Drug Abuse and the Dialysis
Patient
What are some common
misconceptions about Drug and
Alcohol Addiction

Addiction is an issue of willpower.

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If a person had more self control they could
stop using!
Addiction is a moral failing.

He or she is a bad person. They care more
about drugs then they do about their family!!

Drug addiction is problem of poverty and
lower class people.
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Addiction is when someone can no longer
hold down a full time job.

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Of course he uses drugs he grew up poor and
…….
He can’t be an addict he goes to work
everyday and provides for his family.
Culture

It is ok that she abuses “XYZ” it is part of her
culture!

Addiction is not a disease.


Cancer is a disease! Smoking crack is a
choice!
They don’t use enough to be an addict.

You have to use drugs or alcohol every day to
be an addict.
Who considers addiction to be a
disease?

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World Health Organization
American Medical Association
American Psychiatric Association
American Medical Association
Etc. etc.
But how is that?
Addiction is a Primary Disease
1.
It is Chronic

2.
It is Progressive

3.
If left untreated it will get worse.
It is Primary

4.
Can not be cured, requires ongoing treatment.
It has no other root cause.
It is characterized by relapse

Just like cancer comes back, addicts relapse to
their drug of choice.
Addiction is a Primary Disease
If left untreated addiction will result in death.
5.

Lenny Bruce
Janis Joplin
Jimmy Hendrix
Mamma Cass
Tommy Dorsey
John Entwistle
Chris Farley
John Belushi
Judy Garland
Margaux Hemingway
Marilyn Monroe
Jim Morrison
Gram Parsons
River Phoenix
Ike Turner
Sid Vicious
Understanding addiction and drug
abuse as a disease allows:
1.
2.
3.
Patients to seek treatment in medical
facilities.
To see treatment as their responsibility.
To remove addiction from the world of
blame and shame to a place where it is a
treatable and a manageable chronic
illness.
“Drugs” fall into two categories:

Street Drugs
And

Prescription Drugs
Street Drugs

Narcotics

Opiates

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Heroin and Opium
(legal versions are Codeine, Demerol, Methadone, Morphine,
Darvon)
They can be injected, snorted, smoked or swallowed.
They produce a rush of Euphoria.
They are characterized by an increased tolerance and
physical dependence.
Street Drugs

Cocaine

Crack - Freebase

Can be injected, snorted, smoked or swallowed.

Produces a rush of euphoria.

Characterized by an increased tolerance and
physical dependence.
Street Drugs

Hallucinogens – Psychedelic Drugs


LSD, PCP, (Ecstasy)
Can be injected, snorted or swallowed or
absorbed through membrane.

Produces enhanced sensations and hallucinations.

Can cause psychosis.
Street Drugs

Amphetamines - Methamphetamines



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Crank, Tina
(Legal Versions Ritalin, Cylert, Adderol)
Can be injected, snorted, smoked or swallowed.
Used by the Nazis in WWII. Hitler received up to 3
injections a day at the end of the war.
Produces powerful stimulant affect and feeling of euphoria.
People can stay up several days and become highly sexual.
Risk of sexually transmitted diseases.
Street Drugs


Amphetamines are a huge problem
because they can be “cooked” up in a
home lab from ingredients easily
obtainable such as cold medication.
These labs are highly flammable and
render the home they were in
permanently toxic!
Street Drugs

Marijuana / Cannabis



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Creates a relaxed and elevated mood.
Can produce an altered state of consciousness.
Can become addictive physically, but more
importantly “emotionally addictive.”
Modern forms of Marijuana are profoundly
more powerful then the 1960’s plant.
Street Drugs

Alcohol
Think of it as a drug in liquid form!
 The only difference is that it is a socially acceptable
drug.
 Drugs go through popularity shifts, prohibition, medical
marijuana.

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Causes Intoxication, Euphoria and a lowering of inhibition.
Characterized by tolerance and withdraw.
Is actually one of the most toxic and damaging of all
substances that people use.
Prescription Drugs
All of the drugs we just looked at can have
medical purposes and can appear in
prescription form.

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Opiates: Codeine, Morphine, Oxycodone
Cocaine: Used medically for some nasal operations
largely replaced by benzocaine, proparacaine, lidocaine
etc.
Amphetamines: Ritalin, Aderol
Marijuana: Medical Use, Synthetic Versions Dronabinol
Marinol.
Benzodiazepines: Enhance the sedative effects of the
neurotransmitter Gamma-Amino Butyric Acid GABA.
Prone to cause dependence with prolonged use.
Valium, Xanax, Klonopin. Can have up to a year long
withdraw.
In the 1970’s Valium was the most prescribed drug in
the US topped in 1986 by Xanax.
How to Identify Signs of Drug
Abuse in your Patients.

Ask them if they use drugs in initial
interviews.

This is rarely effective. Rarely admit to
drinking let alone street drugs, but some will.
IF THE PATIENT DOES NOT ADMIT TO DRUG
USE BUT YOU SUSPECT IT WHAT DO YOU
DO?
Look for Clues
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Does the patient look lethargic but their
blood pressure and pulse are elevated.
Patient gets on the machine and
consistently asks to go to the bathroom
about an hour or so into treatment.
Patient’s behavior seems strange and or
erratic.
You see the patient taking pills.
Evidence of drug paraphernalia.
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Concern from patient or family.
Unexplained patient wasting, dirty clothes,
poor nutrition.
Misses treatments on the check day!
Misses treatments on binge days.
What is the difference between
Drug Abuse and Drug Addiction?
They are often used interchangeably but there
is a slight difference.
Drug Abuse

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Is an increased use and a desire of a substance
to the exclusion of other activities.
Some people can abuse a substance without
becoming addicted.
A person can also go through a period of
substance use without becoming dependent
(college students……).
Still can have huge consequences, drunk driving,
lost of job etc.
Drug Addiction/Dependence

