Course 2: Beyond SBIRT


Introduction

Okay, so you learned what SBIRT—screening, brief intervention, and referral to treatment—is all about, and you may have already given it a shot in practice.

questions

But, you may have more questions about treatment options for those you identify or the discussion about abusable prescription medications may have piqued your interest about what you might do to prevent patients from developing misuse and abuse issues with the medications you yourself prescribe. If it didn’t pique your interest, it should have!

  • Are there things you can do to reduce the likelihood that the medications the prescriptions you write will lead to substance misuse problems for your patients?
  • Can you pick up on any such issues as early as possible?
  • How about treatment options? Do you know how detox works, or what medications might reduce cravings and/or relapse?
  • Finally, have you thought about ways you can, and should, support your patients on an ongoing basis, during and after outpatient services, to increase their chances for initial and continuing success?

Well, that’s what this course is all about…


Chronic Diseases

We are trained in healthcare to treat many chronic diseases that commonly come our way.

Diabetes and hypertension, for example, are two of the diseases we recognize that can be screened for, treated through behavior modifications and medications, and managed to prevent the development of disease-related complication.

Are we missing some very common chronic diseases?We recognize the importance of identifying and managing these diseases to improve quality of life and prevent morbidity and premature mortality. We recognize that preventing complications may also benefit society at large in terms of preventing lost productivity and decreasing healthcare costs.

We have plenty of evidence-based guidelines that help us prevent exacerbations or complications of chronic diseases.

But what if there was a group of diseases just as prevalent as diabetes or hypertension and whose multimodal treatment was similar in efficacy, that was often being overlooked by general internists (who are superbly trained to care for a variety of chronic diseases)?

Are we missing chronic diseases right in front of us?

 


Overlooked Chronic Diseases: Alcohol and Substance Use

Consider the case of alcohol and substance abuse taken as a group of disorders.

drug & alcohol abuseLet’s compare these disorders to a well-recognized chronic disease such as hypertension. Substance abuse, like hypertension:

  • has been shown to have a strong genetic heritability
  • can be affected by behavior modification as well as diet
  • can follow a course marked by exacerbation followed by periods of stability.

Both disorders can be associated with relapse, or exacerbation. For example, about 50% to 70% of adult patients with hypertension experience a worsening of their blood pressure or other disease-related signs or symptoms each year that requires additional medical intervention to reestablish control.

Substance use and abuse isn’t just about the substance, its about whole health.


Comparing Substance Use to Other Chronic Diseases

“But substance use and abuse treatment doesn’t always work.
Patients don’t stick to it…”

That can be true, but that’s not a good reason to not try…

typical adherence rates

The numbers comparing treatment adherence between substance abuse and other chronic diseases are also enlightening.

  • Drug and dietary adherence rates in patients with hypertension are reported at less than 40% and less than 30%, respectively.
  • Follow-up studies of patients with alcohol dependence typically show approximately 40% to 60% of patients are continuously abstinent after discharge from inpatient treatment, and about 15% to 30% have not resumed dependent use during the year after discharge.

Are you surprised that treatment of alcohol abuse is roughly as successful as control of hypertension? Are you convinced that hypertension treatment is worthwhile, but not sure about substance abuse? Why?

Just because adherence to a treatment regimen may be challenging, does not mean it isn’t worthwhile. At a minimum, using the numbers above, you might help 40-60% of patients.


Missed Opportunities=Poorer Patient Outcomes!

There are many pitfalls that can occur when we fail to recognize and treat substance abuse disorders as a chronic disease.

health history form

1. Substance Use/Abuse and General Health.

So many diseases that you treat everyday can be caused or significantly affected by substance use disorders.

Consider, for example, the effect of alcohol or cocaine use on hypertension or heart failure. Think about the mood-altering effect of chronic substance use: alcohol and depression, methamphetamine and anxiousness, cocaine and mood lability.

treatment2. Scattershot Substance Use Treatment

Patients frequently miss out on effective therapy for their specific “stage” or severity of substance use.

By treating substance use as an acute, episodic illness, you could apply the same one-size-fits-all approach to the management of abuse disorders. Just as you consider the A1c before you choose a diabetes treatment, you should determine the severity of the abuse and choose the next therapeutic step that fits the clinical picture. And just like glycemic control, the severity can change over time and monitoring is necessary.

3. Perpetuating a Problematic Perspective

If you don’t see it as a chronic disease, do you expect your patients to?

patient consultation

By discussing ongoing use, abstinence, treatment and recovery with patients can serve many purposes. The first is educational. Just as you have learned to give feedback to patients about their substance use, you can also educate them about the need for monitoring and the chronic, neuro-biologic basis of their illness. By discussing their substance use with your patients, however briefly, at follow-up visits, you can also go a long way to destigmatizing the illness and giving them an outlet to talk openly about their use. And that gets you both closer to finding the best therapy for them over time.

Will you avoid these pitfalls in your practice, or perpetuate the problem?

 


What is Detox?

Sometimes when people use and abuse substances intensely or for long periods of time, they can build up a tolerance to these substances.

patientIn fact, not only do they build up a tolerance but their bodies can become reliant on those substances in order to function, so even though the substance(s) may be harmful to them, the body develops a physical need for them. This is physiological dependence. If the substance is removed, or withdrawn, the physiological dependence leads to a condition known as withdrawal.

Withdrawal symptoms can vary from mild to life threatening.

Detoxificiation, or detox, is the process of the body removing and eliminating the toxic, or harmful, substance. Detox is also used to refer to the process by which we as healthcare providers supervise a treatment program designed to support our patients through this process of detoxification.

Detox is, therefore, how we help our patients get through getting rid of substances to which they have become addicted.

You may never be involved in the actual oversight of alcohol or opiate detoxification, but it may be helpful to understand the process for a number of reasons. Treatment for substance dependence often begins (but certainly doesn’t end) with detoxification. It may be done as an inpatient or outpatient process and the most likely substances involved are opiods and alcohol.


Opioid Detox

The general goal of opioid detoxification is to transition the patient off the opioid humanely, without causing the intense symptoms of stopping the drugs abruptly.

Though not life-threatening, narcotic withdrawal syndrome is very unpleasant and is one of the reasons that addicts seek their drug. The symptoms are basically the reverse of the drug effects: instead of pupillary constriction, the pupils dilate The patient experiences goose flesh (hence the term “going cold turkey”). The constipation of narcotic use is replaced with diarrhea, and the analgesia of narcotis is replaced by diffuse aches and pains.

Opioid Detox, General Approaches

Opioid detoxification can be achieved in either the inpatient or outpatient setting. If inpatient, this is usually achieved over 3 to 10 days. The patient is assessed which includes a full history and physical exam and a treatment plan is devised that fits the patient’s needs, wishes, co-morbidities, and insurance status. If a patient arrives to a clinic or hospital exhibiting symptoms or signs of opioid withdrawal, other causes are ruled out by a careful history, physical examination and targeted laboratory tests.

The general approach to opioid withdrawal is to replace the opiate drug of abuse (heroin, prescription narcotics) with another opiate in a controlled manner in order to halt or minimize symptoms. This replacement opiate will be weaned over time. This varies from patient to patient. Some patients are kept on the opioid agonist (such as methadone or buprenorphine) while they continue non-pharmacologic therapy for prevention of relapse. Other patients are weaned over 7-10 days and the remaining symptoms of withdrawal are managed with non-opioid medications such as those listed in the table above.

Inpatient Pharmacotherapy

Insurance does not typically pay for inpatient opioid detox because it is not life threatening. However, when patients have complicating factors likely medical or psychiatric conditions that will or can destabilize with withdrawal they may warrant inpatient detox. Though opiate withdrawal is generally considered less likely to produce severe morbidity or mortality compared with barbiturates, benzodiazepines, or alcohol, many patients and physicians prefer to utilize medications to manage the symptoms of withdrawal in hopes of improving overall chances of longterm abstinence. The most common symptoms of opioid withdrawal include dysphoria, restlessness, rhinorrhea, lacrimation, myalgias, arthralgias, nausea, vomiting and diarrhea. These symptoms and signs can begin 6 to 12 hours after the last dose of short-acting opioid and 24 to 48 hours after the last dose of long-acting acting opioid.

Methadone and Related Drugs

Methadone, buprenorphine and other non-opioid drugs, such as clonidine, are the most commonly used methods of pharmacologic detoxification.

Methadone is the best studied medication for opioid detox and has been shown to be more effective than alpha-2 agonists for use in the general adult population. It is also effective for opioid withdrawal symptoms in emergency settings. Though little evidence exists for the use of this drug in adolescent populations, methadone is used for medically stable adolescent patients to prevent withdrawal symptoms. The safety of detoxification with methadone in pregnancy is also not well-studied. Though case reports of harm to the fetus have been published, most evidence suggests that there is no increased risk of harm.

Alpha-2 Agonists

Alpha-2 agonists such as clonidine or lofexidine are used suppress autonomically mediated signs and symptoms of abstinence such as tachycardia and tremor. See more below in “Outpatient Pharmacotherapy”

UOD

A treatment option called Ultra-rapid Opioid Detoxification (UOD) during which the patient is placed under conscious sedation or general anesthesia and naloxone administered intravenously. This precipitates acute withdrawal while the patient is unconscious. After several hours, the patient wakes up with most of withdrawal finished. This approach is controversial because of the questionable risk benefit ratio of exposing the patient to the effects (and cost) of anesthesia for a non-life threatening condition that can be managed in other safe and relatively inexpensive ways. There is no definitive evidence to suggest that UOD patients experience higher rates of successful recovery.

Outpatient Pharmacotherapy

There are multiple options available for outpatient treatment of opioid dependence detoxifications. Options are based on numerous factors including the substance being used, the length its been used, use of other substances, and co-occurring psychiatric and medical problems. Methadone and buprenorphine are the only opioid medication that is FDA-approved to detox outpatients. Buprenorphine is an opioid partial agonist. At low doses buprenorphine produces sufficient agonist effect to enable opioid-addicted individuals to discontinue the misuse of opioids without experiencing withdrawal symptoms. The agonist effects of buprenorphine increase linearly with increasing doses of the drug until at moderate doses they reach a plateau and no longer continue to increase with further increases in dose (known as the “ceiling effect.”).

