Screening and Treatment for
Substance Use Disorders
Joseph Sakai, MD Associate Professor
Division of Substance Dependence Dept of Psychiatry
UCD SOM
Learning Objectives:
Q Describe the epidemiology of substance use
disorders
Q Know approaches to screening and diagnosis of
substance use disorders
Q Know basic elements of motivational interviewing
and brief interventions
Q Know available pharmacological treatments for
alcohol and nicotine dependence
Statement of problem:
Common in general population
Hasin, D. S. et al. Arch Gen Psychiatry 2007;64:830-842. Compton, W. M. et al. Arch Gen Psychiatry 2007;64:566-576
Alcohol
abuse
Alcohol
dependence
Drug
abuse
Drug
dependence
Lifetime 17.8%
12.5%
7.7%
2.6%
12-month 4.7%
3.8%
1.4%
0.6%
Statement of problem:
↑ common in general medical settings such as ER
and primary care
Actual causes of death in 2000:
#1 Tobacco (435,000 deaths per year)
#3 Alcohol (85,000 deaths per year)
#9 Illicit drugs (17,000 deaths per year)
Cherpitel & Ye, Drug & Alcohol Dependence 2008; 97:226-230. Mokdad et al. JAMA 2004; 291:1238-45.
Screening?
Physicians generally – poor job of screening Survey of FP’s (n=648)
90% failed dx substance abuse when presented with early symptoms of alcohol abuse in an adult patient
Another study in primary care practices – patients with alcohol dependence received assessment and referral to treatment only 10% of the time
Only about 3% of those with alcohol use disorder in past 12-months report that they had received help from a physician or other health care professional
National Center on Addiction and Substance Abuse, 2000 McGlynn et al. NEJM 2003; 348:2635-2645 Hasin, D. S. et al. Arch Gen Psychiatry 2007;64:830-842
Screening:
Q Single question about illicit drug use – some use past 30 days, others longer periods (any use considered a positive)
Q Single question – alcohol use
– “How many times in the past year have you had 4/5 or more drinks in a day?” (4 for women and 5 for men, ≥1 time is considered positive)
88% sensitivity and 67% specificity for current alcohol use disorder in primary care setting.
Approaches to screening – many options to choose from: Q MAST – Michigan Alcoholism Screening Test Q CAGE Questionnaire
Q Substance Abuse Subtle Screening Inventory (SASSI) Q TWEAK
Q Self Administered Alcoholism Screening Test (SAAST) Q AUDIT – Alcohol Use Disorder Identification Test
Screening:
AUDITQ No copyright fee
Q Add responses with score ≥ 8 (males) indicating further evaluation (lower
cut-off ↑ sensitivity at cost of specificity) Q http://www.who.int/ substance_abuse/activities/sbi/ en/ Q http://whqlibdoc.who.int/hq/ 2001/ WHO_MSD_MSB_01.6a.pdf
Adapted from Reinert & Allen. Alcoholism: Clinical & Experimental Research 26:272, 2002
Screening:
Computer, self report, interview Non-threatening, non judgmental
Explain purpose of screening (i.e. medical context and concern about patient’s well being)
Assurance of confidentiality Defining a standard drink Who do you screen?
Screening:
Screening Assessment Education re-screen annuallyScreening/Assessment
Q
“At-risk drinking”
–
Men
≥ 5 standard drinks in a day
or > 14 per week
– Women
≥ 4 in a day
or > 7 per week
↑ risk for alcohol related problems
Screening:
Screening Assessment “at-risk” drinking Education Brief re-screen Intervention annuallyBrief Intervention
1. Discuss finding
2. Assess ““how ready to change?”” and ““how able?””
Perceived positives and negatives of continued use
Stages of change:
Pre-contemplation – “ignorance is bliss” Contemplation – “sitting on the fence” Preparation – “testing the waters” Action – “practicing new behaviors”
Maintenance – “commitment to sustain behavior”
Feedback Responsibility Advice Menu of options Empathy Self efficacy
Brief Intervention
“At risk drinking”
Ready to commit to a change?
