Alcohol and Drug Problems and Dependence

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Alcohol and Drug Problems and Dependence

• FCM 110 March 29, 2004
• San Francisco General Hospital
• Ken Saffier, MD
• Contra Costa Regional Medical Center

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Learning Objectives

• At the end of this session, you will be able to
• Define alcoholism
• Use a practical screening tool for alcoholism
  (CAGE or 2 Question screen)
• Identify the common signs and symptoms of alcohol
  withdrawal
• Know when to offer out-patient detox for alcohol
  dependent patients

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Learning Objectives (contd)

• List and understand the stages of change for
  substance use disorders
• Explain how your understanding can help motivate
  patients to choose recovery
• Understand how and why a positive provider
  attitude correlates with successful outcomes

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Why are we exploring this subject?

• Alcohol dependence affects about 6 of the US
  population
• 38 of adults have experienced alcohol abuse or
  alcoholism in their families
• 157 billion in 1999 from alcoholism and abuse (
  110 billion for other drugs)
• 70 of above is due to lost wages and
  productivity due to alcohol related illness and
  early death

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• Substance use disorders are treatable like other
  chronic diseases
• Patients with untreated alcohol dependence incur
  general health care costs at least 100 higher
  than those without alcoholism
• Every dollar invested in tx for SUDs saves 7 in
  future costs

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How are we doing as physicians?

• CASA National Survey of Primary Care MDs
• And Patients on Substance Abuse
• 94 of PCPs (except pediatricians) failed to
  include SA with their top five diagnoses for
  early symptoms of alcohol abuse in adult
  patients
• 59.2 of pediatricians mentioned SA (40.8 did
  not consider the dx)

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Presentations of Alcohol Problems

• I want to get a check-up for VD.
• I had an accident and broke my wrist.
• My heart was beating real fast yesterday.
• My speech is slurred and I went to the ER
  yesterday. They sent me home thinking I was
  drunk.
• Im a policeman and I had a seizure 3 days ago.
• ___________________

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Case Presentation - FPC

• Kate is 35 years old, has no significant past
  health problems on her problem list, and is here
  because of headaches and abdominal pain. Her
  husband, Hal, is with her.
• What questions do you want to ask?

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Kates History - 2

• Headache is often in the morning, pounding,
  bilateral. No sxs now.
• Her abdominal pain x 6 months is epigastric,
  burning at times, with occasional nausea and
  rarely vomiting. No hematemesis or melena.
  Loose stools often.
• Has difficulty sleeping x years. Awakens
  frequently.
• Any other questions come to mind?

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The art of interviewing .

• Need to be tactful
• Non-judgmental
• High clinical suspicion but
• Low suspiciousness
• In almost every person who is harmfully involved
  with alcohol or drugs, there is part of them that
  is interested in getting help.

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Screening tools for substance use disorders

• Simple
• Inoffensive
• Easy to administer
• High sensitivity and specificity
• Valid and reproducible
• Examples CAGE, Two Question Screen

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CAGE

• Have you felt a need to Cut down on your
  drinking? (or using _____?)
• Have you been Angry (or annoyed) by others
  comments about your drinking?
• Have you felt Guilty (or badly) about your
  drinking?
• Have you had an Eyeopener in the morning to
  steady your nerves?
• Ewing, J., JAMA, 1984, 252 1905-7

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CAGE
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CAGE (compliments of www.nofreelunch.org)

• Have you ever prescribed Celebrex?
• Annoyed by people who complain about drug lunches
  and free gifts?
• Is there a medicine loGo on the pen youre using
  right now?
• Do you drink your morning Eye-opener out of a
  Lipitor coffee mug?
• If you answered YES to 2 or more of the above,
  you may be drug company dependent. Dont
  despair! Look up www.nofreelunch.org

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Two Question Screen

• Have you ever had a drinking problem ?
• Did you have a drink within the last 24 hours?
• Cyr and Wartman, JAMA, 259 51-54, 1988

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Two Question Screen
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What about lab screening?

• GGTP and MCV - 20 -60 sensitivity
• Others CDT (carbohydrate deficient transferrin)
  not effective in primary care populations and
  are expensive.