Many outpatient detoxification regimens utilize a combination of supportive medications. Clonidine is the most common and helps reduce many of the symptoms associated with withdrawal. It needs to be sufficiently dosed to provide relief of autonomic symptoms while being cautious of over medicating due to its affects on blood pressure. It is dosed until some sedation is felt while maintaining blood pressure of at least 90 to 100 systolic.

Promethazine or other anti-emetics are commonly used to relieve vomiting and severe nausea. Patient will often need this medication in order to continue adequate fluid intake to compensate for vomiting and diarrhea. Imodium is generally effective in standard dosing to alleviate the frequent diarrhea. Hydroxyzine and trazodone are often used to provide some relief of anxiety and insomnia that are both significant during the withdrawal process.

It is impossible to alleviate all withdrawal symptoms. A discuss to provide realistic expectations, while remaining optimistic, is important. The severe withdrawal symptoms of opioids, although not life-threatening, are generally so intolerable that they are the most likely cause to continue use and relapse. Much of the care at this point of treatment is both physical and psychologically supportive.

Behavioral and Social Support

For opiate dependence treatment to be successful, it needs to be followed by ongoing therapy, which may include relapse maintenance therapy. For example, over 90% of heroin addicts will relapse after detoxification if no further treatment given. After patients have completed initial detox, they are strongly encouraged to enter into outpatient treatment program to learn about their disease of addiction and the necessary coping skills needed to remain drug free. They will also obtain the support needed that is not often available from family and friends that do not understand their disease. For some patients, pharmacotherapy to support abstinence and prevent relapse will be used. These programs can last from months to years, depending on the program and the patient’s progress.

Opioid Detox: Conclusions

When your patient becomes convinced of the need to stop using opioids, either street drugs or prescription opioids, the first step will be detoxification. There are several ways this can be done: the choice may depend on the patient’s social support, insurance coverage, and the presence of additional medical or psychiatric problems. It is important for you to know the plans that are developed for your patient by the providers who will oversee the detoxification and subsequent care so that you can support the process as they go through it. This may come in the form of avoiding writing prescriptions for opioids, answering patient’s questions about the drug therapy that was used during their detox or providing ongoing encouragement and assurance to the patient when they question the efficacy of this treatment.

 


Alcohol Detox

Prevention is Key

alcohol abuseMost patients who drink heavily and daily will have at least mild withdrawal when they stop drinking, e.g., with headache, nausea, tremors, diaphoresis, and anxiety. This usually starts about 12 hours after the last drink and lasts 4 to 5 days. Hospitalization for another problem or inter-current illness are classic precipitating factors so every patient admitted to the hospital should be asked about their alcohol use to ensure appropriate precautions are taken to prevent the development of serious withdrawal states in patients at risk. Severe alcohol withdrawal (seizures and DTs) are preventable if treated early, and are far easier to prevent than to treat.

As with opioids, the care of patients dependent on alcohol begins with detoxification. This is arguable even more important that for opioids because the alcohol withdrawal syndrome is more dangerous: seizures and delirium tremens can result in death. Heavy drinkers usually don’t understand this possibility until they first experience withdrawal, so individuals motivated to stop drinking need to be explicitly guided into detoxification.

Pathophysiology: What’s withdrawal all about?

80% or more who have alcohol withdrawal will not progress past the mild withdrawal stage. However, the more severe withdrawal states are medical emergencies which should be prevented. They are alcoholic hallucinations, alcohol-related seizures, and delirium tremens.

These responses can be understood by understanding the pharmacology of alcohol (and benzodiazepines). GABA is the major inhibitory neurotransmitter in brain. Chronic exposure to alcohol stimulates GABA activity in brain and mediates sedative effects of alcohol. The brain compensates by suppressing GABA activity and simplistically, tolerance to alcohol is a balance of GABA stimulation and suppression that allows person to function. When alcohol is removed, unopposed down-regulation of GABA receptors leads to lack of inhibitor neurotransmission which leads to stimulated state, anxiety, insomnia. Stimulation of sympathetic autonomic system via the locus caeruleus leads to tremors, ↑BP, ↑HR, diaphoresis, and fever.

Alcoholic hallucinosis, typically visual, but occasionally auditory, occur in about one third of those suffering milder withdrawal symptoms, and may be a harbinger of more severe features.

Alcohol withdrawal seizures occur in 10-20% who have alcohol withdrawal. They are usually a single grand mal (generalized) seizure, occurring within 48 hours of last drink. They may occur later, especially if the patient is taking benzodiazepines. The risk for seizures is thought to increase with repeated withdrawals. Rarely, this can lead to status epilepticus. Alcohol withdrawal seizures can be prevented by initiation of benzodiazepine in early withdrawal. There is no indication for phenytoin or any other anticonvulsant prescribed long term in patients who have alcohol withdrawal seizures. Anticonvulsants indicated only if there is history of underlying seizure disorder. If patient stops drinking, he will have further seizures only if there is an underlying seizure disorder.

Delirium tremens is most serious type of alcohol withdrawal. When untreated, this has a mortality of 30-40%. Even with treatment, mortality is approximately 5%. The DTs usually start about 48 hours after the last drink and, as with seizures, this may be delayed if the patient taking benzodiazepines, receiving opiate pain meds, or has been under anesthesia recently. The hallmark of delirium tremens is delirium, but it is a diagnosis of exclusion: all other causes of delirium must be ruled out. One of most common errors in treatment of DTs is missing underlying cause of the delirium.

Reversible Causes of Delirium


Infection

meningitis, pneumonia, bacteremia, bacterial peritonitis


Metabolic

Low Na+ or glucose, elevated NH3, calcium, or CO2, acidosis


Medications

Benzodiazepines, prednisone,  stimulant use, serotonin syndrome, neuroleptic malignant syndrome


CNS injury

Subdural hematoma, cancer, stroke, brain abscess, encephalitis


Nutritional

Thiamine or riboflavin deficiency


Drug Withdrawal


The signs of DTs include an acute onset altering of all levels of consciousness, including a reduced ability to focus and sustain/shift attention, disorientation, poor recall and hallucinations. These symptoms and signs can wax and wane throughout the day or night so, at times, the patient appears to be improving. DTs usually last 3 to 5 days. If patient’s delirium does not resolve after several days consider other diagnoses again. Since some patients remain delirious from benzodiazepine being given to treat the DTs, consider stopping this medication once the autonomic overactivity has subsided.

CIWA-arMeasuring Withdrawal

Symptoms of withdrawal can be quantified and monitored using the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale. This scale uses 10 criteria with a range of 0-7 for each (except for orientation). The total score is the sum of these measures, and it is recommended that benzodiazepines be started for patients with a total CIWA-Ar score of 8 or greater, and additional medication should be given on a prn basis for a total CIWA-Ar score > 15. The form allows documentation of vital signs, CIWA scores, and total medication administration. This appears to be the most sensitive tool for assessing alcohol withdrawal and early intervention at a score 8 or greater provides a means of preventing progression of withdrawal.

Ways to Detox Alcohol

To determine the need for detoxification, and inform the patient of the process, you will need a good history (to assess the likelihood that withdrawal could be severe), and you will need to explain why we use a potentially addicting drug (benzodiazepines) for a short term to prevent withdrawal complications. This point may be quite important to some patients, who have decided that “the problems is the use of drugs”, and therefore are resistant to use drugs for detoxification or maintenance of sobriety.

It starts with a History

Take a good alcohol history! Quantity, frequency, pattern (binge drinking). If the patient reports heavy daily consumption and has tremors when not drinking, there is risk. Patients with prior history of seizures or DTs are at particular risk.

Many patients are discovered to have alcohol withdrawal when admitted to the hospital for other reasons but some patients seek care specifically for the alcohol dependence. The majority of these patients do not require inpatient admission for detox. The following is a partial list of criteria for inpatient alcohol detox.

  • Current symptoms of severe alcohol withdrawal
  • Known history of DTs or withdrawal seizures
  • Unable to tolerate oral meds
  • Multiple past detoxes
  • Significant co-morbid psychiatric or medical conditions such as active psychosis or severe cognitive impairment
  • Recent high levels of alcohol consumption
  • Poor social support
  • Pregnancy

Inpatient v Outpatient: When and why?

Several factors impact the venue in which a patient is treated for alcohol dependence including patient preference, program availability, insurance and individual patient factors such as co-morbid conditions that could increase the risk of poor patient outcomes (e.g.., cardiovascular disease, cerebrovascular disease, serious mental illness, etc.) the ability to complete close follow-up during the outpatient detox process, social support and the patient’s level of understanding of the process.

Several regimens for detox exist. In the gradually tapering regimen, patients receive a predetermined dose of medication that is gradually weaned over a few days. In the fixed dose regimen, patients received a specified dose of medication several times daily for 2 to 3 days. These 2 regimens can be given in either the inpatient or outpatient setting. A symptom-triggered regimen utilizes the patients symptoms, assessed at frequent intervals (i.e., every 1-2 hours), to help determine the dose and frequency of the medication. This approach may yield less sedation as it is responsive rather than pre-emptive in its approach but it requires close monitoring by experienced personnel.

In motivated patients who are at low risk for complications, detox can be managed by daily dispensing of one-day supply of medication such as chlordiazepoxide at a fixed or tapering dose. Giving alcohol-dependent patients prescription for several days benzodiazepine with expectation they can “wean” themselves off is unrealistic for many patients who may have no greater control over benzodiazepines than alcohol.

Alcohol Detox: Pharmacological Tools

When symptoms and signs of DTs do develop, benzodiazepines are the treatment of choice because they are GABA agonists and thus restore GABA-ergic inhibitory tone. All are equally efficacious. Choice is based on: onset of action, half-life of drug, presence of active metabolites, functional status of patient’s liver, route of administration. Two of the most common medications used for alcohol detox are lorazepam and chlordiazepoxide.

Lorazepam has intermediate half-life (about 12 hours), is easier to titrate upwards rapidly, and can be given IV, IM, or PO. It has no active metabolites and has less potential for over-sedation. Lorazepam is less dependent on liver metabolism, so is a better choice for patients with severe liver disease. However, it can still cause over-sedation and should be used cautiously in patients with liver disease.

Chlordiazepoxide is longer acting and its active metabolite has a half-life of 24-48 hours which allows for a smoother taper and less fluctuation in blood concentration. This drug is metabolized in liver and should be used with caution in patients with liver disease.

