Your SlideShare is downloading. ×
Medical Comorbidities - ASAM - American Society of Addiction ...
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×
Saving this for later? Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime – even offline.
Text the download link to your phone
Standard text messaging rates apply

Medical Comorbidities - ASAM - American Society of Addiction ...

550

Published on

0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total Views
550
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
15
Comments
0
Likes
0
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide
  • 1. This section reviews common comorbid medical conditions found in patients with opioid dependence, and also provides a review of the preventive health care that should be followed in such patients. 2. Some of the most common comorbid medical disorders in patients with opioid dependence are viral infections. Many of these infectious complications are the result of the process of injecting opioid substances. In one study, the prevalence of viral infections in injection drug users was: Infection Seroprevalence HCV 77% HBV 66% HIV 21% HTLV 22% [ Reference : Garfein R.S., Vlahov D., Galai N., Doherty M.C., Nelson K.E. Viral infections in short-term injection drug users: the prevalence of the hepatitis C, hepatitis B, human immunodeficiency, and human T-lymphotropic viruses. Am J Public Health 86:655-61, 1996.]
  • Purpose: To illustrate the high costs associated with alcohol misuse Key Points: Excessive alcohol consumption costs the United States billions of dollars annually ($184.6 billion) Individual cost components are depicted in millions of US dollars (percentage of the total cost of $184.6 billion) and are as follows: Specialty alcohol services — alcohol abuse and dependence treatment, prevention, research, and training, as well as insurance administration ($7,466 million; 4%) Medical consequences excluding fetal alcohol syndrome (FAS) ($15,963 million; 9%) Medical consequences associated with FAS ($2,909 million; 2%) Lost future earnings due to premature death includes motor vehicle crashes and other alcohol-related accidents ($36,499 million; 20%) Lost earnings due to alcohol-related illness ($86,368 million; 47%) Lost earnings due to FAS ($1,253 million; 1%) Lost earnings due to crime/victims — includes lost productivity due to alcohol-related crime and incarcerated persons ($10,085 million; 5%) Crashes, fires, criminal justice ($24,093 million; 13%) Source: Harwood, H. Updating Estimates of the Economic Costs of Alcohol Abuse in the United States: Estimates, Update Methods, and Data. Report prepared by the Lewin Group for the National Institute on Alcohol Abuse and Alcoholism; 2000. National Institutes of Health, NIH Publication No. 98-4327. Rockville, MD. http://www.niaaa.nih.gov
  • Purpose: To illustrate the high costs associated with alcohol misuse Key Points: Excessive alcohol consumption costs the United States billions of dollars annually ($184.6 billion) Individual cost components are depicted in millions of US dollars (percentage of the total cost of $184.6 billion) and are as follows: Specialty alcohol services — alcohol abuse and dependence treatment, prevention, research, and training, as well as insurance administration ($7,466 million; 4%) Medical consequences excluding fetal alcohol syndrome (FAS) ($15,963 million; 9%) Medical consequences associated with FAS ($2,909 million; 2%) Lost future earnings due to premature death includes motor vehicle crashes and other alcohol-related accidents ($36,499 million; 20%) Lost earnings due to alcohol-related illness ($86,368 million; 47%) Lost earnings due to FAS ($1,253 million; 1%) Lost earnings due to crime/victims — includes lost productivity due to alcohol-related crime and incarcerated persons ($10,085 million; 5%) Crashes, fires, criminal justice ($24,093 million; 13%) Source: Harwood, H. Updating Estimates of the Economic Costs of Alcohol Abuse in the United States: Estimates, Update Methods, and Data. Report prepared by the Lewin Group for the National Institute on Alcohol Abuse and Alcoholism; 2000. National Institutes of Health, NIH Publication No. 98-4327. Rockville, MD. http://www.niaaa.nih.gov
  • Purpose: To illustrate the high costs associated with alcohol misuse Key Points: Excessive alcohol consumption costs the United States billions of dollars annually ($184.6 billion) Individual cost components are depicted in millions of US dollars (percentage of the total cost of $184.6 billion) and are as follows: Specialty alcohol services — alcohol abuse and dependence treatment, prevention, research, and training, as well as insurance administration ($7,466 million; 4%) Medical consequences excluding fetal alcohol syndrome (FAS) ($15,963 million; 9%) Medical consequences associated with FAS ($2,909 million; 2%) Lost future earnings due to premature death includes motor vehicle crashes and other alcohol-related accidents ($36,499 million; 20%) Lost earnings due to alcohol-related illness ($86,368 million; 47%) Lost earnings due to FAS ($1,253 million; 1%) Lost earnings due to crime/victims — includes lost productivity due to alcohol-related crime and incarcerated persons ($10,085 million; 5%) Crashes, fires, criminal justice ($24,093 million; 13%) Source: Harwood, H. Updating Estimates of the Economic Costs of Alcohol Abuse in the United States: Estimates, Update Methods, and Data. Report prepared by the Lewin Group for the National Institute on Alcohol Abuse and Alcoholism; 2000. National Institutes of Health, NIH Publication No. 98-4327. Rockville, MD. http://www.niaaa.nih.gov