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Kate (contd) - 3

• Kate says that shes thought of cutting down on
  her drinking. In fact shes stopped drinking
  cocktails, and only has wine.
• She denied being angry at anyones talking about
  her drinking, but as she says this, you notice
  her husband reacts to her response.
• Yes, Ive felt guilty about drinking too much in
  the past. My kids missed their soccer practice
  once.

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Kate (contd) - 4

• She said she doesnt drink in the mornings.
• If Kate were pregnant, how would you approach
  screening for substance abuse? Would you ask any
  of these questions differently?

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T-ACE CAGE G T

• Tolerance How many drinks does it take to make
  you high or tipsy?
• A
• C
• E
• gt 2 is positive for risk drinking in pregnancy

• 2 points
• (more than 2 drinks)
• 1 point
• 1 point
• 1 point
• 69 sensitivity
• 89 specificity
• Sokol, R., et.al., Am J Obstet Gynecol 1989
  160863-70

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Kate (contd) - 5

• Upon reviewing her chart, recent labs were WNL.
  Her husband had a vasectomy.
• Hal reminds Kate that her maternal grandfather
  died of cirrhosis and who had a drinking
  problem.
• What else would you do at this point? What would
  you ask?

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Kate (contd) - 6

• With Hal out of the room, Kate admits to drinking
  vodka in the morning because she has the
  shakes. She drinks at lunch, dinner, and
  throughout the evening.

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Kate (contd) - 7

• Kate tearfully says her life is falling apart and
  desperately wants to stop drinking but her
  tremors, inability to sleep, and anxiety are
  helped with wine and vodka.
• What else do you want to know and what do you ask
  and do at this time?

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Kate (contd) - 8

• She replies that she has been using
  methamphetamine intermittently to get some extra
  energy so she could be more effective at work
  and attend to her kids needs.
• She also admits to taking her mothers valium to
  help calm her nerves and for sleep.

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Physical exam

• Looks stated age. NAD. BP 155/94 pulse 100.
  Temp 99F
• Head and neck nontender. Fundi w/sharp discs.
  Neuro grossly wnl.
• Mild epigastric tenderness. No organomegaly or
  masses. BS slightly hyperactive.

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What is your Current Assessment ?

• Headache
• Abdominal pain
• Other diagnoses/hypotheses/suspicions

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Addiction A Diseasewith bio-psycho-social-spirit
ual components

• Bio - a brain disease, receptors, altered
  neurophysiology, dopamine reward system,
  genetic predisposition
• Psycho - psychological and behavioral
• denial is a key feature
• Social - family, community, society, enabling
• Spiritual - relationship with self and beyond the
  personal, greater than self (not
  limited to religion)

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Substance Use DisordersWhat are they?

• Abuse Use, consequences, repetition
• Dependence (addiction) 3 Cs
• Control problems
• Compulsive use
• Continued use despite negative consequences
• Tolerance and withdrawal may be present depending
  on the drug and how it is used
• Denial is a key feature of this disease

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Denial

• In addition to lying, blackouts, euphoric recall,
  etc., denial can be thought of as
• Fear which keeps reality from consciousness
• Honest self-deception
• A barometer of emotional pain the more pain,
  the stronger the denial
• The river in Egypt

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Denial

• Denial facilitates use
• Use facilitates denial

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Family Members Roles in Substance Abusing
Families

• Chemically dependent person (identified pt.)
• Chief Enabler
• Hero
• Scapegoat
• Lost Child
• Mascot
• From Sharon Wegscheider-Cruse, Another Chance
  Hope and Health for the Alcoholic Family. Science
  and Behavior Books, Palo Alto, CA, 1981

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Rules of Chemically Dependent and other
Severely Dysfunctional Families

• Dont Talk
• Dont Trust
• Dont Feel
• Claudia Black, It Will Never Happen To Me,
  Children of Alcoholics as Youngsters ,
  Adolescents, Adults, M.A.C., 1981

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Summary of DSM-IV Criteriafor Substance
Dependence Maladaptive pattern causing harm with
3 or more of the following any time in 12 months

• Tolerance (may be absent)
• Withdrawal (may be absent)
• Using larger amounts/ longer time than intended
• Unsuccessful efforts to control or cut down

• Much time spent getting, using, or recovering
  from use
• Work, social, recrea-
• tion compromised
• Continued use despite negative consequences

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Motivational Interviewing

• How do you assess her readiness to change?
• What stage do you think best describes where and
  how Kate is?