Body has a physical need for a particular
substance.
It is important to note that being physically
addicted to a substance is not the indicator of a
serious problem. Getting drunk twice a month
and abusing your spouse and losing your job
means that you probably have a serious
substance abuse problem even though you may
not be “physically addicted.”
The ultimate Question


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“Do you continue to use a substance despite
repeat negative consequences in your life.”
A person who continues to use cocaine despite
problems at work and a separation from their
spouse.
The woman who still smokes marijuana despite
the fact that her children may be taken from her
if she tests positive for drug use.
Acceptance

In the long run the patient will have to self
identify, accept or diagnose themselves as
having a substance abuse problem in
order to become and maintain sobriety.
Addiction and Pain
Control/Management

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Drug addiction can start out “innocently.”
Patient will be resistant to seeing
increasing dependence as a problem.
May honestly believe that their excessive
use of pain killers is justified since they
still have pain.
May shop from doctor to doctor even
within a medical group.
Pain Management Issues


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Refer patient to pain management.
Explore alternatives.
Check patient records for previous
referrals.
Communication is key.
Where can you go for help

I may be biased but….
Speak to the social worker. They probably
have a closer relationship to the patient
then the psychiatrist and may, through
that relationship, be able to get the
patient to admit to drug use. Also social
workers have usually dealt with substance
abusers before.
Patient Interventions

Long-term Inpatient treatment

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Usually 28 day programs-longer if possible.
Pros: Intensive, year of therapy in one month.
Away from all temptation.
Wide range of specialties with focused
treatment.
Cons: Extremely expensive $30-40,000.
Insurance unlikely to cover.
Patient Interventions

Outpatient treatment


Usually once or several times per week.
Pros: Same outcome as inpatient treatment.
May work better with a more motivated and
functional patient.
Real world coping skills: passing the drug dealer
on the corner on the way to group.
Affordable and may be covered by insurance.
Cons:
Patient is still in original “triggering”
environment. Takes longer…
Patient Interventions

12 Step Meetings: NA AA DA etc.
Pros:
They are everywhere and are free..
Gives the patient opportunity to develop a sober
network of friends and peers in their
community.
Real world coping skills.
Long success record for motivated individuals.
Cons:
Not professionally run.
Quality of the meeting depends on those
running it.
Patient Interventions

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Religion
Some individuals stop drug abuse through
a religious experience or realization.
Medications
Antabuse, Cocaine Vaccine
Patient Interventions

Some patients will just stop, age out of
addictive behaviors or after traumatic event
such as a death of a loved one.
Ethical Issues

The impaired professional:

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Drug abuse is a significant problem for medical
professionals.
A 1984 Study by McAuliffe and Rohman showed that
59 percent of physicians and medical students who
responded to their study reported having used a
psychoactive drug at some time in their life.
An impaired professional may be reluctant to identify
drug use in a patient.
May know the individual from “the street”.
Ethical Issues

What is our responsibility to the patient?

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Are we the police officer.
Are we supposed to stop recreational use.
What if the patient is a functional addict.
Conflicting information: A study by the American
Society of Transplantation stated that substance
abuse by renal transplant recipients does not
significantly affect graft and patient outcomes.
(Schieszer, 2010)
“I don’t want to report she will lose her kids…”
“Who cares, they have smoked crack for years I don’t
want to fill out one more form or deal with that crazy
social worker!”
Let Review our earlier ideas about
addiction and drug abuse

Addiction is an issue of willpower


Addicts have a disease that they can not
overcome. Willpower alone is not enough.
Addiction is a moral failing

Addiction happens to moral and immoral
people. Strong courageous people have had
substance abuse problems that they could not
overcome on their own.

Drug addiction is problem of poverty and
lower class people.


Addiction is when someone can no longer
hold down a full time job.


Drug addiction affects all levels of society rich
and poor.
Many “functional” addicts maintain
employment and hide their addictions.
Culture

A culture may be more permissive of a
substance use, but abuse and dependence
does not change

Addiction is not a disease


Addiction is a disease since it is Chronic,
Progressive, Primary, Characterized by relapse
and if left untreated will result in death.
They don’t use enough to be an addict.

You do not have to use drugs or alcohol every
day to be an addict.
Questions?
Case Study

Mr. Jones
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54 years old with a rumored but undocumented
history of Heroin use.
Misses treatments on the 1st and 15th or each month.
Dry weight continues to go down.
Patient looks unkempt and complains that he does
not have enough food.
Denies any drug use at all.
Doctor is unconcerned about his drug use since “he
has been that way since he came here 3 years ago.”
What do you do?
Case Study
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You could:
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Consult the social worker/refer to psychiatry.
Ask the patient if you can speak to their family.
Explain to the patient why you are concerned and
what you are worried about.
Explain that your motivation is preserving health –
You are not the police.
If they admit to drug use ask them if they see it as a
problem or if they want to stop.
Case Study

Ms. Annoying
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43 years old complains of constant back problems.
Comes to each treatment with her adult son.
Arrives on a stretcher because she has “back pain.”
Your coworkers have see her walking on the streets of Paterson
in the middle of the night.
3-4 monthly emergency room visits for pain.
Hospitalized for severe constipation.
Has hit all three doctors in group for Vicodin and is angry when
she only got Percocet.
Wild and angry reactions to not getting her way or to being
confronted by her behavior.
What do you do?
Case Study
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You could:
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Consult the social worker/refer to psychiatry.
Communicate with all caregivers and alert
them of potential drug seeking behaviors.
Establish consistent and appropriate
expectation of behaviors from the patient.
Basically shut off or make it more difficult for
patient to manipulate the system and obtain
drugs.
Copyright Peter Staller LSW 2010