  • Source: SAMHSA. (2006). Results from the 2005 National Survey on Drug Use and Health: National Findings (Office of Applied Studies, NSDUH Series H-30, DHHS Publication No. SMA 06-4194). Rockville, MD (Table 8.29A)
  • 1. During early viral hepatitis, serum transaminase levels can rise to 10-20x normal. Bilirubin and alkaline phosphatase will also likely be elevated. 2. Symptoms of acute hepatitis can include malaise, fatigue, anorexia, nausea, vomiting, myalgia and headache, along with arthritis, urticaria, and mild fever. The majority of patients make a full recovery (94%), but a minority of patients (5%) do develop chronic hepatitis (and 30-40% of those patients develop cirrhosis), and 1% develop fulminant hepatitis (with 80% of that 1% requiring liver transplantation). 3. Evidence of portal hypertension can include ascites, gynecomastia, and esophageal varices. 2. Evidence of poor hepatic synthetic function can include decreased albumin and elevated prothrombin time.
  • 32 30
  • 31 31
  • 1. 1. According to the CDC in 1999, there are 30,000 new cases of Hepatitis C in the U.S. each year.
  • 1.
  • 36
  • 37
  • 1.
  • 1. [Reference: Edlin BR et al, NEJM 2001; 345:211-214.]
  • 1.
  • 1. Note that further compounding the difficulty in prescribing antiretrovirals to patients with opioid addiction is that methadone has pharmacokinetic interactions with several of these medications, including zidovudine, didanosine, stavudine, abacavir, nevirapine, efavirenz and nelfinavir. Sullivan LE, Fiellin DA. Hepatitis C and HIV infections: implications for clinical care in injection drug users. Am J Addictions 13:1-20, 2004.
  • 1. There has been rising concern about tuberculosis since the mid-1980s, since TB is 200 times more common in persons who are HIV+ than those who are HIV-. In addition, strains of TB that are resistant to usual drug treatment regimens have been identified.
  • The Quality Chasm report well documented that quality problems occur typically not because of failure of goodwill, knowledge, effort or resources devoted to health care, but because of fundamental shortcomings in the ways care is organized. It concluded that trying harder will not work: changing systems of care will! To help change the system, the chasm report articulated: six aims for quality health care, ten rules that redesigned healthcare should follow to achieve the Aims, and priority components of the health care system that should be the focus of redesign efforts. In the next few slides, I will briefly review the Quality Chasm Aims, Rules, and redesign principles, which served as the analytic framework for this present study on improving the quality of health care for mental and substance-use conditions.
  • The six dimensions of good quality care as articulated in the Quality Chasm framework are (Refer to slide)
  • Finally, Crossing the Quality Chasm identified six key components of the healthcare system that need to be re-engineered in accord with the rules in order to achieve the aims. These include (refer to slide) :
  • Each year, more than 33 million Americans use health care services for their mental problems and illnesses or conditions resulting from their use of alcohol, inappropriate use of prescription medications, or illegal drugs. This includes: [Refer to info on slide on pervasiveness] In addition to the millions of people who use M/SU services, from 2001 to 2003, only 41 percent of people 18–54 years old who met a specific definition of severe mental illness received any treatment. And, in contrast with the more than 3 million Americans 12 years old or older who received treatment during 2003 for a problem related to alcohol or drug use, more than six times that number reported abusing or being dependent on alcohol, illicit drugs, or prescription drugs. This does not necessarily mean that the healthcare system is not seeing these people or incurring costs for their care. In addition to accompanying a substantial number of chronic general medical illnesses such as diabetes, heart disease, neurologic illnesses, and cancers, they also sometimes are expressed as separate somatic problems. For example, headache, fatigue, dizziness, and pain are the leading cause of outpatient medical visits and often medically unexplained. Depression and anxiety are strongly associated with each. They also are more often present in individuals with the not yet well understood medical conditions of chronic fatigue syndrome, fibromyalgia, irritable bowel syndrome, and non-ulcer dyspepsia.
