Substance Use and
Addictive Disorders
A Patient-Centered, Evidence-Based
Diagnostic and Treatment Process1,2,3
A Presentation for SOMC Medical Education
Kendall L. Stewart, MD, MBA, DLFAPA
November 16, 2012
This presentation is designed as a problem-based learning module.
will be amazed by the devastation that substance use will cause in your patients’ lives.
3Some of you and your colleagues will struggle with substance use. When you see it, do the right thing.
1
2You
Why is this important?
• Substance abuse kills and
devastates the living.
• It is a huge problem here in
Portsmouth.
• We still suffer from the
reputation of being the world
leader of oxycodone
prescriptions.
• Substance abuse contributes to
Scioto County’s being
consistently ranked as one of
the most unhealthy counties in
the nation.
• This presentation will provide
a foundation for your efforts to
lend a helping hand.
1
• After listening to this
presentation, you will be able
to answer the following
questions:
– Why is this important?
– What diagnoses are included in
this DSM-5 Category?
– What are some of the
demographics of the substance
use disorders?
– What are some clues to alcohol
abuse?
– What is the CAGE screening
tool?
– What medications are helpful?
– What counseling techniques are
helpful?
– What should you do?1,2
Not surprisingly, these people are often untruthful; their families will call you with the real scoop.
presentation does not address alcohol, tobacco or gambling.
2 This
What diagnoses will likely be
included in this category in DSM-5?1
•
•
•
•
•
•
•
•
•
•
•
•
1
Alcohol-Related Disorders
Caffeine-Related Disorders
Cannabis-Related Disorders
Hallucinogen-Related Disorders
Inhalant-Related Disorders
Opioid-Related Disorders
Sedative/Hypnotic-Related Disorders
Stimulant-Related Disorders
Tobacco-Related Disorders
Unknown Substance Disorders
Gambling Disorder
Review the proposed revisions here.
Further study will be suggested for Caffeine Use Disorder, Internet Use Disorder and Prenatal Alcohol Exposure.
What are the diagnostic criteria?1
• Problematic pattern of substance use causing
significant impairment or distress
–
–
–
–
–
–
–
–
–
–
–
1
These are the proposed DSM-5 criteria.
Substance used in greater amounts and longer than intended
Unsuccessful efforts to cut down usage
A great deal of time consumed by substance-related activities
and complications
A substance-related failure to fulfill obligations at school,
work or home
Continued substance use in spite of the problems it causes
Substance use negatively impacts social, occupational or
recreational activities
Recurrent use when physically hazardous
Continued use in spite of substance-related complications
Tolerance
Withdrawal
Craving
How many people (in millions) use
drugs each year?1
Hallucinogens 1.1
Cocaine 1.9
Prescription Drugs
6.2
Marijuana 15.2
Methamphetamine
0.3
1
Rakel and Rakel, Textbook of Family Medicine
is the huge appeal of marijuana?
2What
What are some of the key
demographics of substance use?1
• About 8% of us abuse illicit drugs each year.
• About 8,000 people try illegal drugs for the
first time each day.