No Yes
- Restate concern - Set goal - Encourage reflection - Plan
- Reaffirm willingness to help - Educational
materials
Brief Intervention
Brief interventions:
Unsafe drinking levels (n=774)
Two 10-15 minute educational sessions Two nurse telephone contacts
Control group booklet on general health issues Efficacy:
40% in the intervention group reduced drinking to safe levels – benefit persisted at four year follow up
Positive results also emerging for illicit drug use
Fleming et al., 1997 Vinson, 2003 Madras et al., Drug and Alcohol Dependence; 2009:280-295
Screening:
Screening Assessment
“at-risk” Substance abuse drinking or dependence Education Brief Treatment
re-screen Intervention Referral (w/d risk) annually Possible medication
Screening/Assessment:
Q
Substance Abuse
–
Never met criteria for dependence
– 1/4 in 12 month period
Q Role failures Q Hazardous use Q Legal problems
Screening/Assessment:
Q
Substance Dependence
– 3/7 in 12 month period
Q Tolerance Q Withdrawal
Q More than intended Q Cut down
Q Time spent using Q Limit activities
Q Use despite consequences
Physiologic dependence diminished control
Screening:
Screening Assessment“at-risk” Substance abuse drinking or dependence Education Brief Treatment
re-screen Intervention Referral (w/d risk) annually Possible medication
Substances of Abuse:
Q
Alcohol
Multiple (GABA)
Q
Nicotine
Nicotinic
Q
Opioids
Opioid (i.e.
µ)
Q Cocaine
dopamine (t)
Q Amphetamines
dopamine (t)
Q Sedative-hypnotics
GABA
Q THC
Cannabinoid
Q PCP
NMDA
Q Hallucinogens
Multiple
Q Inhalants
Multiple (NMDA)
Alcohol:
Medications - FDA approved
Q
Disulfiram
Q
Naltrexone
Q
Acamprosate
Alcohol:
Medications - FDA approved
Q
Disulfiram
Q
Naltrexone
Q
Acamprosate
Disulfiram:
How does it work?
Alcohol
Acetaldehyde
ADH
ALDH
(alcohol
(aldehyde
dehydrogenase)
dehydrogenase)
Disulfiram :
Q
Disulfiram reaction
– Flushing
– Headache
–
Nausea
–
Dizziness
–
Tachycardia
Disulfiram :
Q Br J Psych study
– Open label (informant blinded)
– Supervised
– N=126 – 6 month – Outcome
Q Increased total abstinent days Q Decreased amount consumed
Q GGT ↓21 disulfiram group vs. ↑13 in placebo group
Disulfiram :
Q
Dosage and Administration
– Breath zero
– Load 500mg PO QD for 5 days
–
250mg PO QD or 500mg M-W-F
–
Some patients require higher doses to have
disulfiram reaction
– Supervised administration recommended
(spouse, clinic, or some arrangement)
Disulfiram :
Q Side effects/complications:
Metallic taste Headaches Drowsiness or fatigue Optic neuritis Peripheral neuropathy Hepatitis RashDisulfiram :
Q Interactions:
Alcohol Disulfiram rxn Metronidazole Psychosis/confusion Amitriptyline Psychosis/confusion Phenytoin Phenytoin toxicity Diazepam Sedation
Perphenazine Breakthrough
Isoniazid Nausea/lethargy/ataxia
Addiction Treatment, Avoiding Pitfalls, GAP Report 142: p 82
Disulfiram :
Q Some Contraindications
– Risk for MI – Risk for CVA
– Cognitive dysfunction (can’t understand or remember what will happen if drinks)
– Pregnancy/breast feeding safety unknown
Alcohol:
Medications
Q
Disulfiram
Q
Naltrexone
Q
Acamprosate
Naltrexone:
Q
Pure opioid antagonist
Q
Blocks µ opioid receptors
Naltrexone:
Q Why might it work?