  • Consideration of the high rates of co-occurrence of general, mental and SU problems and illnesses lead to the committee’s first conclusion and recommendation: (refer to slide) . . . . . . and underpin all of the committee’s more detailed recommendations.
  • Making the policies and practices used for determining dangerousness and decision-making capacity transparent to patients and caregivers/ Obtaining the best available comparative information on safety, effectiveness, and availability of care and providers and using it to guide treatment decisions. Maximizing patient decision-making and involvement in the selection of treatments and providers.
  • Transcript

    • 1. Medical Co-Morbidities in the Substance Using Patient Adam J. Gordon, MD, MPH, FACP, FASAM University of Pittsburgh School of Medicine VA Pittsburgh Healthcare System [email_address] [email_address] Wilford:
    • 2. ASAM’s 2008 Review Course in Addiction Medicine ACCME required disclosure of relevant commercial relationships: Dr. Gordon has nothing to disclose.
    • 3. GOALS
      • Understand that alcohol and drug use can become disorders, that are chronic medical conditions
      • Understand the epidemiology and harm associated with alcohol and other drug use
      • Understand the complex relationship between alcohol and other drug use with other disease processes
    • 4. OUTLINE
      • Discuss the harm and other diseases associated with the use of the “big three” substances:
        • Alcohol
        • Opioids
        • Cocaine
      • Discuss (briefly!) the harm and other diseases associated with the use of “non-big-three” substances
      • Discuss the complexity of defining and clinically dealing with co-morbidities
      • Summarize and further discussion
    • 5. BACKGROUND
      • Alcohol and other drug use patients who present for treatment often have other medical problems
      • These medical conditions are consequences
        • of both their current and their past high risk behaviors
        • Injection or route of drug use
        • direct toxic effects of illicit drugs or caustic agents
      • Clinicians should screen for and treat (or refer for treatment) common comorbid medical conditions
    • 6. BACKGROUND
      • Treating alcohol and other drug use in an office based settings provides a unique opportunity to integrate the delivery of substance abuse treatment with screening and management, increasing effectiveness and patient compliance
      • Clinicians should know the common comorbid medical conditions found in alcohol and other drug use patients and promote preventive health care for these patients
    • 7.  
    • 8. ALCOHOL USE and DISORDERS: HARM and MEDICAL CO-MORBIDITIES Adam J. Gordon, MD, MPH, FACP, FASAM University of Pittsburgh School of Medicine VA Pittsburgh Healthcare System
    • 9. Medical Harm of Hazardous Drinking
      • Hazardous drinking is associated with an increased risk for:
        • All-cause mortality
        • Hypertension
        • Cardiomyopathy
        • Diabetes
        • Trauma
        • Stroke
        • More serious alcohol disorders
        • Cancers
          • particularly upper GI and breast cancers
      Figured from Babor et al (World Health Organization), AUDIT Guidelines for Use in Primary Care, 2001
    • 10. Brief Primer of Physical Exam Features for Alcohol Use
      • Tachycardias
      • Tremor
      • Hypertension
      • Hepatosplenomegaly and a tender liver edge
      • Peripheral neuropathy
      • Spider angiomata
      • Conjunctival injection
      • Unexplained trauma
    • 11. Some Associations with Hazardous Drinking
      • Injuries
      • Infections
      • Gastritis and duodenitis
      • Hematologic effects
      • Early hepatic injury
      • Cardiac effects
    • 12. Injuries
      • Due to
        • Fights and homicide attempts
        • Auto accidents
          • 50% of injuries involve some alcohol consumption
        • Drowning and other accidents
        • Suicide attempts
      • Patient neglects injuries until the next day
        • Injuries not painful until the following day
    • 13. Infections
      • Heavy drinkers are more susceptible to pneumonia and other infections
        • Pneumococcal infections
        • Pseudomonas infections
        • Gram-negative infections
