Substance Abuse

Chapter 50


Substance Abuse






INDICATIONS





This chapter discusses drugs used to treat abuse of alcohol and other drugs. A brief listing of pharmacologic treatments for opiate dependency is provided. In general, pharmacologic treatment can be especially helpful when used in conjunction with other treatment modalities for patients who are dependent on alcohol or opioids. Primary care often involves use of medications for the treatment of alcohol abuse. Treatment of opioid addiction is now within the scope of primary care by providers who receive additional approved training in the use of buprenorphine.



Therapeutic Overview


Alcohol and drug addictions are chronic bio-psycho-social-spiritual diseases that profoundly affect individuals, their families, and society in general. Alcohol dependence is a serious disease that causes approximately 100,000 deaths per year in the United States. Approximately 8 million people in the United States have an alcohol dependence problem. CDC data suggest that more than 38 million U.S. adults are binge drinkers, with 18- to 34-year-olds and seniors having the highest prevalence, drinking alcohol excessively an average of four times a month. Although not required for diagnosis, tolerance and withdrawal are frequently seen in substance use disorders. Tolerance is a central nervous system adaptation that occurs when a larger dose of alcohol or another drug of abuse is needed to obtain the desired effects. Withdrawal syndromes develop in alcohol- and drug-dependent individuals upon cessation or marked decrease. The physiologic effects of withdrawal symptoms are usually the opposite of those of the abused substance. Denial is seen invariably in individuals with substance use disorders.


Addiction to and misuse of prescription painkillers is a growing problem. A 2011 CDC report revealed that more than 40 people die each day due to overdoses of prescription painkillers such as Vicodin, methadone, Opana, and OxyContin. Deaths from painkiller overdoses have more than tripled in the past decade. The National Survey on Drug Use and Health found that 1 in 20 people aged 12 and older admitted using prescription painkillers for nonmedical reasons in 2010. Another study suggests that more than one in five children prescribed a controlled medication, such as Ritalin, take too much of it or misuse it. These children are more likely than others to abuse other substances and to start giving or selling drugs to their peers.


The U.S. Substance Abuse and Mental Health Services Administration reports a huge increase in the last 10 years in opiate admissions, mostly due to the use of prescription opioids. In response to the soaring demand, more community-based programs offering opioid overdose prevention services have become available in the United States, with the goal of more quickly reversing the potentially fatal respiratory depression caused by overdoses of heroin and other opioids, including prescription analgesics such as oxycodone, hydrocodone, and methadone.


Increasing numbers of newborns suffering drug withdrawal symptoms (or Neonatal Abstinence Syndrome) led the American Academy of Pediatrics to update treatment guidelines and call on hospitals to develop specific drug abuse screening protocols for mothers. Researchers report that in some area of the United States, up to 25% of NICU babies are treated for withdrawal, and the guidelines include how to best treat their pain during that time.



Assessment


All patients should be screened at least annually, both for extent of alcohol and drug use and any related problems. Alcoholics usually understate the amount of alcohol they consume. Addictions are largely the problem of people who begin the addictive behavior before the age of 21. However, individuals who continue to use illegal hard drugs from young adulthood into middle age face an increased risk of dying prematurely fivefold compared with those who do not use drugs.


It is important to assess for use of medications that interact adversely with alcohol, including H2-blockers, aspirin, benzodiazepines, antidepressants, narcotics, barbiturates, antihistamines, NSAIDs, metronidazole, sulfonamides, methyldopa, nitroglycerin, acetaminophen, isoniazid, antihypertensives, antidiabetic agents, warfarin, propranolol, and β-blockers. Also ask about profound drug–drug interactions that may result from alcohol-induced liver impairment and activation of CYP 2E1 metabolism.


Physical examination findings may include alcohol odor on the breath, flushed face, scleral injection, tremor, bruising, or peripheral neuropathy. Injuries from accidents such as falls may be evident. Frequently, people have severe alcohol disorders without apparent physical findings.


