A Real Case… Substance Use Disorders in Primary Care ...€¦ · Primary Care: Screening, Brief...

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Substance Use Disorders in Primary Care:

Screening, Brief Interventions, PharmacotherapyKatherine Julian, M.D.

UCSF Division of General Internal MedicineAugust 7, 2013

A Real Case…� 31 yo man presenting to resident clinic for new

patient appt� Recently hospitalized with new onset atrial

fibrillation. Resolved with cardioversion. Given coumadin and presenting to titrate this medication.

� Prompted to take an alcohol history→bingedrinking with indications of alcohol dependence

Quiz…Your Clinic PanelIn your clinic panel, what percentage of your current clinic patients would be classified with

alcohol abuse or dependence*?

< 1%

2 -5 %

6 -9 % 1 0 % 2 0 %

0%

14%

27%

35%

24%

A. <1%B. 2-5%C. 6-9%D. 10%E. 20%

Substance Use Issues are Highly Prevalent in Americans

At Risk Drinking* 23%Illicit Drug Use 8%Substance Abuse/Dependence 9%

Alcohol 7%Illicit Drugs 3%

SAMHSA, National Survey on Drug Use and Health, 2008Ages 12+ in the United States

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Alcohol Use in Primary Care � 3439 primary care

patients� 11% had “at risk”

drinking defined as any of the following:� > 2 drinks/day� > 2 episodes of 5+ drinks/day in 30 days

� Drinking and driving

Curry SJ, et al. Prev Med 2000;31(5):595-607

Alcohol Use Disorders in Older Adults

�3% met full criteria for an alcohol use disorder�At-risk drinking was reported in:

�17% of men, 11% of women ages 50+�19% of all respondents ages 50-64�13% of all respondents ages 65+

�Binge drinking was reported in:�20% of men, 6% of women ages 50+�23% of all respondents ages 50-64�15% of all respondents ages 65+

NSDUH, 2009Blazer D, Wu L. Am J Psychiatry, 2009

Outline� Substance Use Disorders - Definitions� SBIRT

� Screening: quickly assess use and severity of alcohol, illicit drugs, and prescription drug abuse

� Brief Intervention: a 3-5 minute motivational intervention given to risky or problematic substance users

� Referral to Treatment� Motivational Interviewing� ETOH and Opiate Substance Use Pharmacotherapy

Why SBIRT? The Evidence…� Brief interventions can reduce alcohol use for at

least 12 months in patients who are not alcohol dependent.

� 10-30 % of patients can be expected to change their drinking behaviors as a result of a brief intervention.

Babor & Higgins-Biddle, 2000; Fleming and Manwell, 1999.

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Quiz…Which of the following is NOT considered to be “at risk” drinking?

4 5 y o

w om a

n wh . . .

7 0 y o

m an w

h o . . .

2 5 y o

w om a

n wh . . .

4 0 y o

m an w

h o . . .

8%

64%

11%17%

A. 45 yo woman who drinks 1-2 glasses of wine each night

B. 70 yo man who drinks 1-2 beers each night

C. 25 yo woman who drinks 4-5 drinks once a week when she goes out with friends

D. 40 yo man who drinks 1-2 glasses of wine each night

Definition – At Risk Drinking� Men

• >4 drinks/day or• >14 drinks/week

� Women (and > than 65 yrs)• >3 drinks/day or • >7 drinks/week

� Increased risk of alcohol-related problems

Quiz…� Which of the following is NOT

considered to be “at risk” drinking?A. 45 yo woman who drinks 1-2 glasses of wine each nightB. 70 yo man who drinks 1-2 beers each nightC. 25 yo woman who drinks 4-5 drinks once a week when she goes out with friendsD. 40 yo man who drinks 1-2 glasses of wine each night

What is a Drink?A standard drink is any drink that

contains about 14 grams of pure alcohol (about 0.6 fluid ounces or 1.2 tablespoons)

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New DSM5 - Substance Use Disorder

� No longer need to differentiate between substance abuse and substance dependence

� Each substance can be categorized as a disorder� Ex: Alcohol use disorder, stimulant use

disorder, etc� Grade Severity: Mild, Moderate, Severe

New DSM5 - Substance Use Disorder

� “Maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 2 (or more) of the following, occurring within a 12-month period:”� Failure to fulfill role obligations� Recurrent substance use in situations that are physically hazardous