      • Heavy drinkers have impaired immunity
        • Increased sequestration of neutrophils
        • Decreased fixed macrophage phagocytic capacity
        • Decreased white blood cell production
        • Decreased cell mediated immunity
    • 14. Gastritis and Duodenitis
      • Most commonly observed effects
        • Epigastric pain
        • Morning nausea and vomiting
        • Melena
        • Gastric Esophageal Reflux Disease (GERD)
      • Eventually
        • Consequences of liver disease including varices and portal hypertension
    • 15. Hematologic Effects
      • Macrocytosis
        • Due to direct cytotoxic effects
        • Due to vitamin deficencies
      • Decreased platelets (may be down to 30,000 to 50,000)
      • Anemia usually due to
        • Bleeding from gastrointestinal tract
        • Folic acid deficiency
        • Also remember other vitamin deficiencies
    • 16. Hepatic Effects
      • Alcoholic hepatitis in 10% to 15% of alcoholics
        • Increased liver enzymes and bilirubin
        • Enlarged tender liver
        • 80% can progress to cirrhosis
        • 20% result in liver failure
      • Cirrhosis
        • 40% have a 5-year survival if they continue to drink
        • 77% have a 5-year survival if they stop drinking
      • Liver cancer (also esophageal, laryngeal, and nasopharyngeal cancers)
    • 17. Early Hepatic Markers
      • Increased gamma-glutamyl transpeptidase (GGT) up to 3 times normal in 20% to 30% of heavy drinkers
      • Liver enzymes
        • AST/SGOT > ALT/SGPT
      • Production Problems
        • Coagulopathies in end stage alcoholic liver disease
      • Don’t forget the pancreas!
        • Acute and chronic pancreatitis
        • Complications:
          • Diabetes, Steatorrhea, Pseudocyst
    • 18. Cardiac Effects
      • Increased blood pressure
        • From withdrawal
        • Without withdrawal
      • Increased ischemic heart disease
      • Cardiomyopathy
      • Arrhythmias
        • Especially tachyarrhythmias
        • Atrial flutter
        • Atrial fibrillation – “Holiday Heart”
        • Paroxysmal Atrial Tachycardia
    • 19. Nervous System Effects
      • Headaches
      • Sleep disorders
      • Wernicke syndrome
      • Korsakoff psychosis
      • Organic brain disease
        • Cognitive
        • Memory
      • Peripheral neuropathy
    • 20. Nervous System Effects
      • C – C onfusion
      • O – O phthalmalplegia
      • A – A taxia
      • T – Early T hiamine Deficiency (Wernicke’s)
      • R – R etrograde Amnesia
      • A – A nterograde Amnesia
      • C – C onfabulation and meager C onversation
      • K – Korsakoff Syndrome
      • (Also lack of IN sight and G reater apathy)
    • 21. Fetal Alcohol Spectrum
      • Growth retardation
        • Head circumference, height, and weight less than tenth percentile
      • Facial malformation
        • Palpebral fissure
        • Philtrum
        • Thin upper lip
      • Neurodevelopmental delay
        • Intelligence
        • Boundaries
        • Memory
        • Aggression
        • Motor skills
        • Right/wrong
    • 22. Fetal Alcohol Spectrum
      • Defects occur before most women know they are pregnant
      • No known safe level of drinking for pregnant women
        • Binging may be worse than daily drinking
        • The higher the blood level of alcohol, the greater the chance of damage
    • 23. Associations with Other Diseases
      • There exist many diseases that co-exist with alcohol use disorders that may complicate the treatment of either disorder
        • HIV
        • Major Depressive Disorder
        • Hepatitis
        • Cirrhosis
        • (Social morbidities – homelessness)
      • Emerging research is examining treatment modalities for co-morbid conditions
    • 24. Alcohol Use of the Elderly
      • Of the 80% of elderly persons who have ever consumed alcohol, two-thirds continue to drink, often at hazardous levels of consumption
      • Of the elderly:
        • 15% drink alcohol at levels considered hazardous
        • 5% have diagnosis of abuse or dependence
        • many more drink sporadically in binge episodes
      • The problem drinking elderly consist of :
        • 30% of the hospitalized elderly
        • 10% of the elderly primary care