Laboratory tests should include CBC and LFTs. Macrocytosis is seen in more than 90% of patients (MCV 100-110 fL). This finding correlates with approximately 80 grams of alcohol consumption per day (e.g., one bottle of wine). The most sensitive laboratory tests for excessive chronic alcohol use included elevated AST and ALT, and especially GGT. When the ratio of AST to ALT becomes greater than 2, alcoholic hepatitis should be strongly suspected. A breath or blood alcohol level can also reveal the level of alcohol intake.



Classification Levels for Alcohol Intake




• Low risk: Less than 1 drink/day for women, 2 drinks/day for men; or 7 drinks/wk for women, 14 drinks/wk for men; or 3 drinks for women and 4 drinks for men on any occasion; 0 CAGE score, no dysfunction related to drinking and not using medications that interact adversely with alcohol.


• Heavy and/or risky drinking: More than 7 drinks/wk, or 3 drinks/occasion for women; for men, 14 drinks/wk or 4 drinks/occasion; score greater than 1 on CAGE, evidence of drinking-related dysfunction, or use of alcohol and medications that might adversely interact with alcohol.


• Abuse: More than one of the following recurring situations: drinking resulting in failure to fulfill major obligations, drinking in hazardous situations, alcohol-related legal problems, continued drinking despite persistent problems caused or worsened by alcohol.


• Dependence: The “3 C’s” can identify dependence: compulsive use, continuing use despite negative consequences, and lack of control. DSM-IV criteria require three or more of the following features: tolerance, withdrawal, drinking more than intended, persistent desire to drink or unsuccessful efforts to cut down or control drinking, increased time spent in activities related to alcohol, giving up important activities because of drinking, or drinking despite knowledge of problems caused or worsened by alcohol.




Mechanism of Action and Effects of Alcohol Treatment


For alcohol withdrawal treatment, benzodiazepines demonstrate cross-tolerance with alcohol via GABA receptors. Long-acting benzodiazepines, such as diazepam or chlordiazepoxide, generally are preferred to minimize the occurrence of breakthrough agitation and seizures. Short-acting drugs such as lorazepam and oxazepam are used in patients with severe liver disease.


Naltrexone is an opioid antagonist with highest affinity for the mu opioid receptor. Occupation of opioid receptors by naltrexone may block the effects of endogenous opioid peptides. The neurobiologic mechanisms responsible for the reduction in alcohol consumption observed in alcohol-dependent patients treated with naltrexone are not entirely understood. However, involvement of the endogenous



TABLE 50-1


Screening and Assessment Tools for Alcohol Use Disorders

























Alcohol Assessment Tools Alcohol Intake Equivalents∗ Interpretation and Comments
∗Quantity-frequency question: Do you sometimes drink alcoholic beverages?
If positive, next screen with the CAGE, RAPS4-QF, or Audit questionnaire.
CAGE questions are as follows:
C = Pt felt need to Cut down on drinking?
A = People Annoyed you by criticizing your drinking?
G = Felt Guilt about drinking?
E = Need an Eye-opener in the morning?

Scoring:
Positive if respond positive to 2 of these questions


 To distinguish those with alcoholism from those without; does not differentiate dependence from abuse
RAPS4-QF
R = Do you use alcohol/drugs at Regular times?
A = Use alcohol/drugs Alone, or with friends or family?
P = Problems due to alcohol/drugs?
S = Has alcohol/drug ever made you feel Sick?
4 = Have you had more than 4/5 drinks in one setting? More often than once a month?		 Scoring:
Positive if answers yes to questions; greater sensitivity and specificity over CAGE for all gender, ethnic, and service utilization groups in ERs		 Eliminates many cultural terms that do not translate to other ethnic groups, such as “eye-opener”; concept of guilt, social surroundings addressed
AUDIT: 10-question bilingual written screen that can be filled out by patient Scoring:
Positive: 8 for men up to 60;
4 for women, adolescents, or men >60		 Variable cutoff scores distinguish between harmful use, hazardous use, and dependence
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Jul 22, 2016 | Posted by in PHARMACY | Comments Off on Substance Abuse

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