Substance-Use-Disorders课件.ppt
Copyright Annals of Internal Medicine,2016Ann Int Med.164(4):ITC4-1.In the ClinicSubstance Use Disorders Copyright Annals of Internal Medicine,2016Ann Int Med.164(4):ITC4-1.How common are substance use disorders?Alcohol useq30%Americans 18 years old exceed recommended limitsqSmaller percentage have alcohol use disorder Illicit drugsq9%Americans 12 years useqMarijuana(7.5%)qPrescription drugs(2.5%,mostly opioids),Heroin(0.1%)qCocaine(0.6%),Hallucinogens(0.5%),Inhalants(0.2%)qMethamphetamine a major problem in some regionsqDesigner drug use increasing(synthetic cannabinoids)Copyright Annals of Internal Medicine,2016Ann Int Med.164(4):ITC4-1.What are the risk factors?Genetic polymorphisms qMay contribute 40%to 60%of an individuals riskEnvironmental factors in childhood or adolescenceqAge of first exposure to alcohol or drugs qAdverse childhood experiences Psychiatric comorbiditiesqDepression,anxiety,bipolar disorderqMay contribute to vulnerability to addictionqAnxiety and depressive symptoms may be a consequence of long-term substance use Copyright Annals of Internal Medicine,2016Ann Int Med.164(4):ITC4-1.Unhealthy substance useAlcohol:consumption at a level that has negative health consequencesqMen 65 years:risky use 4 drinks per occasion or 14 drinks per weekqMen 65 years and women,risky use 3 drinks per occasion or 7 drinks per week qUnhealthy alcohol becomes a disorder when person experiences negative consequences and/or loss of control around their drinkingDrugs:ANY use Copyright Annals of Internal Medicine,2016Ann Int Med.164(4):ITC4-1.Copyright Annals of Internal Medicine,2016Ann Int Med.164(4):ITC4-1.What health system measures are effective in reducing or preventing unhealthy substance use?Risky alcohol use:brief interventions can be effectiveqSBIRT:screening,brief intervention,referral to treatmentqIf screening positive:assess further and refer for treatmentqClinical cues should trigger investigation about alcohol use(pancreatitis,elevated liver function test results)For drug use,brief interventions not shown effective qUse safe practices when prescribing opioids for pain qAsk about use:when social functioning deteriorates,family history is present,or associated comorbidities diagnosed(hep C,upper extremity abscess)Copyright Annals of Internal Medicine,2016Ann Int Med.164(4):ITC4-1.How can opioids for chronic pain be prescribed safely and effectively?Monitor for behaviors that indicate opioid use disorderPredictors of opioid use disorder include qHistory or family history of substance use disorders qMental health diagnosisqCurrent cigarette smokingqHistory of legal problems qConcurrent benzodiazepines,and higher opioid dosesOnly consider long-term opioid treatment whenqModerate to severe pain affects function and/or QOL qPotential therapeutic benefits outweigh risks Copyright Annals of Internal Medicine,2016Ann Int Med.164(4):ITC4-1.Use risk management strategiesqOptimize alternatives to opioid treatment for chronic painqAssess for risk for aberrant drug-related behaviorsqStructure appropriate treatment and monitoring planqConsider a medication agreementqRegularly assess opioid benefit and decision to use qRegularly assess drug-related behaviors,using urine drug testing,pill counts,state prescription monitoring dataDiscontinue(tapering)if benefits are not commensurate with risks or if drug taking behaviors are aberrant Seek appropriate specialist assistance Copyright Annals of Internal Medicine,2016Ann Int Med.164(4):ITC4-1.Copyright Annals of Internal Medicine,2016Ann Int Med.164(4):ITC4-1.DiagnosisScreening for alcohol useqSingle-item:How many times have you consumed alcohol over the recommended limits?qAUDIT-C:3-item survey more specific for unhealthy use qAUDIT:10-item survey often used as follow-up to single-item question or as initial screening toolqCAGE:assesses lifetime rather than current use patternScreening for drug useqSingle-item:How many times in the last year have you used an illegal drug,or a prescription medication for a nonmedical reason(bc of experience or feeling it caused)?qDAST-10:initial screening or follow up on single-itemqPay attention to key aspects of history Copyright Annals of Internal Medicine,2016Ann Int Med.164(4):ITC4-1.Assess withdrawal in patients with alcohol or opioid disorder who report recently stopping useqHistory and physical examination qCIWA(Clinical Institute Withdrawal Assessment)for alcohol withdrawalqCOWS(Clinical Opiate Withdrawal Scale)score for opioid withdrawalTo further assess for complications of substance useqLaboratory evaluation often important Diagnosis Copyright Annals of Internal Medicine,2016Ann Int Med.164(4):ITC4-1.Copyright Annals of Internal Medicine,2016Ann Int Med.164(4):ITC4-1.ComplicationsInjection drugs qLocal infections(abscesses,cellulitis)qBlood-borne infections(bacterial and viral)Opioids(in addition to complications of opioid injection)qNausea and constipationqEffects of HPA axis suppression(amenorrhea,low bone density,loss of libidoqHyperalgesia qOverdose Copyright Annals