� Persistent use despite social/interpersonal problems

Criteria for Substance Use Disorder (contd)

� Tolerance� Withdrawal� Using more than originally intended� Persistent desire or unsuccessful efforts to cut-down� Time spent obtaining/using substance or recovering from side effects� Reduction of social/occupational activities� Use despite physical/psychological problems� Craving

� Need 2 criteria for SUD� 2-3 criteria =mild� 4-5 = moderate� >6 = severe

ScreeningSome key opportunities include:� As part of a routine examination� Before prescribing a medication that interacts with

alcohol or other drugs� In the emergency department or urgent care center�When seeing patients who..

� Are pregnant or trying to conceive� Have health problems that might be alcohol or drug induced/

related� Have a chronic illness not responding to treatment� Are likely to drink heavilyNIAAA, 2005. Helping Patients Who Drink Too Much: A Clinician’s Guide (Updated)

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How to Screen?� Ask permission: “Would it be ok to spend the next few minutes talking about alcohol?”� Pre-screen: Do you sometimes drink beer, wine, or other alcoholic beverages?� Single Alcohol Screen Question:

�Men: How many times in the past year have you had 5 or more drinks in one day?�Women (or >65 yo): How many times in the past year have you had 4 or more drinks in one day?

� Positive Screen=1 or more

Smith PC, et al. J Gen Intern Med 2009;24(7); NIAAA Guidelines 2005

How to Screen?� Single Drug Use Screen Question:�How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?

� Positive Screen=1 or more

Smith PC, et al. J Gen Intern Med 2009;24(7); NIAAA Guidelines 2005

Evidence for the Single Screen� Single Question Screen� Sensitivity/specificity: 88%/ 67% for alcohol use d/o� Sensitivity/specificity: 82%/79% for unhealthy use

� CAGE: � Sensitivity/specificity: 92%/ 48% for alcohol dependence

� AUDIT� Sensitivity/specificity: 96%/ 57% for unhealthy use� Sensitivity/specificity: 90%/ 61% for alcohol use d/o� Single Drug Screen� Sensitivity/ specificity: 100%/ 74% for drug disorder� Sensitivity/specificity: 71%/ 95% for use with consequences

Smith PC, JGIM 2009; Smith PC, Arch Intern Med 2010

A Positive Screen…� 1 or more heavy drinking days� Any positive drug screen� What to do next? Assess…

� Determine how many drinks/day in a week� Ask which drugs the patient has been using� Ask about negative impacts

The follow-up questions are to assess impact and whether or not use is serious enough to warrant a

substance use disorder diagnosis.

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Criteria for Substance Use Disorder

� Failure to fulfill role obligations� Recurrent substance use in situations that are physically hazardous� Persistent use despite social/interpersonal problems� Tolerance� Withdrawal� Using more than originally intended� Persistent desire or unsuccessful efforts to cut-down� Time spent obtaining/using substance or recovering from side effects

� Reduction of social/occupational activities� Use despite physical/psychological problems� Craving

Determining “At Risk” vs. “Substance Use Disorder”

� Pts who meet criteria for “at-risk” should get a brief intervention

� Patients who meet substance use disorder criteria abuse should get a � Brief intervention

AND� A referral to specialty care (if they are willing)

AND� Be considered for pharmacotherapy

What is a Brief Intervention?� Advise and Assist the patient� Short, 3-5 minute motivational interviews that

encourage patients to create a plan of action (ex: reduce drinking) that is based on their willingness to change their behavior

� Feedback and recommendations are given respectfully in the form of useful information.

Brief Intervention� Non-judgmental but give direct, honest feedback� Provide advice on what a patient should do� Negotiate a concrete, realistic plan for behavioral change� If not ready to change→harm reduction� Plan for follow-up

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Advise and Assist

�State your conclusion and recommendation clearly

HOW TO HELP PATIENTS: A CLINICAL APPROACH: NIAAA 2005 Resource for Clinicians

image credit: Comstock

“You are drinking more than is medically safe.”