The benzodiazepines are the first line choice to prevent and treat alcohol withdrawal. Other drugs, such as anti-epileptics, have been studied in selected patient populations. Anti-epileptics are efficacious in preventing seizures as well as limiting the amount of benzodiazepines required for control of multiple symptoms of withdrawal. Carbamazepine has well-documented anticonvulsant activity and can prevent alcohol withdrawal seizures. The drug does not carry the same abuse potential as benzodiazepines and is less sedating. The major limitation of this drug is the likelihood of interaction with other medications. Valproic acid also limits seizure activity but its use is largely limited by GI and CNS side effects such as nausea, confusion and somnolence.

Social and Behavioral Support

Few patients with alcohol dependence will successfully maintain long-term abstinence without support. There are several structured programs that exist that focus on similar aspects of aftercare, including education about addiction for patients and their families, exploration of the risk factors that led to the aberrant coping mechanisms that patients develop, development of better coping mechanisms to deal with current and future stressors and building new social support systems to ensure long-term abstinence. This learning and re-learning process often takes months in a more formal setting (dedicated addictions program) and years in a less formal setting (group sessions at a mental health clinic or other facility or Alcoholics Anonymous meetings). The addition of aftercare in a more formal program has been shown to increase the rates of abstinence over self-care (“I can do it on my own”) alone.

A Team Approach

The decision of when, where and how to treat should be managed by an addiction specialist working in conjunction with a multidisciplinary team with expertise in detox and care transitions from detox to the next stages of treatment. Both inpatient and outpatient detox can be efficacious and successful long-term recovery after either requires that a patient engage in aftercare that includes education regarding their disease and the necessary coping skills needed to remain abstinent. As with any substance dependence, they must also obtain the support needed that is not often available from family and friends that do not understand their disease.

Alcohol Detox: Key Issues and Conclusions

When your patient decides that alcohol abstinence is their goal and they wish to stop completely and abruptly, the first step will be detoxification. As with opioid detox, there are several ways this can be done: the choice may depend on the patient’s social support, insurance coverage, and the presence of additional medical or psychiatric problems. Again, it is important for you as their primary care provider to understand the detox process so that you can support the patient in their continued recovery after the initial detox. This may come in the form of avoiding writing prescriptions for benzodiazepines, answering patient’s questions about the risks involved with alcohol detox or providing ongoing encouragement and assurance to the patient in follow-up.

 


Other Substances

benzodiazepine

The other substances which need careful detoxification are sedatives, in particular the benzodiazepines.

Like alcohol withdrawal, benzodiazepine withdrawal can result in seizures and autonomic over-activity. Detoxification is performed by slowly reducing the dose of a long acting benzodiazepine such as chlordiazepoxide over many days, until the patient is completely off the drug.


Ongoing Support & Care

Just as an insulin drip used in diabetic ketoacidosis cannot ensure good diabetes control in the long run, alcohol and drug detoxification is insufficient to ensure longterm sobriety.

doctor with female patientPatients must:

  • identify those factors that led to and sustained their use
  • rebuild relationships
  • learn new coping mechanisms for stress management
  • and many other skills to successfully negotiate the recovery from dependence.

When treating patients who have completed detox, it is important to positively reinforce their successes, address issues, and to support ongoing engagement in care and support, and you should include these in every follow-up visit.

Like every other chronic disease, substance use requires ongoing support. You may even use the diabetes analogy to help them understand that each of their chronic illnesses deserves treatment and follow-up.


Detox: Summary & Key Issues to Remember

Detoxification is a key step in the ongoing management of many substance use disorders. Some key things to remember:

  • For many patients, completely and abruptly stopping their substance use may be best before entering into a long-term treatment program.
  • Withdrawal is both uncomfortable, and, in the case of alcohol and sedatives, dangerous. Therefore it needs to be managed carefully.
  • Detoxification can be done safely as an outpatient for some individuals with general good health and reasonable social support.

Detoxification alone is never enough: patients are not able to avoid relapse without transition to treatment to help them maintain sobriety.


Staying Clean

Recognizing Triggers, Managing Craving, and Preventing Relapse.

Patients who have gone through the acute withdrawal period (whether on their own or under detoxification treatment) from opiates or alcohol have already completed a major step in their recovery. But it is just one step of many. As with all chronic diseases, acute intermittent treatment–including responding to the crises of relapse, intoxication, or medical consequences–does not typically lead to long-term treatment success. The crucial phase of substance abuse treatment is maintenance of sobriety.

alcohol addictionTriggers, triggers, everywhere…

Substance addiction is much more than simply pharmacological dependence that can be broken by detoxification. A cardinal feature of addiction is that the patient’s life progressively centers on the cycle of obtaining, using, and recovering from drugs. Other family, work, and recreational interests fade into the background as the drug use takes center stage. Friendships and places where people spend time together become inextricably linked to drug use. It’s like walking into the bar in “Cheers”- where everybody knows your name. Patients in treatment need the cognitive skills to recognize triggers to drug or alcohol use: associations with people (their drinking buddies), places (the bar), and visual, olfactory, and auditory cues (the look and smell of a beer in a frosty mug)- the sound of a wine cork being pulled, the image of a cocaine pipe or a hypodermic syringe: all of these cues are well established to trigger craving and other behaviors, and one of the bases of cognitive behavioral therapy is to help the patient identify and avoid these high risk episodes.

This module is not designed to go into detail about the more complex “dual diagnosis” patients who have addiction plus another mental health problem, but it is clearly the case that management of the addiction cannot proceed without addressing comorbidities such as depression or generalized anxiety.

Relapse happens.

And finally, the patient and the providers need to understand that a relapse is more likely than not, just like relapse with heart failure or cancer. When it happens the therapeutic team needs to move quickly to minimize the duration and severity of the relapse and get the patient sober again.

Triggers, Craving, and Relapse…Are you ready to help?

 


General Strategies for Relapse Prevention

writing prescriptionA major decision that occurs after a patient completes detox is whether or not to utilize medication in the prevention of relapse in addition to psychological care such as counseling, group therapy and educational programs.

Patients who cut down and stop on their own also need follow-up therapy which may or may not include pharmacotherapy. This can be an important patient preference: some are convinced that the problem is “chemicals” and very much want to maintain sobriety without medications. And there is a rationale for this: in controlled trials of alcoholism treatment before the introduction of naltrexone and acamprosate, the overall rate of maintaining sobriety was around 30%.  Some patients simply quit drinking and stay sober entirely on their own.  However, for other patients, medications can help by reducing craving or by reducing the positive rewards from drug or alcohol use.


Opioid Pharmaceutical Maintenance Therapy

Several factors are taken into account when considering a patient for maintenance therapy with medications including type, duration and amount of opioid use as well as social factors.

The decision to use medication to prevent craving and relapse is rarely made by a primary care physician alone, but when you are the acute or ongoing primary care provider for these patients, it’s helpful to know what they are on and why they are on it.

Pregnancy is a special circumstance in which the benefits of opioid replacement therapy with methadone may actually outweigh the potential harms to the baby. Given the high relapse rates in the treatment of opioid dependence, a stable daily dose of methadone may pose less risk to the fetus than the fluctuating doses that occur with illicit opioid use. In addition, the patient may experience fewer perinatal complications with daily methadone as compared to intermittent opioid use (let alone the risks of varying purity of street drugs and transmission of needle-borne illnesses like HIV and HCV).

Now let’s look at the current choices available to addiction specialists in the U.S. The chart below includes selected risks involved with these medications. Note that these medications have shown efficacy in clinical situations where the medications are administered in a controlled setting and in tandem with counseling and social services.


METHADONE

Drug Class: Opioid agonist

Dose: 30-100 mg PO daily (initial doses 15 to 20 mg/day)>100 mg/day in persistent heroin abuse or co-morbid conditions such as chronic pain or other dependence

Patient Population: Adult, adolescent, obstetric

Therapeutic Risks:

  • Abuse/overdose, particularly in non-directly observed therapy
  • QTc prolongation, sudden cardiac death
  • Increased potential for overdose with use of short-acting opioids or benzodiazepines (such as ED or surgical setting)
  • Acute withdrawal with use of mixed agonist/antagonist opioid analgesics

BUPHRENORPHINE

Drug Class: Partial opioid agonist

Dose: 8 mg sublingual (liquid) daily; 1 mg sublingual tablet daily

Patient Population: Adult, obstetric

Therapeutic Risks:

  • Abuse/overdose, typically related to mixed use with benzodiazepines and/or alcohol
  • Increased potential for overdose with use of short-acting opioids or benzodiazepines (such as ED or surgical setting)
  • acute withdrawal with use of mixed agonist/antagonist opioid analgesics

NALTREXONE

Drug Class: Opioid agonist

Dose: 50 mg oral daily; 380 mg IM Qmonth (extended release)

Patient Population: Adult

Therapeutic Risks:

  • Hepatotoxicty
  • Acute withdrawal if used prior to completion of detox
  • Overdose (e.g., when using high amounts of opioids to overcome antagonist blockade)

BUPRENORPHINE-NALTREXONE

Drug Class: Mixed partial opioid agonist & antagonist

Dose: One to three 8/2 mg Sublingualfilm(s) daily

Patient Population: Adult

Therapeutic Risks:

  • See individual risks for Buprenorphine & Naltrexone above Appears to decrease the potential for abuse or diversion compared with methadone.
  • Injection of buprenorphine-naltrexone could precipitate opioid withdrawal.
  • Risk of acute withdrawal when injected

BUPRENORPHINE-NALOXONE

Drug Class: Mixed partial opioid agonist & antagonist

Dose: one to 2 1.4 mg/0.36 mg or 5.7 mg/1.4 mg sublingual tabs daily

Patient Population: Adult

Therapeutic Risks:

  • See Buprenorphine-Naltrexone

Does it work?

Although multiple studies do show that patients stay in treatment longer and report lower use rates when using opioid agonist and/or antagonist maintenance medications, these studies have several limitations including different endpoints measured and patient drop-out from the non-medication arms. The bottom line is that patients need follow-up treatment ad medication maintenance is an efficacious and safe option for some patients and appears to decrease total opioid usage, decrease drug-related crime and improve social functioning in patients with opioid dependence.

Can I just prescribe it?

Federal and state regulations require special licensing for clinics, inpatient units and physicians who prescribe methadone, a schedule II narcotic, to treat opioid dependence. In addition, federal and state laws mandate certain age restrictions on its use and documentation guidelines including documentation on the duration of opioid use and risk of relapse.