        • 50% of the mentally ill elderly
    • 25. Alcohol Use of the Elderly
      • With mild alcohol consumption, compared to the non-elderly, the elderly are at increased risk for:
        • greater numbers of harmful medication interactions
        • increased falls
        • more cognitive deficits
        • greater sleep impairments
        • increased sexual dysfunction
        • greater numbers of hip fractures
        • more psychiatric problems compared to younger populations
    • 26. Alcohol and Breast Cancer
      • More than 30 epidemiologic studies have evaluated a possible association between alcohol intake and breast cancer
      • Alcohol consumption is associated with a linear increase in breast cancer incidence in women over the range of consumption reported by most women (Smith-Warner)
      • In a recent study of 70,000 women, a drink a day increased their risk by 10 percent, and more than three daily drinks by 30 percent (Lew)
      • Women's Health Study, daily alcohol intake again was shown to modestly increase risk (Zhang)
        • The relative risk for each 10 gram increase in daily alcohol intake was 1.11 (95% CI 1.03-1.20) for ER and PR+ cancer
      Smith-Warner SA, JAMA 1998; Lew: Ameri. Assoc. for Cancer Research 2008; Zhang SM, Am J Epidemiol. 2007
    • 27. Societal Costs of Alcohol Dependence Total Cost: $184.6 Billion Harwood H, NIH Publication No. 98-4327 1998 $86,368 (47%) $36,499 (20%) $2,909 (2%) $15,963 (9%) $7,466* (4%) $24,093 (13%) $10,085 (5%) $1,253 (1%) Specialty alcohol services Medical consequences (except FAS) Medical consequences of FAS Lost future earnings due to premature deaths Lost earnings due to alcohol-related illness Lost earnings due to FAS Lost earnings due to crime/victims Crashes, fires, criminal justice, etc
    • 28.  
    • 29. OPIOID USE and DISORDERS: HARM and MEDICAL CO-MORBIDITIES Adam J. Gordon, MD, MPH, FACP, FASAM University of Pittsburgh School of Medicine VA Pittsburgh Healthcare System
    • 30. Balloons, Bags, and Pills
    • 31. New Prescription Drug Users NSDUH, SAMHSA, 2005 Past Year Initiation of Non-Medical Use of Prescription-type Psycho-pharmaceutics Age 12 or Older: In Thousands from 1965 to 2005
    • 32. Opioid Withdrawal
      • Severe flu-like symptoms including shaking chills
      • Anxiety
      • Hyperactivity
      • Drooling
      • Lacrimation/Tearing
      • Rhinorrhea/Runny nose
      • Anorexia
      • Nausea
      • Vomiting
      • Diarrhea
      • Myalgias
      • Muscle spasms
    • 33. Street Stuff
      • Sold in “stamp bags” and “balloons”
      • A opioid user will maintain a steady supply of opioids - not a binge addiction
      • Combination of abuse is important
        • Can be combined with a stimulant (ala speedball)
        • Rarely with a depressant
    • 34. Changing Route of Heroin Administration Treatment Episode Data System, 1992-2000
    • 35. Hepatitis B
      • DEFINITION
        • Hepatitis B (HBV) is a blood borne viral pathogen
      • EPIDEMIOLOGY
        • Estimated 1.25 million chronically infected in U.S.
        • Approximately 300,000 new cases per year
        • Transmission by blood borne, sexual, or perinatal
        • Approximately 50% of active injection drug users have serological evidence of prior exposure to HBV
    • 36. Hepatitis B – Clinical Course
      • Early and mild viral hepatitis manifests with symptoms of hepatic inflammation and damage with elevated serum transaminases (> 10-20x normal)
      • Chronic viral hepatitis manifests as chronic liver disease with portal hypertension and poor hepatic synthetic function
      • Likelihood of developing chronic infection is related to age:
        • 80 to 90% of infants infected develop chronic disease
        • only 2 -10% of infected adults progress to chronic disease
    • 37. Acute Hepatitis B Infection with Recovery Weeks after Exposure Titer Symptoms HBeAg anti-HBe Total anti-HBc IgM anti-HBc anti-HBs HBsAg 0 4 8 12 16 20 24 28 32 36 52 100
    • 38. Progression to Chronic Hepatitis B Infection Weeks after Exposure Titer IgM anti-HBc Total anti-HBc HBsAg Acute (6 months) HBeAg Chronic (Years) anti-HBe 0 4 8 12 16 20 24 28 32 36 52 Years
    • 39. Hepatitis C - Epidemiology
      • Hepatitis C (HCV) is the most common bloodborne infection in the U.S.