AT-RISK DRINKING

Advise and Assist


HOW TO HELP PATIENTS: A CLINICAL APPROACH


AT-RISK DRINKING

“I strongly recommend that you cut down (or quit) and I’m willing to help.”

Advise and Assist



�Gauge readiness to change drinking habits


“Are you willing to consider making changes in your drinking?”

AT-RISK DRINKING

Advise and Assist


Is the patient ready to commit to change at this time?

NO

Do not be discouraged. Ambivalence is common. Your advice has likely prompted a change in your patient’s thinking. With continued reinforcement, your patient may decide to take action.For now, restate your concern about his or her health.

AT-RISK DRINKING

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Advise and Assist



NO

� Encourage reflection: Ask patients to weigh what they like about drinking versus their reasons for cutting down. What are the major barriers to change?

Reaffirm your willingness to help when he or she is ready. Don’t forget FOLLOW-UP

AT-RISK DRINKING

Advise and Assist



YES

� Help set a goalto cut down to within maximum limits or abstain for a period of time.

Agree on a plan, including—-What specific steps the patient will take-How drinking will be tracked-Who can help

-How to manage high-risk situations

AT-RISK DRINKING

Advise and Assist

� State your conclusion and recommendation clearly.

Example 2 --For patients who meet the criteria for

ALCOHOL USE DISORDERS

• Relate to the patient’s concerns and medical findings, if present.


“I believe that you have an alcohol use disorder. You are drinking more than is medically safe. I’m concerned about your health. I strongly recommend that you quit drinking and I’m willing to help.”


Advise and Assist

� Negotiate a drinking goal:

• Abstaining is the safest course for most patients with AUDs.

• Patients who have milder forms of alcohol abuse or dependence and are unwilling to abstain may be successful at cutting down.

If needed, refer for additional evaluation by Specialized Substance Abuse Services

Consider recommending a mutual help (self-help) group, like AA.For patients with dependence, consider medically managed

withdrawal vs. medications

ALCOHOL USE DISORDERS


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Motivational Interviewing

Motivational Interviewing� Specialized skill set designed to help

patients become ready and motivated to change health-related behaviors

Stages of Change from Transtheoretical Model

PrecontemplationContemplation

Preparation

Action

Maintenance Lapse

Mentality of the Stages

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Motivational Interviewing Principles

� Express empathy� Develop discrepancy� Roll with resistance – patients aren’t “resistant”

(they just aren’t seeing things the way you do!)� Support self-efficacy

MI: Assess Readiness to Change� Readiness Ruler� “On a scale of 0-10, how ready are you to stop

drinking?”� “I would say about a 3”

� “So it sounds like you aren’t too interested right now. But I’m curious why you said ‘3’ rather than ‘0’.” OR “What would it take to move you to a 5?”� “Well, I know I should stop at some point.”

� “Can you say a bit more about why you think that you should stop?”

MI: Enhance Motivation� Listen for “change talk”

� Small verbal cues that the patient has thought about changing/need to change or health consequences of their behavior

� “I was worried there at first, but I don’t really think I have a problem.”

� “I don’t see why everyone is making such a fuss about this. I can handle it.”

MI: Enhance Motivation� When you hear “change talk”, use MI skills

(OARS) to respond� Open-ended questions

� “Why do you think everyone is making such a fuss?”� Affirmations

� “I can see you really care a lot about your health”� Reflections

� “You are really considering whether you should cut down”

� Summary statements: tie together multiple points� “I hear you saying that you don’t drink more than most people but everyone is making a fuss about your drinking”

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MI� Ask Importance/Confidence Questions

� “On a scale of 1-10, how important is it to you to stop drinking (or cut back)? On a scale of 1-10, how confident are you that you can stop drinking (or cut back)?”