Buprenorphine, a schedule III narcotic, can be prescribed in an office setting, though the clinician must register with and complete training through the Center for Substance Abuse Treatment (CSAT) of the Substance Abuse and Mental Health Services Administration (SAMHSA). See www.buprenorphine.samhsa.gov for more information.

Naltrexone can be prescribed by any licensed practitioner. Both the oral daily form and the monthly injectable monthly extended-release form are FDA approved for treatment of opioid dependence.

Pharmaceuticals can play an important part in prevention of craving and relapse. When, how, and when to fade use is an important decision among the care team and the patient.

 


Alcohol Relapse Prevention

Though the mainstay of treatment for alcohol dependence is psychosocial intervention, medications to maintain abstinence have an important role to play in improving the efficacy of treatment. Up to 70% of patients relapse after psychosocial treatment alone.

alcohol addiction

Pharmacotherapy should be used in dependent patients who are motivated to reduce or abstain from alcohol intake and who do not have contraindications to the medications. Now let’s look at the current choices available to physicians in the U.S. Many of these medications can be used in general medical settings. The list below includes selected risks involved with these medications.

Note that only naltrexone, acamprostate and disulfiram have been FDA approved for the treatment  of alcohol dependence. Other medications have shown some promising results and are also included here.


NALTREXONE

Drug Class: Opioid agonist

Dose: 50 mg oral daily for 12 weeks; 380 mg IM Qmonth (extended release)

Patient Population: Adult

Therapeutic Risks:

  • Hepatotoxicity
  • Acute withdrawal/overdose if used in patients on opioids

ACAMPROSTATE

Drug Class: Glutamate receptor agonist

Dose: 333-666 mg TID

Patient Population: Adult

Therapeutic Risks:

  • Diarrhea
  • Nervousness
  • Fatigue

DISULFIRAM

Drug Class: Aldehyde dehydrogenase inhibitor

Dose: 125 to 500 mg PO daily

Patient Population: Adult

Therapeutic Risks:

  • Hepatotoxicty
  • Acetaldehyde accumulation with alcohol intake: hypotension, nausea, flushing
  • Depression, psychosis

TOPIRAMATE

Drug Class: GABA receptor agonist

Dose: 25 to 200 mg PO BID

Patient Population: Adult

Therapeutic Risks:

  • CNS side effects- such as diplopia, memory loss, confusion, incoordination, dizziness
  • Hyperthermia
  • Metabolic acidosis

BUSPIRONE

Drug Class: Serotonin agonist

Dose: 7.5 to 15 mg PO BID

Patient Population: Adult

Therapeutic Risks:

  • Dizziness
  • Drowsiness

Does it work?

A meta-analysis of 18 clinical trials of oral naltrexone found the medication to reduce the risk of relapse, number of drinking days, and cravings in comparison to placebo.

Parenteral naltrexone has been shown in some to reduce the rate of heavy drinking and increase the number of abstinent days.

Acamprostate has been shown to improve abstinence rates but numerous other studies have shown variable benefit in terms of drink-free days and time to heavy drinking.

Disulfiram was studied in a VA cooperative trial and was found to be no more effective than placebo. However, among the patients compliant with the medication, fewer drinking days were recorded. Non-compliance with self-administered home dosing is very high.

Topiramate has been shown to improve abstinence rates and decrease heavy drinking in several trials. Dropout rates have been higher than placebo. Head-to-head studies with other medications for alcohol dependence have not been published. Topiramate is not FDA-approved for the treatment of alcohol dependence.

Each of these therapies should be combined with psychosocial support (there is no evidence for superiority of any particular form, e.g., cognitive behaviorally therapy, motivational interviewing, 12 step programs). The duration of treatment has not been defined: many treatment specialists used the drugs for 6 months, followed by 6 months of follow-up.

Can I just prescribe it?

Any of the above medications can be prescribed by non-specialist providers.

As with opiods, medications can play an important part in prevention of alcohol craving and relapse. Whether, when and how to use them, and when and how to remove them, is an important decision among the care team and the patient.


Other Substances

other drugsOther sedatives drugs, such as benzodiazepines, have properties similar to alcohol (as described in the module on detoxification of benzodiazepine users), and the management of patients after detoxification is conceptually similar:

  • cognitive behavioral therapy,
  • re-establishment of alternative activities not related to obtaining and using drugs,
  • possibly linked with random urine drug screens.

Cocaine and other stimulant addiction is very common, and no FDA-approved pharmacotherapy exists. However, several trials have shown promise using anticonvusants, and other medications including disulfiram. The use of relapse prevention medications is very complex in these patients and should be managed by an addiction specialist.

Polydrug Users

A much more complicated issue is the polydrug user: a subset of patients appear to use whatever drug is available: alcohol, cocaine, heroin, other stimulants, maybe mix in benzodiaepeines to counteract the highs. These patients typically have severe psychosocial stressors and are very difficult to treat. Patients with polysubstance abuse can present significant psychosocial and pharmacologic management challenges and are best managed by a team approach led by an addictions specialist.


Swapping Substances

It is very important to remember that many patients who develop dependence on one substance may have a very high risk of developing dependence on another substance.

liquor with pills

For example, your alcohol dependent patient may develop benzodiazepine dependence. This may be because both substances utilize similar neural pathways. Additionally, patients may have developed coping mechanisms centered around obtaining relief or comfort from a substance, rather than from non-chemical coping mechanisms.

pain relieversIrrespective of the etiology of dual or polysubstance dependence, you must be aware of the additional risk when prescribing substances such as benzodiazepines and opioids to patients with a history of any type of substance dependence or abuse. You just might precipitate a “sideways” relapse.
Educating patients about this risk is key as well. If they know the risk of using other substances (aside from the one that they had the abuse issue with), they can become a partner in their own care. A well-informed and motivated patient will sometimes decline the dentist’s one-time hydrocodone prescription or the primary care doctor’s short-term lorazepam prescription to avoid the risk altogether.


When Relapse Happens

alcohol abuse

A core principal of treatment of drug abuse is that relapse is a part of the chronic nature of this disease.

relapse

When relapses occur, the patient is not abandoned but rather every effort needs to made to bring the patient back under care, with repeat detoxification and renewed therapy to assist her/him in remaining sober and clean.

As the primary care provider (or any other non-addiction specialist), you should discuss the relapse openly with your patient. Though relapse can be disappointing, it can be an opportunity to learn. Encouraging the patient to re-engage in specialized addiction treatment whether through a formal clinic-based program or through less formal venues such as Alcoholics Anonymous (or Narcotics Anonymous, Cocaine Anonymous, etc.), can be very helpful for re-educating patients and re-establishing a support network. Don’t let your patient go it alone.


Relapse Management: Summary & Key Issues to Remember

Successful management of substance abuse, like all chronic diseases, is best handled by an interdisciplinary and individualized approach.

Some patients need detox; others can cut down on their own. Some patients need pharmacotherapy to increase their chances of long-term sobriety and others do not. Everyone needs education, counseling, and social support even if the venues and programs differ.

  • And every patient needs their entire medical team to understand the chronic nature of their disease, the high rate of relapse, factors that can lead to relapse and who the patient can call on when they do need help
  • doctor with female patientAsk the patient about their substance use and ask every time, no matter what your specialty
  • Keep the door open to these conversations
  • Use your Motivational Interviewing skills so that patients feel more comfortable admitting their setbacks with substance use

You may or may not be the one to “manage” their treatment, but you have an important role to play in monitoring this chronic disease, even if it is no more involved than calling a counselor or social worker for a struggling patient to speak with. Screening tools may help to uncover substance abuse or dependence but the conversation shouldn’t end there.


Why Refer?

Are you feeling a little overwhelmed by opening the “can of worms” when it comes to substance abuse?

Many of us feel uncomfortable discussing these issues with patients for a variety of reasons. One common area of concern is our ability to make the “right” diagnosis and choose the “right” treatment for the patient. Another concern is that addressing such issues will take far more time than you have in your clinic.

referralWe are not trained or expected to be experts in the diagnosis of substance use disorders. But using a non-judgmental and concerned approach and after a few screening and follow-up questions, you will often be able to tell whether the patient has a problem with their substance use or not. Offering expert help from other treatment team members in the form of a mental health or, even better, a specially-trained substance use professional is the next step in the process. And they will take it from there.

Patients may jump at the chance to get more help or they may take some time to even consider that step. In fact, most patients who enter and complete a substance use program do so from self-referral. Retrospectively, they are surprised that their physicians didn’t discuss the problem with them. But because of the high prevalence of substance use disorders in the general medical population, we still have a very important role to play in helping patients get to the next step in care.

What services a patient needs and will accept depends on a variety of factors such as severity of dependence, willingness or ability to engage in intensive treatment, insurance, and many others.


The Referral Process

Jack Logan

Mr. Logan comes to the office for his 3-month follow-up appointment. At his last visit, you and he discussed his alcohol intake and the possibility that his poorly controlled blood pressure may be related to his drinking. He agreed to cut down but declined to discuss any formal treatment for his drinking as he felt that he didn’t have “a problem with it.” Today, when you ask if you can revisit his drinking habits, he says that it has been harder than he thought it would be to cut down. You tell him that it is commonly very hard to make such changes and remind him that help with these changes is available and that he might be surprised by the variety of programs and services available. He agrees that hearing more about such services is the next best step to get him toward his personal goal of cutting down and, maybe, quitting drinking altogether. You call your substance abuse counselor to see if she is available to talk with Mr. Logan right now.

Lucinda Stark

Miss Stark comes to your clinic for a new patient appointment following a hospitalization for cellulitis. During the hospitalization, she was noted to have methicillin-sensitive Staphylococcus aureus bacteremia that was thought to be due to a spider bite*. She had a transesophageal echocardiogram to rule out endocarditis and was treated with 2 weeks of antibiotics which she has nearly finished. As you interview her, you bring up the issue of alcohol and drug use. She begins to tear up when she describes her belief that her infection was probably due to her drug use. You inquire further to discover that she has been using hydrocodone orally or nasally off and on for the past couple of years but recently, she has tried injecting it. She is really scared about this, her first, complication of her drug use and wants to quit but doesn’t know how. You congratulate her for her decisions and drive and suggest that she discuss what type of inpatient or outpatient therapy that may be available with your substance use counselor.

add EITHER a picture of someone for each, or a stick figure. RICK: age/race pref for these?