        • 1.8% of the U.S. population are infected
        • Of the 3.9 million people in the U.S. who are infected, 2.7 million are chronically infected
      • At least 30,000 new infections (cases) annually
      • Morbidity and mortality
        • Chronic liver disease – HCV-related: 40% - 60%
        • Deaths HCV chronic disease/year: 8,000-10,000
        • Most common reason for (~40%) liver transplants
    • 40. Hepatitis C - Epidemiology
      • In some series, greater than 90% of injection drug users have antibodies to HCV
      • HCV is more prevalent and more infectious than HIV
        • with 170,000,000 infected with HCV worldwide
        • In injection drug users, infection results from contact with contaminated needles, syringes, paraphernalia
        • Blood and blood products are more infectious than saliva, vaginal secretions, or semen
    • 41. Hepatitis C: Acute Infection with Recovery Symptoms +/- Time after Exposure Titer anti-HCV ALT Normal 0 1 2 3 4 5 6 1 2 3 4 Years Months HCV RNA
    • 42. Hepatitis C: Progression to Chronic Infection anti-HCV Symptoms +/- Time after Exposure Titer ALT Normal 0 1 2 3 4 5 6 1 2 3 4 Years Months HCV RNA
    • 43. CHRONIC Hepatitis C: Clinical Course
      • Symptoms: 50% of patients report chronic fatigue and abdominal discomfort
      • Serum transaminases:
        • Persistently elevated - 43%
        • intermittently elevated - 42%
        • normal - 15%
      • Risk factors for disease progression:
        • alcohol use, hepatitis B virus, HIV (modifiable risks)
        • < 40 years old when infected, male sex
    • 44. 30 Year Progression of Chronic Hepatitis C Acute hepatitis C Chronic hepatitis C Cirrhosis < 20% Hepatic failure < 20% HCC (30 years) >85% (10 years) 20% - >50% (20 years)
    • 45. Hepatitis C: HIV Co-infection
      • 30% of HIV positive patients in the U.S. are co-infected with HCV
      • In HIV infected injecting drug users, the prevalence of HCV is 50 to 90%
      • HIV has a significant effect on progression of liver disease in HCV-infected patients
      • Must balance hepatotoxicity of HIV therapy with need to treat HIV in HCV-infected patients, while HIV therapy can worsen the symptoms of HCV
    • 46. Hepatitis C: Treatment in Drug Users
      • Standard recommendation: >/=6 months “clean”
      • Arguments for not treating: poor adherence, side effects, re-infection, non-urgent treatment – but data supporting these arguments are lacking, some drug users may do well
      • Treatment should be based on individual risk-benefit assessments
        • Edlin BR et al. NEJM 345:211-214, 2001
    • 47. Hepatitis C: Treatment in Drug Users
      • The 2002 NIH Consensus Guideline on the Treatment of HCV is available at
        • Active injecting drug use should not exclude patients from HCV treatment
        • HCV treatment of active injecting drug users should be considered on a case-by-case basis
        • Web site: http://www.guideline.gov
    • 48. HIV/AIDS: Epidemiology
      • Approximately 1.1 million cases in the US
      • 0.7 - 34% (median 15%) seroprevalence entering substance abuse treatment
      • IV Drug Use (IVDU) associations
        • From 1993-1999 IVDU persons living with AIDS jumped from 48,244 to 88,540
        • 15-20% long-term IVDUs infected (43% of women AIDS)
        • 25% of the approximately 40,000 new HIV infections/year through IVDU
    • 49. HIV/AIDS: Treatment in Drug Users
      • High risk for non-receipt of antiretrovirals:
        • 2-3 times as likely not to be on antiretroviral treatment if not in SA treatment
      • High risk for non-adherence:
        • 1998 CDC guidelines recommend delaying HAART until active opioid use has been addressed
    • 50. Tuberculosis: Epidemiology
      • Worldwide, approximately 2 billion people (1/3 of world population) are infected with M. tuberculosis
      • Since the HIV pandemic began in the U.S. in the mid-1980s, there has been increased concern about TB since it is more common in this population
      • Tuberculosis is also more common in alcohol users and injection drug users in general and in patients with alcohol use disorders
    • 51. Opioid Dependence is Costly
      • Medical Costs
        • Mental illness
          • An environmental and disease stressor
          • Co-morbid interactions
        • Trauma and infections
        • Hepatitis and HIV
      • Medical Cost
        • $20 billion per year total costs
        • $1.2 billion per year health care costs
    • 52. How Do They Get Hooked?