� This will help guide your next steps� Ask about pros/cons of the behavior

MI: Negotiating a Plan� Plan should match the patient’s level of

readiness to change� It is concrete, specific and realistic� Patient agrees to it and is able to repeat it back

to you

MI Practice Continuum of Care for Substance Use Disorders

� Self-help (AA, etc)� Outpatient – with or without sober housing

• Intensive outpatient - > 3x/wk• Day treatment• Usually group-based

� Sober Housing (“Halfway House --can be unstaffed)� Residential - brief (< 28 da) or extended, non-medical (“rehab”)� Inpatient hospital for true medical detoxification� Aftercare – usually low intensity 1/wk indiv or group

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PharmacotherapyDecision Making

(Counseling)

Limbic Drive(Pharmacotherapy)From Pettinati, NIH 2006

Addiction Treatment Model: Treating Limbic Drive and Cortical

Thinking Structures

Substances for which Pharmacotherapy

is Available

� Opioids� Alcohol� Tobacco (nicotine

dependence)

� Cocaine� Methamphetamine� Hallucinogens� Cannabis� Solvents/Inhalants

Substances for which Pharmacotherapyis Not Available

Phases of Substance Use as Targets for Pharmacotherapy� Intoxication/overdose� Withdrawal/detoxification� Abstinence initiation/use reduction� Relapse prevention� Sequelae (psychosis, agitation, etc.)

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Alcohol Use Disorder Pharmacotherapy

Two Phases of Alcohol Use Disoder Treatment:� Acute Alcohol Withdrawal� Subacute/Chronic Treatment: Maintenance

medications to reduce use or prevent relapse to alcohol use (FDA approved)

� Disulfiram� Acamprosate� Naltrexone (oral and injectable)

� Minimum trial of 3 months (risk of relapse high 6-12 months)

Alcohol Withdrawal � Most alcohol withdrawal is managed in an inpatient

setting� Meds typically include:

� Benzodiazepines � Anticonvulsants � Adjunctive Medications/supplements

� Avoid outpatient detox; best to refer to specialized programs with close monitoring

� What’s the role of an outpatient provider?� Refer for alcohol detox and ongoing substance abuse treatment

Alcohol Relapse Prevention Meds: Disulfiram (Antabuse)

� Blocks alcohol metabolism (prevents acetaldehyde→acetate); increase in blood acetaldehyde levels

� Antabuse reaction: flushing, weakness, nausea, tachycardia, hypotension (up to 2 weeks later!)

� VA Cooperative Study of Disulfuram in 605 men� No effect on number of patients maintained abstinence� Among non-abstinent, signif fewer drinking days� High rate of non-compliance: 80%� If adherent, more likely to be abstinent

� Works better if given in monitored fashion

Fuller RK, et al. JAMA, 1986;256

Alcohol Relapse Prevention Meds: Disulfiram (Antabuse)

� Pt should avoid alcohol containing foods � Clinical Dose: 250mg daily (range 125-500mg/d)� SE: metallic taste, sulfur-like odor� Rare: hepatotoxicity, neuropathy, psychosis� Check LFTs before, q1mo X 3, then q3 mo

� Contraindications: CAD, hypersen to rubber, varices, renal disease, severe hepatic dysfunction (LFTs> 3x upper level of nl)

� Encourage patient to attend substance abuse treatment where disulfiram could be administered by staff/family

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Alcohol Relapse Prevention Meds: Acamprosate

� Acts on GABA and glutamate neurotransmitter systems� Impact is anti-craving, reduced protracted withdrawal� Dose: 2 g daily (6 pills/day= TWO 333 mg pills three

times/d)� SE: Diarrhea (up to 16%), nausea, itching (up to 4%)� Contraindications: severe renal disease (creat cl < 30

ml/min); dose adjust if CrCl 30-50� Only approved for people who are abstinent

Alcohol Relapse Prevention Meds: Acamprosate

� Recommended length of treatment: 1 year� Effective in reducing relapse to alcohol use in studies

leading to FDA approval� Meta-analysis of European trials: 36% on acamprosate abstinent at 6 months vs. 23% on placebo

� Not effective in Project COMBINE: 1383 patients� Only naltrexone signif increased % days abstinent and time to heavy drinking� More severe dependence in European trials (acamprosate with greater effect in longer h/o dependence)?� Fewer abstinence days required to enter COMBINE

Mann K et al. Alcohol Clin Exp Res, 2004Anton RF et al. JAMA, 2006

Naltrexone for Alcohol Use Disorder� Similar structure to naloxone (Narcan)� Potent inhibitor of Mu opioid receptor binding