Common Referral Services

Inpatient Treatment

Detoxification – Designed for alcohol and/or opiate dependence.  Typically involve 24 – hour medically assisted detoxification as well as intensive counseling. Often 1-2 week admission but more rapid programs exist.  Typically followed by IOP (see below).

Outpatient Treatment

Detoxification – For alcohol, benzodiazepines, and opiates. Involves daily visits for medications, assessment of symptoms, vital signs, and brief mental status exams.  Generally runs for 1-2 weeks.  Typically covered by insurance and IOP is also followed by IOP (see below)

Intensive Outpatient Treatment (IOP) – appropriate for patients with mild to moderate withdrawal symptoms. Treatment includes group therapy and medication management.  Typically last from 6-12 months.  Typically covered by insurance.

Dual Diagnosis – Treatment for co-occurring substance use and mental illness.  Provides medication evaluation and supportive counseling for mental illness and addiction. Often covered by insurance.

Narcotics or Opiod Treatment Programs– Individual, family, and group counseling; medication treatment including methadone and buprenorphine.  This service is not covered by insurance.

Residential short-term and long term treatment – Medical Treatment with community and living environment.  Can last between a month and a year and is ideal for patients with unstable living situations or limited social support. Patients have limited visitation and leave privileges.

Community Based Treatment

Support Groups –  Meetings to offer social support and a community for people with addictions problems.  No medical treatments, instead help addicts deal with the social and mental aspects of addiction and give them tools and resources for combating their addiction.  Most are free and do not have mandatory attendance. Examples include Alcoholic Anonymous, Narcotics Anonymous, and Cocaine Anonymous. You can also join these groups from home as they have web based groups.

Faith-based programs – Volunteers of America, Church –based outreach programs, etc. Treatment typically involves group meetings and individual counseling. Free of Charge

Transitional Living homes often referred to as Half Way homes-

Patients can reside for several months in home or apartment where substance use is prohibited. Group counseling and other resources are available during stay. Cost associated with housing.

This page summarizes some of the many services that are available for your patients.

Special Populations.

Pharmacotherapy. The stereotype is that addiction treatment is mainly about counseling and anti-alcohol drugs are very much under-prescribed. Remember, pharamcotherapeutic detox is an important tool in your clinical toolkit (see Module 2 of this course).

Adolescents, pregnant or post-partum mothers, and patients with HIV/AIDS often have other options for treatment that are designed especially for them. For example, programs exist in Indianapolis that include in-home and clinic-based comprehensive outpatient treatment and services for pregnant, postpartum and parenting woman who abuse substances. Services include, group and family therapy.

Is your head spinning yet? The point of letting you, the doctor, know about these services is to give you a sense of the breadth of treatment and recovery services available. The message you can now send to patients is that treatment is highly variable, recovery is possible and help is available. They only have to be willing to take the next step and get more information.

Which ones your patient makes use of will depend heavily on the individual circumstances of your particular patient and can only be decided working together with the patient to identify his or her needs and willingness to make use of services.


Why Patients Don’t Followup

Common Reasons Patients Don’t Followup on Referral

Patients may have many misconceptions about what a referral to a substance use counselor entails. You, as their physician, can be a trusted voice to reassure them or help dispel some myths about this next step in their care.

The grid below lists a few common patient worries and misconceptions regarding initial referral to a substance use professional and the corresponding facts.

What patients think The reality
If I talk to the counselor, I have to agree to treatment There is no implied or explicit commitment to treatment that has to precede the 1st meeting. The only requirement is that the patient is willing to hear and consider treatment options.
I have to be sober or drug-free to start any kind of treatment Many substance use treatment programs focus on “harm reduction” and do not require abstinence as a prerequisite to beginning therapy.
I have no choice in the program I participate in For many patients, there are options that range from Alcoholics Anonymous (or other similar programs) meetings, to structured group or individual therapy that may or may not include inpatient time.
Once I start a program, I will be required to stay until the end Except in cases where it is legally required (court-ordered), participation in substance abuse programs is voluntary and patient driven
All treatment is inpatient Most treatment actually is outpatient
I can’t afford treatment Groups such as Alcoholics or Narcotics Anonymous are free. Professionally led, structured inpatient or outpatient programs are associated with a cost. This cost is often largely covered by most insurance plans. This is just the type of information that your substance use professional can give the patient.
I can’t handle group therapy so I can’t participate Therapy can include group meetings, one-on-one sessions or a combination of both.

Will you help patients separate the fact from the fiction so they will follow through on your referral?

 


Referral in Action: What might the patient expect?

Typically here at IU, and at many other provider locations, in-house referrals are called Consults.

For our SBIRT program, typically you would:

  • Page the SBIRT counselor towards the end or at the end of your exam.
  • Briefly, inform of patient targeted drug (s), medical record number, and exam room.
  • In an ideal situation, a ‘warm hand off’ from physician to counselor will occur. If not, the SBIRT Counselor will take it from the phone call.
  • After the consult, the counselor will attempt to locate the referring Physician in order to provide an update of the encounter.
  • A progress note is then entered into the electronic medical record.
insert image of the referral sheet here. RICK: to what are you referring here?

Another way to get an SBIRT consultation started is to complete a Gopher generated Psychiatry Consult Requisition. One example of the instructions could look like this: “Nurse/Staff to schedule an appointment to see SBIRT counselor within1 month for management, suggestions for Alcohol Abuse.

Please note, more often than not, third-party Drug and Alcohol Treatment Centers would like the patient to make initial contact and to set up their own appointments. They want to know that the patient is serious about treatment.


Summary: Key Things to Remember

Sometimes we all need a little help. Referring a patient can help the patient and can help you.

make a referralThere are many different specialized services and one of your jobs is to recognize when a patient may be in need of specialized care and determining which type of care might be best for them, not only in terms of what they need but also in terms of what they are willing to do.

  • You have to help them weigh their options and choose one that will lead to better outcomes for them.
  • Get them to commit to an action.
  • Followup with them to ensure they followed through on their commitment.

Three things to take away.

  1. Your job is to provide your patient with the knowledge that there are many options that can fit into their life and daily schedule. Basically, that there is more than “one right way” to start their path into recovery.
  2. Locate and get to know your respective go-to-person for a Referral to Treamtent. Just like the MA’s, nurses and other clinic members, the substance use or SBIRT counselor in your clinic is a key member of the treatment team for your patient.
  3. Remember don’t “punt” the task of engaging a person’s substance use issue to the nearest behavioral health specialist, provide a “warm hand off” so continuity of care is at it’s optimal level.


Prescription abuse on the rise

Opioid prescribing for acute and chronic pain has been rising dramatically in the United States since the 1990s. In the years from 1997 to 2006, retail sales for morphine, hydrocodone and oxycodone rose 196%, 244%, and 732%, respectively.

Source: http://www.deadiversion.usdoj.gov/arcos/retail_drug_summary/index.html

Mr. Hawkins defaultMeet Mr. Hawkins

Mr. Hawkins is a 46 year-old who comes to clinic for his first visit since losing his job a year ago. His major complaint is back pain that he describes as “8 out of 10” on his worst days.

Opioid abuse rising too

During a similar time frame, prescription opioid misuse has also been on the rise in the United States. The Substance Abuse and Mental Health Services Administration (SAMHSA) Drug Abuse Warning Network (DAWN) reported that the estimated number of ED visits for non-medical use of opioid analgesics increased 111% from 2004 to 2008 (from 144,600 to 305,900 visits) and increased an additional 29% from 2007 to 2008. The highest numbers of ED visits were recorded for oxycodone, hydrocodone, and methadone, each of which showed statistically significant increases during the 5-year period.

Mr. Hawkins defaultClient Case: Mr. Hawkins

Mr. Hawkins has had this pain since a car accident during which he was hit from behind (he was a restrained driver) 2 years ago. He was seen in the Emergency Department after the crash but was released, being told that his x-rays were unremarkable.

With death rates tripling

According to the Centers for Disease Control and Prevention, during the most recent decade, the number of drug poisoning deaths involving opioid analgesics more than tripled from about 4,000 in 1999 to 14,800 in 2008. Opioid analgesics were involved in more than 40% of all drug-poisoning deaths in 2008, up from about 25% in 1999.

Mr. Hawkins defaultClient Case: Mr. Hawkins

Mr. Hawkins’ pain is described as a “dull ache” in the central lumbar area and is worsened by any type of bending or lifting more than 10 or 15 pounds. He also notes that if he stands or walks more than about 20 or 30 minutes, he has to stop due to the pain. He occasionally has a sharp pain that radiates from his back to his buttocks but this doesn’t happen very often. He takes ibuprofen with only minimal relief but has not tried other medications.

Indiana State Legislature Takes Action…

First_Do_No_Harm_V_1_0_Page_001To directly address the problem of controlled analgesic overprescribing, the Indiana State Legislature passed a new resolution that took effect on December 15, 2013, known as the Title 844 Medical Licensing Board of Indiana Emergency Rule. This action allows the Attorney General’s office to move more quickly in taking enforcement action against practitioners who overprescribe and obtain records for investigation. As a result, new guidelines for the ongoing care and documentation of this care, have been mandated. A summary of the requirements are included in First Do No Harm.

First Do No Harm should REQUIRED READING for anyone who writes pain medications for any reason.

Also, see Bitterpill.in.gov for more information on prescription drug abuse.

bitterpill


A Word about Words

A Word about Words: Substance Abuse Terminology

Words are important and sometimes what we call things makes a big difference in how our patients perceive their situations. In fact, in many cases a “diagnosis” is really just applying a term to a set of symptoms, thereby naming what is going on with a patient.