– µ agonists ↑ dopamine release in Nucleus Accumbens – µ agonists ↑drinking in rats
– Opioid antagonists reduce alcohol consumption in rats – Alcohol dependent people may have low baseline
beta-endorphin levels (stress response)
– Alcohol consumption ↑endorphin in those with family history of alcoholism
– Naltrexone blocks euphoria from alcohol
Naltrexone:
Study 1
Study 2
12 wk
12 wk
N=70 veterans
N=97
Delayed 1
stdrink
Replicated findings
Decreased relapse
Decreased craving
Naltrexone:
Q Naltrexone injectable (Vivitrol) Q 380mg IM Q month
Q Multi-center trial
– Fewer drinking days – Greater abstinence rates – Time to first drink
Q Another Multi-center trial
– 25% ↓ heavy drinking days (380mg)
Q One disadvantage is cost (i.e. ~$900/month)
Kranzler et al., 2004; JAMA 293:1617-1625
Naltrexone:
Q
Dosage and Administration
–
50mg PO QD
–
Doses of 25-100mg also studied
–
380mg IM Q month
Naltrexone:
Some side effects/complications:
–
Nausea (10%)
–
Headaches (7%)
–
Anxiety (2%)
–
Sedation (2%)
–
Hepatic failure (rare)
Naltrexone:
Some Contraindications:
Q
Hepatic failure/acute hepatitis
Q
At risk for opioid withdrawal
Q
Hypersensitivity to naltrexone
Q
Pregnancy category C
Naltrexone:
Interactions:
– ↓Benefit from opioid analgesics
– ↓Benefit from some antidiarrheal
– ↓Benefit from opioid containing cough
medicines
Alcohol:
Medications
Q
Disulfiram
Q
Naltrexone
Q
Acamprosate
Acamprosate:
Q
Structurally resembles GABA
Q
Enhances GABA transmission
Q
Interferes with Glutamate transmission
Q
Reduces CNS hyperexcitability
Acamprosate:
Q
3 trials: more likely to maintain abstinence
Q
1 trial: dependent on multiple substances –
no improvement over placebo
Q
Meta-analyses: about 1.9 times more likely
to remain abstinent and improves days of
cumulative abstinence
Nicotine Dependence:
Medications:
Q
Bupropion
Q
Nicotine replacement
Q
Varenicline
Nicotine Dependence:
Bupropion (Wellbutrin/Zyban):
Q
SR (BID), and XL preparations (QD)
Q
Start 150mg PO QD, target dose 150 mg PO
BID
Q
Doubles quit rates
Q
Better outcomes when combined with
psychosocial treatments
Q
Contraindicated: hx seizure disorder, MAO
inhibitor, eating disorder
Nicotine Dependence:
Nicotine replacement:
Nicotine content per cigarette varies (by brand,
behavior of smoker and physiology)
General approximate is 1mg nicotine per
cigarette
General approximate for 1 pack per day is about
20mg of nicotine
Nicotine Dependence:
Gum 1 piece 2 mg (4 mg if tx failure) Q 1-2 hours
(max 30 per day of 2 mg gum)
– No food or drink 15 min before
– Problem include TMJ, hiccups, dyspepsia, difficult with dentures
– Avoid if 1 month post MI, serious arrhythmias, gastric ulcers
Patch : High dose (21 mg) 6-8 weeks, medium dose
(14 mg) 2-4 weeks, low dose (7 mg) 2-4 weeks
– Skin irritation (avoid if systemic eczema), slow delivery, wearing at night may cause sleep problems – Same cardiovascular warnings
Nicotine Dependence:
Varenicline (Chantix):
Q
FDA-approved 2006
Q
Partial agonist α
4β
2nicotinic acetylcholine
receptor
Q
~Quadruples quit rates
Q
?Mood changes, suicidality?
Dealing with Ambivalence:
Patients may be more open to changing than
you expect, but…
Motivational Interviewing:
O pen ended questions A ffirmations
R eflective listening S ummarizing
Miller et al. Alcohol Alcohol. 2006; 41:306-310 Williams et al. Ann Fam Med. 2006; 4:213-220
Dealing with Ambivalence:
Motivational Interviewing:
Strategies
Express empathy
Roll with resistance
Develop discrepancies
Support self-efficacy
Dealing with Ambivalence:
Motivational Interviewing:
Withdrawal Wife left
Social Bad health
Dealing with Ambivalence:
Motivational Interviewing:
Strategies
Express empathy
Roll with resistance
Develop discrepancies
Support self-efficacy
Dealing with Ambivalence:
Motivational Interviewing:
Eliciting self-motivating statements
“On a scale of 1 to 10 how ready are you to stop?” “I’m not ready. Maybe I’m a 2.”
Responses
A) “Look at all your problems. I can’t believe it’s not a 10.”
B) “Good. How can we make you a 3?” C) “Good. Why aren’t you a 1?”