� May explain reduction of relapse � Endogenous opioids involved in the reinforcing (pleasure)

effects of alcohol � May explain reduced craving for alcohol

� Endogenous opioids may be involved in craving alcohol� Shown to reduce drinking in those who have cut down but not abstained (28% naltrexone vs. 43% placebo)

Littleton & Zieglgansberger, (2003) Am J Addict 12[Suppl1]:S3-S11

Naltrexone for Alcohol Use Disorder

� Cochrane Review of NTX (based on 50 RCT)�Reduced risk of heavy drinking to 83% of the risk vs. placebo (RR 0.83; CI 0.76-0.90)

�Decreased drinking days by 4%�Not significant for return to any drinking (RR 0.96; CI 0.92-1.00)

� Estimate…helps 1 out of 9…

Srisurapanont & Jarusuraisin (2005) Cochrane Database Syst Rev. 2005 Jan 25;(1):CD001867

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Pharmacotherapy of Alcohol Dependence: Naltrexone

� Oral Naltrexone Hydrochloride� DOSE: 50 mg per day

� Extended-Release Injectable Naltrexone (Vivitrol)� 380mg IM per month� 624 patients 25% decrease in heavy drinking days vs. placebo� More effective if >7 days abstinence

� Too little data to make conclusion if as effective as PO form (Cochrane review 2010)

� Must be opioid-free for 7-10 days before starting

Garbutt et al. JAMA, 2005

Naltrexone Safety

� Can cause hepatocellular injury in very high doses (eg 5-10 times higher than normal)� Contraindicated in acute hepatitis or liver failure� Check liver function before, q1 month for 3 months, then q 3 months

� Caution about NSAIDS� May have additive hepatic effects

Naltrexone Safety� Other contraindications

� Concomitant opioid analgesics� Opioid dependence or withdrawal� Medical conditions requiring opioid analgesics� Pregnancy (Category C)

� Main adverse effects:� Gastrointestinal: ab pain, N/V� Headache� Dizziness

Summary – Alcohol Use Disorder� If abstinent:

� Consider disulfiram as “insurance” (if monitored)� Consider naltrexone for relapse prevention� Can consider acamprosate

� If still drinking� Consider naltrexone

� If on opioids� Consider acamprosate

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Case StudyA 42 year old man with a 14 year history of alcohol dependence relapsed to alcohol abuse 3 months ago. He currently reports drinking 3-5 drinks 4-5 times/wk, but states that he when he abstains for a day or two occasionally he does not experience alcohol withdrawal symptoms. However, his spouse is upset with his drinking and he now wants medication to help him to abstain. He tried naltrexone in the past, but says it ‘didn’t help much.’ He takes no other medications and has no known allergies.What of the following would you recommend?

L i ve r f

u n ct i o n

. . . A c

a mp r o

s a te 6 6

. . .

D i su l f i

r a m 2 5 0

. . .

100%

0%0%

(from E. McCance-Katz, 2010)

A. Liver function testsB. Acamprosate 666 mg three times dailyC. Disulfiram 250 mg/d

Case Study: Answer� A and C:

�This patient has a long and difficult history of alcohol dependence.

�He has failed naltrexone in the past and acamprosate is not likely to be helpful (the Combine Study showed it to be inferior to naltrexone).

�He has significant consequences of his drinking; is motivated to quit;

� If his liver functions indicate that he does not have significant impairment; a trial of disulfiram 250 mg daily might help.

(from E. McCance-Katz, 2010)

Quiz…Which of the following is the most commonly misused class of prescription drugs?

O pi a t e

s

S t im u

l a nt s

B en z o

d i az e p

i n e .. .

73%

25%

3%

A. OpiatesB. StimulantsC. Benzodiazepines

Rates of Prescription Narcotic Abuse

� Prescription Narcotic Abuse Prevalence:� 12th graders:

� 1992: 3.3% 2007: 9.2%� � 179% increase over 15 years

� OxyContin Vicodin� 8th 1.8% 8th 2.7%� 10th 3.9% 10th 7.2%� 12th 5.2% 12th 9.6%

Source: Monitoring the Future, 2007.