Some key terms in managing commonly abused prescription medications include:

  • Addiction: Neurobehavioral syndrome with genetic and environmental influences that result in psychological dependence for psychic effects. Chronic, Craving, Compulsive and Continuous despite harm
  • Dependence: Neuro-adaptation characterized by withdrawal syndrome if substance is stopped or lowered abruptly
  • Tolerance: Physiologic state resulting from regular use of drug in which the dose must be increased to achieve the same clinical response
  • Diversion: Illegal acquisition and sale of prescription medications (most often stimulants, sedatives, and opioids)
  • Illegitimate use of legitimate Rx, illegitimate Rx and or stolen from pharmacy or manufacturer.
  • Substance abuse
  • Maladaptive use of substances (tobacco, alcohol, licit and illicit drugs) over time that does not meet criteria for addiction
  • Pseudoaddiction: Behavior of a patient who is prescribed pain relieving medication but who exhibits opioid drug-seeking patterns in response to inadequate pain relief through the prescribed treatment
  • Aberrancy: Refers to a range of anomalous events involving prescribed narcotic medications suggestive of patient opioid misuse and possibly a substance use disorder

Aberrant Medication Behaviors
A spectrum of behaviors that may reflect misuse: aberrant drug behaviors are common, with nearly four out of five subjects reporting one or more aberrant drug behaviors. Most patients may exhibit some aberrant drug behaviors.Some warnings are RED FLAGS. If these are indicated, even once, they strongly suggest a problem and merit action. Other warnings are YELLOW FLAGS, and suggest further exploration and monitoring.

Aberrant Medication-Taking Behavior More Likely to be Suggestive of Addiction – RED FLAGS

  • Deterioration in functioning at work or socially
  • Illegal activities – selling, forging, buying from nonmedical sources
  • Injection or snorting medication
  • Multiple episodes of “lost” or “stolen” scripts
  • Resistance to change therapy despite adverse effects
  • Refusal to comply with random drug screens
  • Concurrent abuse of alcohol or illicit drugs
  • Use of multiple physicians and pharmacies
Aberrant Medication-Taking Behavior Less Likely to be Suggestive of Addiction – YELLOW FLAGS

  • Complaints about need for more medication
  • Drug hoarding
  • Requesting specific pain medications
  • Openly acquiring similar medications from other providers
  • Occasional unsanctioned dose escalation
  • Nonadherence to other recommendations for pain therapyWith Yellow Flags, it is the pattern and consistency of a warning, not a single warning itself, that is primarily suggestive of a problem.
  • 2 to 3 minor aberrant behaviors over an 24 month period would not likely represent a type of aberrancy that is worrisome e.g. addiction/diversion
  • Use these opportunities to educate the patient so you can lower the risk of facilitating the development of more aberrant behavior or addiction and increase the chances for improved and safer outcomes. When calm exchanges occur you & the patient gain understandings & appreciations that will more safely allow continued care with or without opiates.
  • Decisions are best made in context, taking account of the patient’s risk of narcotic abuse (current life-stressors, Past Medical History, measures and metrics, and the seriousness of the aberrant behavior(s).
  • 2-3 minor “issues” over a 6-week period is more concerning and would require more immediate action.


Ways Meds Get Abused

Medications are abused in many different ways, and our patients are harmed in equally diverse number of ways. We may fail to diagnose an existing misuse or abuse risk or to monitor for emerging risk.

Medication abuse is not just John buying on the street, or Tara sneaking from her parents’ medicine cabinet: our own prescribing practices may increase the likelihood of patient problems. Patients may misuse or abuse the medications we ourselves prescribe for them, and we may play an enabling role in such abuse by either not identifying those already at risk or by not carefully monitoring those for whom we have prescribed medications with increased risk of abuse/misuse.

Although correlations between total opioid daily dose and risk of opioid overdose and other causes of death exist, a disturbing number of deaths from overdose occur in patients prescribed relatively low doses of opioid analgesics. This may reflect patients varying their dosing of the opioids for “good and bad days” of pain, or interactions with alcohol or other medications (e.g. sedatives). Obviously, patients getting medications from more than one physician risk overdose, and patients may not understand that medications with different brand names may contain the same or similar opioids, and thus unintentionally overdose. They may overdose on other medications combined with opioids (e.g., acetaminophen). Finally, there is the whole problem that opioids do not, by themselves, control chronic pain all that well: if the patient expects complete relief, there is the temptation to increase the dose to the point of overdose. This points to a great need for increased monitoring and multimodal management of chronic pain.

Mr. Hawkins defaultClient Case: Mr. Hawkins

Mr. Hawkins saw his previous primary care physician twice for this problem in the past and was referred to physical therapy after another set of spine x-rays showed “nothing wrong.” He completed 6 weeks of therapy over 18 months ago but states he got little relief from the pain as a result. He does continue to do the home exercises he was given about 3 times a week.


7 Steps to Managing Prescriptions

What can we do?

A growing body of evidence reveals the benefits of a multimodality approach to chronic pain. In some instances, you may decide that judicious use of opioid narcotic analgesia should be part of a comprehensive management plan. We can take several steps to ensure safe analgesic prescribing as well as safe weaning and aftercare of those who have previously been on controlled analgesics.

Mr. Hawkins defaultClient Case: Mr. Hawkins

Mr. Hawkins notes that his inability to maintain activity for extended periods has led to an inability to maintain his work as a foreman for a local corporate construction company. He has had no other trauma or falls and denies weight loss, fever, other arthralgias, lower extremity weakness or in-coordination, or bowel and bladder dysfunction. He has had no other health problems and has no history of surgery. He takes no other medications but over-the-counter ibuprofen and has no medication allergies.

Gourlay et al identified 10 “universal precautions” for managing chronic pain with Opioids, and we have distilled those down to 7 key steps we should do with each and every patient. Always incorporate these 7 steps and you will be well on your way to a standardized approach to managing your patients, and to reducing the risk of misuse and abuse

  1. Determine Pain Etiology
  2. Perform Assessments
  3. Provide Prognosis and Obtain Informed Consent
  4. Discuss Treatment Options
  5. Create a Written Treatment Agreement
  6. Regularly Reassess Treatment
  7. Document Everything

Gourlay DL, Heit HA, Almahrezi A. Pain Medicine (2005) 6:107-12.

Let’s take a look at each of these steps in further detail and highlight related actions required by the new Title 844 Medical Licensing Board of Indiana Emergency Rule.


1: Determine etiology

What’s the cause of the pain?

As with any complaint, care should be undertaken to determine the cause of the primary complaint. A thorough history and physical exam is essential to determine the next best step in the work-up which may or may not include imaging and laboratory studies.

Take the time to decide the most likely diagnosis as well as a plausible differential diagnosis and use further work up to confirm these thoughts rather than as a “fishing expedition” as there are many situations in which a test can come back with unexpected findings that may not correlate with the patient’s symptoms and can lead to unnecessary treatment in many cases. Think, for instance, of the common findings of osteophytes or even spinal stenosis in patients with back pain: these mechanical abnormalities are commonly found in asymptomatic patients, and often mislead physicians.

Be sure to review old records for the results of previous workups if they exist, and to corroborate the patient’s history and results of prior treatment.

Per the new Indiana prescribing law, you must ask your patient to complete an objective pain assessment too,l such as the Brief Pain Inventory  to gain an objective measure. This should be done at least initially, according to the law, but periodically thereafter, ideally at each visit.

 

Mr. Hawkins defaultClient Case: Mr. Hawkins

On Mr. Hawkins’ exam, he is a well-groomed, obese male appearing in no physical or emotional distress. He ambulates without abnormality and is able to move to the exam table without difficulty. He has no spinal deformity or point tenderness. There is slight loss of lumbar lordosis and minimal palpable tenderness in the lumbar paraspinal muscles bilaterally. Patient has slightly limited flexion/extension/rotation of the lumbar spine. Patient can lower and rise from full squat without assistance, toe walk and heel walk. There is normal muscle tone and 5/5 motor strength in both legs. Straight leg raise and FABER tests are negative bilaterally. Patellar and Achilles deep tendon reflexes are 2+ bilaterally. Light touch & vibratory sensation are present and symmetric bilaterally.

Knowledge Check

Best practices in the care of this patient involve which of the following:

a. Prescribe a limited amount of opioid narcotics for pain management b. Refer the patient to a neurosurgeon c. Obtain an MRI to rule out dangerous pathologies such as bony metastases d. Discuss Mr. Hawkins prognosis and goals for treatment


2. Perform Assessments

Gather Data and Perform Assessments

To do our jobs, we need data. To understand our patients complaints, and to know which treatments are indicated, we need more data!

Several data analyses have estimated that opioid abuse among patients receiving drugs for chronic pain ranges from 18% to 41%. Remember that opioid “abuse” may or may not mean addiction (see below). Additionally, depression and other mood disorders are seen in over 1/3 of patients with chronic pain by some estimates.

This may sound complex or something you aren’t used to doing as part of your routine history-taking, but many studies show that a personal or family history of mental illness and/or substance misuse increases the risk that a patient may misuse controlled substances prescribed for the treatment of their chronic pain. Screening for alcohol, tobacco and drug use can be accomplished by formal validated tools or by taking a thorough social history. This is where your Screening, Brief Intervention & Referral to Treatment (SBIRT) training comes in handy!

Screening tools and instruments

Talking about Substance Use

Asking questions about substance use can be uncomfortable for physicians and patients alike. Often the discomfort stems from a misunderstanding about why the questions are being asked. In the best scenario, a physician may be attempting to thoroughly understand the health habits of the patient. In the worst scenario, the patient may assume the physician is trying to label the patient as an “addict.” Clearly stating why such questions are being asked, avoiding labeling a patient and explaining the difference among terms such as tolerance, dependence, and addiction can help clear up misconceptions and improve trust between the physician and the patient. Formal screening instruments may help destigmatize as well- since you “Ask Everyone”.

Some evidence-based tools exist that help quantify the risk of opioid misuse in a particular patient. The Opioid Risk Tool is one such screen that can help guide management by assessing the potential risk of opioid misuse.

Screening for mental health problems such as depression using validated tools such as PHQ-9 or other methods can help you coordinate care more appropriately and potentially avoid the “pill for every ill” trap of treating each disorder separately. Co-treatment of chronic pain and mental health disorders may improve patient outcomes. Patients with unrecognized or untreated mood disorders may be less motivated to participate fully in a multimodality pain management program.

These assessments should be done initially and periodically thereafter. Patients found to be “high risk” on opioid misuse screens or who have significant mental illness are typically not appropriate patients for chronic opioid therapy, especially in the primary care setting.

 

Mr. Hawkins defaultClient Case: Mr. Hawkins

After discussing your initial impressions with the patient, your prescribe physical therapy reassessment, obtain consent for medical records from his previous primary care physician and prescribe meloxicam and cyclobenzaprine. You schedule a visit in 8 weeks for reassessment.
Mr. Hawkins returns in 8 weeks reporting little improvement in his pain, noting that his pain still “spikes to 8 out of 10 sometimes” but slight improvement in his overall ability to tolerate walking and doing work around the house since starting physical therapy and using the cyclobenzaprine. He finds that he has 3 or 4 days a week when it is difficult for him to get out of bed due to the pain. He asks you for “something stronger” for these days.