• Illicit drug use varies by race:
–
–
–
–
–
–
–
Mixed races 14.1%
Blacks 10.1%
American Indians 9.5%
Whites 8.2%
Pacific Islanders 7.3%
Hispanics 6.3%
Asians 3.6%
• Educational level:
– High school 8.6%
– College 5.7%
1
Rakel and Rakel, Textbook of Family Medicine
What are some symptoms of
cannabis abuse?1
• Intoxication
–
–
–
–
–
–
–
–
–
Pupil constriction
Conjunctival injection
Headache
Increased breathing
Increased heart rate
Orthostatic hypotension
Ataxia
Increased appetite
Urinary retention
• Treatment
– Supportive care
– Reassurance
1
Rakel and Rakel, Textbook of Family Medicine
• Withdrawal
–
–
–
–
–
–
–
–
Irritability
Insomnia
Restlessness
Anorexia
Vivid dreams
Chills
Nausea
Sweating
• Treatment
– Supportive care
– Reassurance
What are some symptoms of
hallucinogen abuse?1
• Intoxication
–
–
–
–
–
–
–
–
–
–
–
Pupil dilation
Piloerection
Sweating
Increased BP
Increased pulse
Increased reflexes
Tremors
Seizures
Nausea and vomiting
Urinary retention
Impaired temperature
regulation
• Treatment
– Supportive care
– Reassurance
1
Rakel and Rakel, Textbook of Family Medicine
• Withdrawal
– Fatigue
– Irritability
– Inability to experience pleasure
• Treatment
– Supportive care
– Reassurance
What are some symptoms of inhalant
abuse?1
• Intoxication
–
–
–
–
–
–
–
–
–
Horizontal nystagmus
Increased tears and saliva
Pupil dilation
Coma with eyes open
Sweating
Flushing
Absent gag reflex
Apnea
Increased pulse and BP
• Treatment
– Supportive care
– Reassurance
1
Rakel and Rakel, Textbook of Family Medicine
• Withdrawal
–
–
–
–
–
–
–
Depression
Anxiety
Sleepiness
Irritability
Sweating
Tremor
Craving
• Treatment
– Supportive care
– Reassurance
What are some symptoms of opioid
abuse?1,2
• Intoxication
– Miotic pupils
– Euphoria
– Altered level of
consciousness
– Constipation
– Respiratory depression
• Treatment
– Naloxone (Narcan) 0.4 to
0.8 and repeated as needed.
• Withdrawal
–
–
–
–
–
–
–
–
Strong craving
Nausea and vomiting
Body aches
Insomnia
Anxiety
Runny nose
Yawning
Pupil dilation
• Treatment
– Clonidine (Catapres)
– Methadone (Dolophine)
– Buprenorphine (Subutex)
1
Rakel and Rakel, Textbook of Family Medicine
will be able to see which patients are at risk for addiction.
2You
What are some symptoms of sedative
abuse?1
• Intoxication
–
–
–
–
–
–
Slurred speech
Ataxia
Respiratory depression
Stupor
Coma
Death (with mixed OD)
• Treatment
–
–
–
–
1
Respiratory support
GI evacuation
Activated charcoal
Flumazenil (Romazicon) with
caution because of increased
seizures and cardiac
arrhythmias
Rakel and Rakel, Textbook of Family Medicine
• Withdrawal
–
–
–
–
–
–
–
–
–
–
–
–
Tachycardia
Hypertension
Fever
Agitation
Hallucinations
Insomnia
Irritability
Nightmares
Tremor
Anorexia
Seizures
Delirium
• Treatment
– Tapering using long-acting
sedatives
What are some symptoms of
stimulant abuse?1
• Intoxication
–
–
–
–
–
–
–
–
–
Pupil dilation
Headache
Increased respiration
Chest pain
Tremor
Seizures
Myoclonus
Nausea and vomiting
Fever
• Treatment
– Supportive care
– Reassurance
1
Rakel and Rakel, Textbook of Family Medicine
• Withdrawal
–
–
–
–
–
–
–
Depression
Anxiety
Fatigue
Increased appetite
Craving
Increased dreaming
Sleepiness
• Treatment
– Supportive care
– Reassurance
What is the CAGE1 screen for drug
abuse?
• Have you ever felt you should cut
down on your use of drugs?
• Have people annoyed you by
criticizing your use of drugs?
• Have you ever felt bad or guilty
about your use of drugs?
• Have you ever used first thing in the
morning to steady your nerves or to
get rid of a hangover (eye opener)?
• (Any positive answer is a source of
concern.)
1
Ewing JA, Detecting Alcoholism: The CASE Questionnaire. JAMA 1984; 252: 1905-1907.
What counseling techniques may be
helpful in alcohol use disorder?1,2
•
•
•
•
•
1
Cognitive-Behavioral Therapy (CPT)
Contingency Management
Motivational Enhancement Therapy
Therapeutic Communities
Twelve-Step Facilitation
Rakel and Rakel, Textbook of Family Medicine
the power of a “positive” addiction.
2Recognize
What should you do?1
• You must be the change you want to see in
the world. Mahatma Gandhi
• Become a wellness champion and continue
that lifestyle as long as you live.