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Source Where Pain Relievers Were Obtained for Most Recent Nonmedical Use among Past Year Users Aged 12 or Older: 2006

Bought/Took from Friend/Relative

14.8%

Drug Dealer/Stranger3.9%

Bought on Internet0.1% Other 1

4.9%

Free from Friend/Relative

7.3%Bought/Took fromFriend/Relative

4.9%One

Doctor80.7%

Drug Dealer/Stranger

1.6%Other 12.2%

Source Where Respondent Obtained

Source Where Friend/Relative Obtained

One Doctor19.1%

More than One Doctor

1.6%Free from

Friend/Relative55.7%

More than One Doctor3.3%

Pharmacotherapies for Opiate Dependence� Methadone � Buprenorphine� Naltrexone

Opioid Dependence Maintenance Therapy: Methadone

� Can only be prescribed through a registered “narcotic treatment program”

� Characteristics� Long acting mu agonist � Duration of action: 24-36 h � 30-40 mg will block withdrawal, but not craving � Illicit opiate use decreases with increasing methadone

dose � 80-100 mg is more effective at reducing opioid use than

lower doses (e.g.: 40-50 mg/d) Strain EC, et al. JAMA, 1999

Opioid Dependence Therapy: Methadone

� Agonist therapy� Prevention of Withdrawal Syndrome � Induction of Tolerance

� Who is appropriate for methadone therapy? � > 18 years� Greater than 1 year of opioid dependence � Medical compromise � Infectious disease � Pregnancy* � ECG: methadone prolongs QT in approx 2%(CSAT 2005)

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Opioid Dependence Maintenance Therapy: Methadone

� Can interact with many commonly used medications� Decreased methadone concentrations:

� Pentazocine� Phenytoin� Carbamazepine � Rifampin � Many HIV meds

� Increased methadone concentrations:� Ciprofloxacin� Fluvoxamine� Discontinuation of inducing drug

McCance-Katz et al. 2009

Opioid Dependence Maintenance Therapy: Buprenorphine

� Mu Opioid receptor, high affinity, partial agonist � Binds opioid receptors; slow to dissociate � If recent opioids, may withdraw� OD can’t be reversed with standard dosing of naloxone� Dosing may be daily, every other day or three

times weekly � Average dose 8-16 mg daily � Little effect on respiration or cardiovascular

responses at high doses McNicholas, 2004


� To reduce diversion, combined with naloxone in 4:1 ratio� Cheaper price than buprenorphine alone!

� Occas increase in LFTs� SE: N/V (?if due to withdrawal)� Equivalent to lower dose of methadone in reducing

illicit opioid use (though 80mg methadone better)� Primary care physicians may be providers of this

treatment as well as addiction specialists


� Metabolized by cytochrome P450� Drug Interactions: Atazanavir/ritonavir: increases

buprenorphine concentrations; rifampin: decreases buprenorphine concentrations; opiate withdrawal possible

� Buprenorphine DEA certification required to prescribe (8 hrs of training)� Can treat up to 100 patients

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Opioid Dependence Therapy: Antagonist Treatment (Naltrexone)

� Prevent impulsive use of drug � Relapse rates high (90%) following

detoxification with no medication treatment� Dose (oral): 50 mg daily, 100 mg every 2 days,

150 mg every third day � Side effects: hepatotoxicity, monitor liver function tests every 3 months � Biggest issue is lack of compliance

� Injectable naltrexone not currently approved for opioid dependence, but likely to also be effective

Take Home Points

� Ask, Assist, Advise, Refer: At-risk and substance use disorders common� Three medications FDA-approved for the

maintenance treatment of alcoholism�Disulfiram: for those already abstaining�Naltrexone (oral daily or injectable once monthly): To reduce use in those still drinking�Acamprosate: for those who can’t take Naltrexone

Take Home Points� Three medications FDA-approved for treatment of

opioid dependence�Methadone (must be given through a licensed narcotic treatment program)�Buprenorphine/naloxone (Suboxone) available by prescription from qualified providers)�Naltrexone: an opioid antagonist best for highly motivated patients

Thank You!� Resources

� Local mutual help groups� www.ncadi.samhsa.gov (resources)� www.aa.org

� Substance Abuse Facility Treatment Locator Website� http://findtreatment.samhsa.gov/

� http://www.niaaa.nih.gov/Pages/default.aspx

A Real Case… Substance Use Disorders in Primary Care ...€¦ · Primary Care: Screening, Brief...

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