Knowledge Check

Best practices in the care of this patient involve which of the following:

a. Perform a brief psychosocial assessment b. Screen for alcohol and substance use c. Discuss the risks and benefits of treatment with opioid narcotics d. Write a limited number of short-acting opioid narcotics that includes 1 refill


3. Prognosis & Consent

Relay Prognosis and Obtain informed consent

Just like any procedure that has significant risks to the patient, it is ethical to discuss the risks and benefits of opioid analgesic therapy. Patients’ ideas of the benefits and risks of this therapy may be unrealistic or uninformed. Letting the patient know how these medications fit into the comprehensive management (not cure!) of their pain is important to clear up any misconceptions they might have. It may even be helpful to ask them what they think that the benefits and risks of treatment are. Specific issues of addiction, physical dependence, and tolerance should be explored in plain language and presented in a way that the patient can easily understand.

Mr. Hawkins defaultClient Case: Mr. Hawkins

After re-addressing your shared goals for the management of Mr, Hawkins’ chronic back pain, you both agree that a trial of prn opioid pain medication is reasonable.

Knowledge Check

What is your next step in managing Mr. Hawkin’s pain?

Discontinue the meloxicam and cyclobenzaprine and prescribe hydrocodone/acetaminophen 5/325mg every 6 hours as needed for pain Discuss the benefits and risks of short & long-term opioid therapy Add oxycodone extended release 10 mg every 12 hours scheduled for pain Add hydrocodone/acetaminophen 5/325mg TID as needed for pain and schedule a 2 week follow-up visit to re-assess


4. Discuss Treatment Options

Discuss Treatment Options and the Role (and limits) of Opioids

Setting functional goals for patients

As with any chronic disease, actual measures and documentation of these measures at baseline and follow-up is absolutely essential in guiding treatment decisions. Definition of treatment “success” may vary between patients and practitioners but using objective measures and sharing changes in these measures with patients may aid in informed decision-making on the part of patients as they discuss future treatment plans.

Once you have determined a diagnosis, agree upon a treatment plan that includes establishing functional goals for the patient, rather than one that is related to the severity of the pain itself. For example, encourage your patient to think about what activity they would like to engage in instead of “get my pain down to a level 3”. This should be done at least initially according to the new law but periodically thereafter, ideally at each visit.

Discuss Treatment Options for Chronic Pain

In assessing different treatment options for your patient’s pain, you should first explore non-opioid methods of controlling pain and improving function.

Refer to the flowchart from First Do No Harm entitled “An Approach to Managing Chronic Non-Terminal Pain” for a range of non-opioid treatment options.

Do no harm approach to managing chronic pain flowchart

For many diagnoses, there is more evidence of benefit of these therapies than for chronic opioid therapy.

Avoid polypharmacy in treatment plans, particularly when using opioids. Medications such as stimulants, benzodiazepines, mixed opioids (long- and short-acting) can be particularly dangerous, harmful or counterproductive and should be avoided. The new state law explicitly discourages this type of polypharmacy.

Though opioids are not widely considered to be a first-line agent in the management of chronic pain, they can play a role in a comprehensive chronic pain management plan. Individualized assessment, rather than absolute “rules” about personal practice patterns (e.g., “I never prescribe narcotics”) should guide treatment decisions. The appropriate combination of agents may include opioids and adjunctive modalities such as other analgesics, antidepressants, anti-epileptics, acupuncture, soft-tissue injections, massage, yoga, TENS unit, water aerobics, meditation, and other evidence-based treatments.

If You Do Decide on Opioids…

The Role of Opioids: Management not Treatment

In the end, it is important that you have a frank discussion with the patient regarding the palliative role of opioid pain management: patients need to be told about the difference between treating the underlying CAUSE of pain, and lessoning the, still underlying, pain through opioid pain management. Having a clear understanding of these differences can help patients better manage their expectations.

Always remember to never start a treatment that you are not prepared to stop. If the patient’s pain or functionality doesn’t improve on the opioid, let them know that it will be discontinued.

The Emergency Medical Rules Law mandates discussion with patients and documentation of risks of opioid therapy (including death) initially and periodically thereafter.

The 3 E’s for Opioid Treatment: Education, Expectations, and Explicit Instructions

When developing a treatment agreement with a patient, it is very important that the patient know what the medication is and isn’t for, what they can expect, and exactly how to take the medication. This involves the 3 E’s.

3 E's

Education:

  • What is chronic pain?
  • What is the risk of aberrancy?
  • What are the diagnoses?
  • Risks of treatment?

Expectations:

  • How much pain relief?
  • How much functional recovery? i.e. Is there increased physical activity?

Explicit instructions:

  • On Medication Use
  • Take as directed only
  • Report side-effects
  • No early refills

and that you will:

  • Monitor use
  • Adjust treatment as indicated based on goals, adherence to program and pain

Mr. Hawkins defaultClient Case: Mr. Hawkins

As with informed consent, these issues should be discussed with the patient to ensure understanding and agreement with the treatment. After discussing the risks and benefits of opioid therapy with Mr. Hawkins, you prescribe hydrocodone/acetaminophen 5/325 mg to be used only for pain that is uncontrolled by local heat, stretching, meloxicam and/or cyclobenzaprine. You advise him never to take the medication “first thing in the morning” before he has tried other modalities and further advise him to avoid routine use.

Knowledge Check

You set other expectations for him that you outline in a written agreement that you have for such purposes, including which of the following?

a. You are the only person who will be prescribing these types of medications b. Lost prescriptions will not be replaced c. You will regularly see and examine your patient and reassess his status d. All of the above


5. Create a Written Treatment Agreement

Create a treatment agreement

treatment agreementJust as it is necessary to discuss prognosis, treatment options, and treatment effects, it is equally vital to lay out expectations for and of patients when the decision is made to include opioid analgesics as part of a treatment regimen, given the risks involved.

A written agreement of the expectations and obligations of both the patient and the practitioner can help set boundaries and provide a basis for detecting treatment problems early. The agreement should be explicit and detailed and include information about.

  • prescribing parameters (only one prescriber, limited day supply, no early refills, etc.),
  • drug monitoring (nature, type and how often),
  • adjunct therapies (type, e.g, physical therapy, mental health; requirements)
  • chronic pain management being participation based
  • repercussions of aberrant behavior and/or failure to comply with the agreement

If You Didn’t Document It, You Didn’t Do It

Discuss and document your entire treatment plan with the patient, noting that no one therapeutic entity will manage their condition. Set up expectations that the patient should comply with the plan as a whole, rather than a single aspect such as pharmaceutical therapy.

This documentation should be done initially and periodically thereafter, not less often than yearly. Documentation should be signed, if possible.  Reading aloud and discussing the specifics with patients in a face-to-face setting is ideal as patients can ask questions and these conversations can help mitigate the problems of poor reading comprehension or health literacy of some patients.

Mr. Hawkins defaultClient Case: Mr. Hawkins

As with informed consent, these issues should be discussed with the patient to ensure understanding and agreement with the treatment.

Knowledge Check

When should Mr. Hawkins return?

a. When he needs a refill on his medicines b. Every 6 months for re-evaluation c. In 1 month d. On an as needed basis


6. Regularly Reassess Treatment

Reassess: Monitor and Modify Treatment, Regularly

Re-Eval, not RefillA new mantra: RE-EVALUATION not a REFILL!

In order to reassess, however, you have to set up the expectation that the patient WILL come back. It may seem obvious to you that patients who are maintained on chronic opioid therapy for their pain need to be periodically reassessed but it may not be obvious to your patients. This might be best summarized by reinforcing that a return visit by the patient is NOT for a REFILL, but for a RE-EVALUATION.

Moreover, you may both disagree on the definition of “periodically”…

The Indiana Emergency Medical Rules now make this quite clear, explicitly stating that patients on chronic opioid therapy must be see every 3-4 months for reassessment of pain, functionality and side effects of their therapy.

Re-assessing the primary measures of pain severity and functional level should be performed and documented at each routine visit, and must occur every 3-4 months. As with any chronic disease management plan, rationale for continuing or modifying treatment should be recorded in the medical record. Of course, if medication isn’t helping, it should be discontinued but often patients (and providers) fall into a pattern and fail to re-assess what they are doing, a sort of therapeutic inertia.

You have probably discovered by now that the pain scale asked of patients as they check into the clinic or the Emergency Department is not very discriminatory. It is certainly not enough to base a whole treatment regimen on. Asking patients questions regarding where they hurt and what makes the pain better or worse can go much further to understanding how they are doing. Additionally, asking them what they are able to do in terms of ADLs and other activities paints a much broader picture.

Assess the 5 A’s of Pain Medication.

Regularly assess the “Five A’s” of Pain Medicine: Analgesia, Activity, Adverse Effects, Aberrancy, and Affect

The big questions on a return visit are: is the pain medication working and is it leading to any adverse affects? With this information, we can decide whether and how to modify the patients treatment regimen.

We should assess:

  1. Analgesia: the patient’s pain severity as compared to previous pain levels
  2. Activity: the patient’s functional status, what they are able to do compared to previous assessments
  3. Adverse Effects: the negative effects of the medications on the patient. Are there any new complaints (such as constipation, fatigue, etc.) that may be medication-related
  4. Aberrant behavior: for patients prescribed opioids, the patient’s adherence to the prescribed regimen.  Review their dosing patterns. Are they taking more than prescribed, sharing their medications with others, taking others’ prescription medications or other behaviors?
  5. Affect: the patient’s mental status, are there any signs of co-morbid mood disorders?

In addition, you should review what medicines they are taking and exactly how they are taking them so you can determine whether they are taking the correctly.

Review Diagnosis and Comobidity.

Just like everyone else, patient’s medical conditions, social situations and habits can change over time. Asking questions regarding their substance use, mood symptoms and other related questions is key to understanding what factors may be influencing their pain and functional status. By Indiana law, formal assessments (substance use screening, depression screening, etc.) should be performed and documented at least yearly but asking about these at each visit can help you better treat the patient more effectively and quickly should a new problem between arise between visits.