of Internal Medicine,2016Ann Int Med.164(4):ITC4-1.Copyright Annals of Internal Medicine,2016Ann Int Med.164(4):ITC4-1.Complications Marijuana qPulmonary complications(cough,bronchitis,asthma)qPossible lung cancer or other cancers qHyperemesis qIn adolescents:abnormal development neural pathwaysqPossble depression and anxiety,psychotic disordersDesigner drugs qSynthetic cannabinoids:seizures,acute renal failure,myocardial infarction(long-term effects not well-known)q“Bath salts”:muscle spasm,bruxism,palpitations,tachycardia,hypertension;psychiatric effectsOral health problems common with substance disorders Copyright Annals of Internal Medicine,2016Ann Int Med.164(4):ITC4-1.CLINICAL BOTTOM LINE:Complications.vSubstance use disorders have myriad medical complicationsvUnhealthy alcohol use:liver disease as well as causing or contributing to a host of other medical conditionsvInjection drug use:local and systemic bacterial infections and blood-borne viruses,including HIV and hepatitis C vCocaine:cardiovascular effectsvMarijuana:pulmonary complications,neurocognitive impairment that may be particularly serious in adolescents Copyright Annals of Internal Medicine,2016Ann Int Med.164(4):ITC4-1.Copyright Annals of Internal Medicine,2016Ann Int Med.164(4):ITC4-1.Alcohol:criteria for outpatient detoxificationqCIWA score 8-15 without seizures or delirium tremensqAbility to take oral medicationsqPresence of reliable support person who can stay throughout the detox period and monitor symptomsqAbility to commit to daily medical visitsqNo unstable medical condition and not pregnantqNot psychotic,suicidal,or cognitively impairedqNo concurrent substance use that may lead to withdrawalqNo history delirium tremens or alcohol withdrawal seizuresqContraindications:60 y,evidence alcohol-related end-organ damageqBenzodiazepines may help manage symptoms and prevent complications Copyright Annals of Internal Medicine,2016Ann Int Med.164(4):ITC4-1.Opioids qTreating as outpatients depends on treatment goals and treatment availabilityqRefer patients experiencing withdrawal and interested in methadone/buprenorphine treatment for such careqFor oral naltrexone use,patient must be opioid abstinent 37 d before initiation;for intramuscular formulation 7 d qPatients often require structure and supervision of inpatient setting during this transitionqIn outpatient setting,manage symptoms with nonopioid medications for anxiety,cramps,diarrheaBenzodiazepines qManage severe withdrawal as inpatients so that IV benzodiazepines can be given and titrated to effect qAfterward,motivated patients can receive gradually tapering dose in outpatient setting over several months Copyright Annals of Internal Medicine,2016Ann Int Med.164(4):ITC4-1.What medications are available for treatment?Alcohol qNaltrexoneqAcamprosateqDisulfiramOpioids qMethadoneqBuprenorphineqSustained-release naltrexoneCocaine qNo FDA-approved medication Copyright Annals of Internal Medicine,2016Ann Int Med.164(4):ITC4-1.What other treatments are available for substance use disorders?Psychosocial treatment qHelps achieve sobriety,rebuild other aspects of lifeCounselingqPeer-support groups(Alcoholics Anonymous)qResidential treatmentqContingency management qMotivational interviewing Copyright Annals of Internal Medicine,2016Ann Int Med.164(4):ITC4-1.For patients who continue to use substances,how can physicians help reduce harms?Needle exchange services:injection drug usersIntranasal naloxone:opioid use disorderTetanus,hepatitis A&B vaccination:injection drug usersPneumonia vaccination:alcohol use disorders Preexposure prophylaxis against HIV:high-risk patients Counsel to avoid driving after unhealthy alcohol,drug useOffer birth control,condom counseling,frequent STI testing to women with heroin use disorders Engage patients in discussions about readiness for changeAddress tobacco use just as with any other patient Copyright Annals of Internal Medicine,2016Ann Int Med.164(4):ITC4-1.Copyright Annals of Internal Medicine,2016Ann Int Med.164(4):ITC4-1.What is the role of primary care physicians vs.addiction physicians and other specialists?Primary care physiciansqCentral roles in prevention,diagnosis,and managementqMay treat patients with substance use disordersqReferral to addiction specialist and/or treatment programAddiction specialistsqComplex patients with substance use disorders Addiction psychiatry subspecialistsqPatients with mental health conditionPain specialistsqOptimize nonopioid treatments of chronic pain Copyright Annals of Internal Medicine,2016Ann Int Med.164(4):ITC4-1.CLINICAL BOTTOM LINE:Management.vWithdrawal managementNecessary bridge to further treatment for many patientsOutpatient management appropriate only for highly motivated patients with ample support at homevTreatment optionsMedications available for alcohol and opioid use disordersPsychosocial treatments effective for many patients Peer-support groups(Alcoholics Anonymous)may benefitvEducate patients who are in early recovery or who are not ready to stop substance use about harm reduction