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Stages of Change

• Precontemplation
• Contemplation
• Preparation
• Action
• Maintenance
• Relapse
• Prochaska and DiClemente, 1982

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An Introduction to Motivational Interviewing

• Building motivation OARS
• Open ended questions
• Affirming, supporting patients involvement
• Reflective listening, be empathic
• Summarizing

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Motivational Interviewing

• Respects individual differences
• Tolerance for disagreement/ambivalence
• Patience with incremental changes
• Nonjudgmental
• Caring and interest in patients served, express
  empathy

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Motivational Interviewing

• A process that works DARES
• Develop discrepancy
• Avoid argumentation
• Roll with resistance
• Express empathy
• Support self-efficacy

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Kate (contd) - 9

• On a scale of 1 to 10, how motivated are you to
  make a change to stop_______?
• On a scale of 1 to 10, what is the likelihood
  that youll stop ________ today or tomorrow?
• Why did you pick ___, and not 1?

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Signs and Symptoms of Alcohol Withdrawal

• Begins in hours, peaks on day 2 or 3, subsides on
  day 4 or 5
• Anxiety
• Malaise
• Insomnia
• Autonomic nervous system dysfunction
• Convulsions
• Organic brain syndrome
• Hallucinations

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Treatment of Alcohol Withdrawal

• Social model programs
• Non-drug treatment
• 3-Rs Reality, Reassurance, Respect
• Medically supervised in-pt. and out-pt. programs,
  and office based treatment
• Pharmacotherapy
• Benzodiazepines are the drugs of choice (except
  in pregnancy phenobarbital substitution as
  in-pt.)

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Pharmacotherapy of Alcohol W/D

• Diazepam 10 mg q 4-6 h on first day and taper
  over next 4-5 days, or
• Chlordiazepoxide 25-50 mg q 6 h on first day and
  taper over the next 4-5 days, or
• If severe liver disease, lorazepam 1-2 mg q 4-6 h
  on first day, and taper over 4-5 d
• Thiamine 50-100 mg/d, folate 1 mg/d, multiple
  vitamins, magnesium, K prn

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Kate (contd) 10Out-patient Detox

• Is Kate a suitable patient for an out-patient
  medically supervised detox?
• Desires to be abstinent from alcohol and all mind
  and mood altering drugs.
• Has withdrawal signs and symptoms, or is likely
  to develop them.
• Is willing to follow a treatment plan, including
  random toxicology testing.

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Contraindications to Out-patient Detox

• Recent head trauma or CVA
• Acute abdominal pain
• Active infections
• C-V illness or potential complications (e.g.,
  angina, arrhythmia)
• Severe respiratory disease

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Components of a Brief Intervention for Kate 5
As

• Ask about use
• CAGE, Two question screen
• Suspect more than one cause or drug
• Asses use abuse, or dependence ?
• Advise about consequences nonjudgmental
  education May I share with you some facts
  about ______?
• Assist with a plan to stop
• Arrange for follow-up or referral

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Brief Physician Advice for Problem Alcohol
Drinkers

• A randomized controlled trial with problem
  drinkers in community-based primary care
  practices, seen by 64 physicians, solo and HMO
• Two 10 to 15 minute periods of scripted advice,
  education and contracting.
• N392 with control n382
• 93 participation and 1 year f/u
• Significant reductions of alcohol intake and
  length of hospitalizations for men.
• Fleming, MF, et. al., JAMA 1997
  2771039-1045

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Based on what youve learned about Kate, what
would you advise/offer?

• Tx? In-pt vs out-pt?
• Tx for W/D?
• Disulfiram?
• Twelve step programs? What kind? How often?
• Anything else?
• Kate agrees to enter New Connections outpatient
  program, attend 90 meetings in 90 days of AA, and
  receive treatment for alcohol withdrawal over the
  next week in your health center. Shell think
  about disufiram (Antabuse).

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Alcohol and Nicotine Dependence

• She usually smokes about 1 PPD, but recently
  shes been smoking 1 ½ PPD.
• Do I have to give up everything at once?

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Additional Reasons to Quit Nicotine

• Discontinuing the mind/mood altering drug,
  nicotine, at the same time as other drugs, has
  been shown to
• Decrease the risk of relapse in chemically
  dependent patients in early recovery
• Correlate with longer periods of sobriety if
  relapse occurs in those who are nicotine
  abstinent

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What really makes a difference?