Re-evaluate, not just a refill. A better way to think about prescriptions.

 


7. Document!

Document, document, document

As mentioned above, it is important to document details of the initial and follow-up assessments of every patient with chronic pain. These details can provide a record of treatment successes or failures and guide future treatment decisions. Additionally this documentation is indicated to help mitigate risk of medicolegal exposure.

A standardized approach to the management of patients with chronic pain that includes appropriate monitoring of patients prescribed opioid analgesics may help reduce the risk of improper usage of these medications and result in more effective and safe treatment for this patient population.

Documentation is now required for patients receiving chronic opioid therapy. For more details regarding what and when, please refer to First Do No Harm.


Prescribing Practices Summary

Opioids are a vital tool for treating, in particular, acute, and in some patients, chronic pain. Yet they also come with great potential for dependence, addiction, and abuse, as the last decade of increased use of potent opioids and patient harm have emphasized. However, careful screening of patients, treatment planning, and frequent reassessment of treatment outcomes and patient status can reduce these risks.

Remember the 7 steps to safer and more effective management of opioid prescriptions:

  1. Determine Pain Etiology
  2. Perform Assessments
  3. Provide Prognosis and Obtain Informed Consent
  4. Describe Treatment Options
  5. Create Treatment Agreement
  6. Regularly Monitor and Modify Treatment
  7. Document Everything

And you will be improving the odds of successful treatment outcomes for each and every one of your patients.


Meet Mr. Hake

Now that you’ve learned about detox, cravings, relapse, and prescribing practices, let’s take a look at all this in action with a patient.

Mr. Hake

Meet Mr. Hake. He is a 62-year-old male well-known to you who comes to the clinic for a 6-month follow up of his diabetes, hypertension and hyperlipidemia. He also has a history of stage II diastolic dysfunction. All of his medical problems are typically well-controlled which is why you are surprised when you receive his chart and see that his blood pressure today is 166/92 and his fingerstick blood glucose is 278. Upon questioning, he tells you that he is taking all of his usual medicines but is feeling fatigued & not sleeping well. He denies chest pain, peripheral edema, orthopnea, paroxysmal nocturnal dyspnea, shortness of breath, polyuria and polydipsia. His vitals reveals a 10-pound weight loss, a regular pulse of 88 and an oxygen sat of 98%. The rest of his exam is unremarkable except that his affect is sad and he is more withdrawn than usual.

Knowledge Check

What should you do next? More than one response may be correct.

a. Screen Mr. Hake for depression by asking him about his mood and interest in his usual pleasurable activities b. Screen Mr. Hake for alcohol and drug use c. Perform a urine drug screen d. Refer Mr. Hake to a mental health counselor e. Increase Mr. Hake’s antihypertensive medications and schedule a follow-up visit to review blood pressure and blood glucose in 2 weeks


Digging Deeper

Mr. HakeUnable to account for the drastic change in his health status, you begin to leaf through his chart searching for results of previous labs or any other clues as to what’s happening. You see the results of Mr. Hake’s substance use screening form and note that he is drinking alcohol daily. Upon further questioning, Mr. Hake tells you that he just has “a few beers to help me fall asleep.” He states that he used to drink “the hard stuff” in the past but quit years ago after he served some jail time for “driving drunk a few times.” As you question further, you learn that Mr. Hake’s wife of 40 years recently died after a stroke and he has been having trouble adjusting to this.

Knowledge Check

What should you do next?

a. Screen Mr. Hake for depression by asking him about his mood and interest in his usual pleasurable activities b. Tell Mr. Hake to stop using alcohol immediately c. Start disulfiram d. Refer Mr. Hake to a substance use counselor e. Increase Mr. Hake’s antihypertensive medications and schedule a follow-up visit to review blood pressure and blood glucose in 2 weeks


A Visit to the ED

Mr. HakeMr. Hake misses his next scheduled clinic follow-up appointment. Four months after his last clinic visit, Mr. Hake is transported to the ED after his daughter visited him at his home and found him confused and combative. Upon arrival to the ED, Mr. Hake is somnolent but able to be aroused. He is oriented to self and place only. His vitals are only remarkable for a BP of 172/96. His neurologic exam is unremarkable but due to his somnolence, his gait is not observed and cerebellar testing is not fully done. A non-contrast head CT only reveals some small vessel chronic ischemic changes and mild cortical atrophy. His labs reveal an ethanol level of 182 mg/dL, normal CBC and chemistries. A urine tox screen is negative.

Knowledge Check

As the EM physician, what should you do next? More than one answer may be correct.

a. Let him sleep it off in the ED b. Transfer him to the general psychiatry ward c. Admit him to the hospitalist team for management of alcohol withdrawal d. Admit him to the substance use detoxification unit for management of alcohol withdrawal


Post ED Followup

Mr. HakeMr. Hake returns to your office for a follow up from his hospital visit. He looks disheveled and unwell. His vital signs again revealed marked hypertension and a pulse of 102. He is afebrile. His exam reveals bilateral upper extremity intention tremor and some inattentiveness on his mental status testing but is otherwise unremarkable. When you ask him when his last drink of alcohol was, he states he went on “a bender” drinking “more than I can remember” after he was released from the hospital. But he notes that he decided 3 days ago he “just can’t go on this way” so he stopped drinking altogether.

Knowledge Check

What should you do next?

a. Send Mr. Hake to the hospital emergency department for immediate evaluation b. Call a substance use counselor for immediate consultation c. Give Mr. Hake the number to a substance use center and urge him to call himself d. Begin chlordiazepoxide 10 mg and have Mr. Hake return for re-assessment tomorrow


Continuing Care

Mr. HakeMr. Hake returns again to your office. He has been sober for nearly 6 weeks, is seeing his counselor 3 days a week and has been staying at home the rest of the time. He states that he is committed to sobriety but he feels he needs more help and sometimes is nervous about leaving his house due to temptation as he lives very close to the tavern at which he typically drank. He says that his daughter is supportive but he only sees her on the weekends since she lives on the outskirts of town.

Knowledge Check

What should you do next?

a. Ask him more about the treatment program he is enrolled in b. Congratulate him on his success so far and encourage follow-up with his counselor c. Discuss starting a medication to maintain sobriety d. Prescribe diazepam for anxiety and agoraphobia


Summary

findSubstance abuse is a pervasive and pernicious health problem among the public and our patients. You can help!

Be vigilant. Look for signs of risk, misuse and abuse, and help you patients reduce their risk.

Such vigilance is not only important when we are supporting our patients through detox or through craving reduction and relapse prevention, but equally so when we are prescribing potentially abusable pharmaceuticals to patients who may have no known history of substance misuse and abuse.


Related Readings

Related Readings

  • AMERICAN ACADEMY OF PEDIATRICS: Tobacco, Alcohol, and Other Drugs: The Role of the Pediatrician in Prevention, Identification, and Management of Substance Abuse PEDIATRICS Vol. 115 No. 3 March 2005, pp. 816-821.
  • American Academy of Pediatrics Committee on Substance Abuse  Substance Abuse: A Guide for Health Professionals, 2nd edition. 2001, American Academy of Pediatrics.
  • American Academy of Pediatrics Committee on Substance Abuse (COSA) – http://www.aap.org/visit/cmte35.htm
  • American Academy of Pediatrics Committee on Substance Abuse. Policy Statement: Alcohol Use by Youth and Adolescents – A Pediatric Concern. Pediatrics. Vol. 125 No. 5 May 2010, pp. 1078-1087.
  • AMERICAN ACADEMY OF PEDIATRICS: Alcohol Use by Youth and Adolescents: A Pediatric Concern PEDIATRICS Volume 125, Number 5, May 2010, pp. 1078-1087
  • AMERICAN ACADEMY OF PEDIATRICS: Indications for Management and Referral of Patients Involved in Substance Abuse PEDIATRICS Vol. 106 No. 1 July 2000, pp. 143-148
  • Baer JS, Kivlahan DR, Blume AW, et al. Brief intervention for heavy drinking college students: 4-year follow-up and natural history. Am J Public Health. 2001;91:1310 –1316.
  • Barangan CJ, Alderman EM. Management of Substance Abuse Pediatrics in Review Vol.23 No.4 April 2002, pp. 123 – 131
  • Borsari B, Carey KB. Effects of a brief motivational intervention with college student drinkers. J Consult Clin Psychol.2000;68:728 –733.
  • Garg A et al. Association of Substance Use Discussion by Pediatric Providers With the Parent—Provider Relationship and Maternal Behavior Change. Clinical Pediatrics.March 2010 49: 240-248.
  • Greer SWBauchner HZuckerman B. Pediatrician’s knowledge and practices regarding parental use of alcohol. American Journal of Diseases of Childhood. 1990 Nov;144(11):1234-7.
  • Levy, S and Knight, JR. Screening, Brief Intervention, and Referral to Treatment for Adolescents. Journal of Addiction Medicine. 2008;2: 215–221.
  • Marlatt GA, Baer JS, Kivlahan DR, et al. Screening and brief intervention for high-risk college student drinkers: results from a 2-year follow-up assessment. J Consult Clin Psychol. 1998;66:604–615.
  • Provider Guide: Adolescent Screening, Brief Intervention, and Referral to Treatment for Alcohol and Other Drug Use Using the CRAFFT Screening Tool (June 2010). Developed by: The Massachusetts Department of Public Health, The Massachusetts Behavioral Health Partnership Boston, MA, and Health Team Works, Lakewood, CO
  • Tobacco, Alcohol, and Other Drugs: The Role of the Pediatrician in Prevention, Identification, and Management of Substance Abuse. John W. Kulig, MD, MPH and the Committee on Substance Abuse. PEDIATRICS Vol. 115 No. 3 March 2005, pp. 816-821.
  • Wagner EF, Dinklage SC, Cudworth C, et al. A preliminary evaluation of the effectiveness of a standardized Student Assistance Program. Subst Use Misuse. 1999;34:1571–1584.

External Resources


Next Steps

ask questionsBeing aware of risk, taking steps to identify risk and to mitigate those risks, and regularly monitoring, modifying, and documenting treatment are straightforward, yet effective, ways we can improve our patient’s outcomes and reduce their risks.

With abuse and misuse rates rapidly rising, the difference between a healthier patient and a dependent one, may turn on as small a thing as asking the right questions and the right time.

Will you do those “small things”?


Thank you for completing this course.