of opiate, cocaine, alcohol, cannabis
    and benzodiazepine addiction
  • Methamphetamine increasing across the state
  • Trend towards opiate dependence plus
  • Younger onset, more severe alcohol problems,
    greater female abuse

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

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

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

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

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

  • Powerfully addictive stimulant
  • Injected, snorted, smoked or ingested
  • High rates of neglect, physical and sexual abuse
  • Environmental toxicity from exposure to meth lab
  • Burns in mouth and throat
  • Asthma

Family effects of addiction
  • Emotional
  • Social
  • Financial
  • Legal

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

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
  • While common, relapse need not be seen as a
  • Pharmacotherapy and behavioral therapies can
    improve outcomes for parents and children

Parenting and substance abuse
  • Are people with substance abuse disorders more
    likely to have been abused or neglected as
  • Are those with history of abuse or neglect more
    likely to develop substance abuse disorders?

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

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
  • Two thirds of incest victims attribute their SA
    to the abuse

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

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

Parenting and Substance Abuse
  • PTSD Harvard meta-analysis 59 of women in
  • 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

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

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

  • 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

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

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

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

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

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
  • Beliefs
  • Adherence

Treatment availability and barriers
  • Barriers
  • Integration
  • Patient selection
  • Side effects
  • Coverage

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

Nurse practitioners role in addiction treatment
  • Apply the tools of chronic disease management
  • Screening
  • Family interventions by trusted primary care
  • Medication management
  • Acamprosate, naltrexone, buprenorphine
  • You must be the change you want to see in the
    world. Mohandas Gandhi

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

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

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

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

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

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