• If you abuse drugs, stop now; if you cannot,
seek treatment and stick with it.
• Support prevention efforts for kids.
• Ask every new patient about drug use.
• Understand that many users will lie.
• Inquire whether patients who are abusing
drugs are ready to stop—at every visit.
1
Rakel and Rakel, Textbook of Family Medicine
What else should you do?1
• Seize every teachable moment to urge
quitting.
• View this as a chronic disease.
• Remember that relapse is the rule rather
than the exception.
• Focus on what you can do instead of fretting
about what you can’t do.
• Bear in mind that the prognosis is not
hopeless.
• Never, never, ever give up.
1
Rakel and Rakel, Textbook of Family Medicine
The Psychiatric Interview
A Patient-Centered, Evidence-Based Diagnostic and Therapeutic Process
•
•
•
Introduce yourself using AIDET1.
Sit down.
Make me comfortable by asking some
routine demographic questions.
Ask me to list all of problems and concerns.
Using my problem list as a guide, ask me
clarifying questions about my current
illness(es).
Using evidence-based diagnostic criteria,
make accurate preliminary diagnoses.
Ask about my past psychiatric history.
Ask about my family and social histories.
Clarify my pertinent medical history.
Perform an appropriate mental status
examination.
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Review my laboratory data and other
available records.
Tell me what diagnoses you have made.
Reassure me.
Outline your recommended treatment
plan while making sure that I understand.
Repeatedly invite my clarifying questions.
Be patient with me.
Provide me with the appropriate
educational resources.
Invite me to call you with any additional
questions I may have.
Make a follow up appointment.
Communicate with my other physicians.
Acknowledge the patient. Introduce yourself. Inform the patient about the Duration of tests or treatment.
Explain what is going to happen next. Thank your patients for the opportunity to serve them.
1
Where can you learn more?
•
•
•
•
•
•
•
•
•
•
•
American Psychiatric Association, Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition, Text Revision, 2000
Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry, Third Edition,
2008
Stern, et. al., Massachusetts General Hospital Comprehensive Clinical Psychiatry,
2008. You can read this text online here.
Flaherty, AH, and Rost, NS, The Massachusetts Handbook of Neurology, April 2007
Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry Clerkship, Second
Edition, March 2005
Klamen, D, and Pan, P, Psychiatry Pre Test Self-Assessment and Review, Twelfth
Edition, March 20093
Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007
Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain, January
2008
Medina, John, Brain Rules: 12 Principles for Surviving and Thriving at Home, Work
and School, February 2008
Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous Patients,” 2000
Order the Kindle version of the Rakel and Rakel Textbook of Family Medicine here.
Where can you find evidence-based
information about mental disorders?
•
•
•
•
•
•
•
Explore the site maintained by the organization where evidence-based
medicine began at McMaster University here.
Sign up for the Medscape Best Evidence Newsletters in the specialties of your
choice here.
Subscribe to Evidence-Based Mental Health and search a database at the
National Registry of Evidence-Based Programs and Practices maintained by
the Substance Abuse and Mental Health Services Administration here.
Explore a limited but useful database of mental health practices that have
been "blessed" as evidence-based by various academic, administrative and
advocacy groups collected by the Iowa Consortium for Mental Health here.
Download this presentation and related presentations and white papers at
www.KendallLStewartMD.com.
Learn more about Southern Ohio Medical Center and the job opportunities
there at www.SOMC.org.
Review the exceptional medical education training opportunities at Southern
Ohio Medical Center here.
How can you contact me?1
Kendall L. Stewart, M.D.
VPMA and Chief Medical Officer
Southern Ohio Medical Center
Chairman & CEO
The SOMC Medical Care Foundation, Inc.
1805 27th Street
Waller Building
Suite B01
Portsmouth, Ohio 45662
740.356.8153
StewartK@somc.org
KendallLStewartMD@yahoo.com
www.somc.org
www.KendallLStewartMD.com
1Speaking
and consultation fees benefit the SOMC Endowment Fund.
Are there other questions?
Justin Greenlee, DO
Thomas Carter, DO
 Safety  Quality  Service  Relationships  Performance 