• A Significant Predictor of Positive Outcome
• A Positive Provider Attitude

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Positive AttitudesImplications for Patient Care

• Increased screening
• Increased diagnoses
• Increased access and referrals to tx
• Improved outcome
• Increased hope for patients, families, staff
• Chappell, JN, Schnoll, S Physician attitudes,
  effect on the treatment of chemically dependent
  patients. JAMA 212318-19, 1977

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Treatment Resources

• Treatment Access Program 522-7100
• Out-patient and inpatient medical programs
• Residential programs
• Faith-based programs (e.g., Salvation Army)
• 12 Step programs

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Twelve Step Programs

• Alcoholics Anonymous
• English 674 - 1821
• Spanish 554 - 8811
• Narcotics Anonymous
• English 621 - 8600
• Spanish 864 - 3155
• Cocaine Anonymous 821 - 6155

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Twelve Step Programs (contd.)

• Al-Anon/Alateen Family Groups
• English 626 - 5633
• Spanish 650 794 - 9654
• Nar-Anon 292 - 3241

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Recovery

• A process which involves
• Recognizing feelings
• Dealing with feelings
• Accepting feelings
• Grieving losses
• Learning to live (in the present)
• Alcoholism is a shame-based disease.
• Healing takes time.

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Meeting the Challenge of SUDs for Patients,
Families, and Providers

• Grant me the serenity
• to accept the things I cannot change,
• the courage to change the things I can
• and
• the wisdom to know the difference

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Summary Screening, Diagnosis, and Brief
Interventions

• With a high index of suspicion and basic
  screening tools, such as the CAGE and the 2
  question screen, physicians can identify more
  patients at risk for substance use disorders.
• Practical definitions such as the 3-Cs can aid
  in diagnosis and education of patients with
  addictive disease.

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Summary (contd)

• Identifying and treating withdrawal in chemically
  dependent people facilitates recovery.
• Motivational interviewing is a respectful process
  to help patients move toward recovery.
• A positive provider attitude toward people with
  addictive disease promotes recovery and a
  positive outcome.

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Selected Web Sites

• www.niaaa.nih.gov National Institute for
  Alcoholism and Alcohol Abuse
• www.nida.nih.gov National Institute for
  Drug Abuse
• www.health.org National Clearinghouse
  for Alcohol and Drug Information

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Selected References

• Cyr, M.G. and Wartman, S.A. The effectiveness of
  routine screening questions in the detection of
  alcoholism. JAMA 1988, 25951-54
• Ewing, J.A. Detecting alcoholism The CAGE
  questionnaire. JAMA 1984, 2521905-1907

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Selected References

• Mayfield, D.G., et. al. The CAGE questionnaire
  Validation of a new alcoholism screening
  instrument. Am J Psychiatry 1974, 1311121-1123
• Sokol, R.J., et. al. The T-ACE questions
  Practical prenatal detection of risk-drinking. Am
  J Obstet Gynecol 1989, 160863-870

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Selected References

• Prochaska, J.O. and DiClemente, C.C.,
  Transtheoretical therapy toward a more
  integrative model of change. Psychotherapy
  Theory, Research, and Practice 1982, 19276-288
• Enhancing motivation for change in substance
  abuse treatment, Center for Substance Abuse
  Treatment, Treatment Improvement Protocol Series
  (35), 1999, [phone]

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Selected References

• Fleming, Michael, et. al., Brief physician advice
  for problem alcohol drinkers, a randomized
  controlled trial in community-based primary care
  practices, JAMA 19972771039-1045
• (1998 Society of Teachers of Family Medicine
  Best Research Paper Award)

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Selected References

• Substance Abuse and Mental Health Administration
• Center for Substance Abuse Treatment
• Treatment Improvement Protocol (TIP) Series
• Detoxification From Alcohol and Other Drugs 19
• A Guide to Substance Abuse Services for Primary
  Care Services 24
• Brief Interventions and Brief Therapies for
  Substance Abuse 34
• Enhancing Motivation for Change in Substance
  Abuse Treatment 35
• National Clearinghouse for Alcohol and Drug
  Information
• (800) 729 6686 or (301) 468 2600
• www.health.org