    • 53. COCAINE USE and DISORDERS: HARM and MEDICAL CO-MORBIDITIES Adam J. Gordon, MD, MPH, FACP, FASAM University of Pittsburgh School of Medicine VA Pittsburgh Healthcare System
    • 54. Cocaine
      • Cocaine is a product of the alkaloid extract from leaves of the Erthroxylon plant originally grown in the Andes Mountains of western South America
      • Evidence of use in 500 AD - coca leaves in tombs in Bolivia and Peru
      • Cocaine was used by Sigmund Freud
      • William Halsted used cocaine for anesthesia in 1884
      • Today, cocaine is still used (sparingly) as a local anesthetic in the upper respiratory tract in concentrations of 4%
    • 55. Cocaine
      • As many as 20 million people in the United States have used cocaine at least once in their lifetime
      • In New York City, cocaine use is extremely prevalent and in one survey 26% of people sustaining fatal injuries had evidence of cocaine metabolites in their urine or blood
      • Of pregnant women, an estimated 11% are substance abusers and cocaine is the most commonly abused drug other than alcohol
      • Cocaine has increasingly been associated with criminal behavior
    • 56. Street Stuff
      • Cocaine exists in many forms
        • Powder
        • Freebase
        • Rock (crack)
      • Crack is convenient
        • The soft mass that develops becomes hard when dry
        • The crack can then be smoked (potent!)
        • Usually it is smoked in a glass pipe or regular pipe or by mixing it with tobacco or marijuana
        • Crack is thought to be termed by the sound of cocaine crystals ‘popping” when smoked
    • 57. Cocaine Intoxication
      • Clinically significant maladaptive behavioral or psychological changes that developed during, or shortly after, use of cocaine.
      • Two (or more) of the following developing during or shortly after cocaine use:
        • Tachycardia or bradycardia
        • Pupillary dilation
        • Elevated or lowered blood pressure
        • Perspiration or chills
        • Nausea or vomiting
        • Evidence of weight loss
        • Psychomotor agitation or retardation
        • Muscular weakness, respiratory depression, chest pain, or cardiac arrhythmias
        • Confusion, seizures, dyskinesias, dystonias, or coma
    • 58. Morbidity and Co-morbidity of Cocaine
      • Can be deadly in intoxication
        • Mainly due to adrenergic stimulus
          • Think that you are injecting epinephrine into the blood
        • Morbidity can occur secondary to social consequences as well as direct effects
      • Long term
        • Cardiac - cardiomyopathy, hypertension, arrythmias
        • Pulmonary – if smoked
        • Renal – rhabdomyolysis and “tea colored urine”
        • Cerebral – TIAs and strokes
    • 59. Cocaine Physical Exam
      • Track marks (injection use)
      • Burnt lips/face/hair
      • Hand findings
      • Look for nasal perforation or hyperemic nares
    • 60. OTHER DRUG CO-MORBIDITIES (briefly!) Adam J. Gordon, MD, MPH, FACP, FASAM University of Pittsburgh School of Medicine VA Pittsburgh Healthcare System
    • 61. Indolealkylamine Hallucinogens (LSA/LSD, DMT, Toads, Psilocybin, Psilocyn)
    • 62. Lysurgic Acid Diethylamide (LSD)
    • 63. Indolealkylamine Hallucinogens (LSA/LSD, DMT, Toads, Psilocybin, Psilocyn)
    • 64. Phenethylamine Hallucinogens (Peyote, Mescaline, MDMA)
    • 65. Ecstasy (MDMA)
    • 66. Sedatives and Designer Drugs
    • 67. Arylcyclohexylamine Hallucinogens (PCP)
    • 68. Marijuana
    • 69. ADDRESSING CO-MORBIDITIES TREATMENTS IN PRACTICE Adam J. Gordon, MD, MPH, FACP, FASAM University of Pittsburgh School of Medicine VA Pittsburgh Healthcare System
    • 70. CROSSING THE QUALITY CHASM
      • “ Quality problems occur typically not because of failure of goodwill, knowledge, effort or resources devoted to health care, but because of fundamental shortcomings in the ways care is organized”
      • Trying harder will not work: changing systems of care will!
      a new HEALTH system for the 21 st century (IOM, 2001)
    • 71. SIX AIMS OF QUALITY HEALTH CARE
      • Safe – avoids injuries from care
      • Effective – provides care based on scientific knowledge and avoids services not likely to help
      • Patient-centered – respects and responds to patient preferences, needs, and values
    • 72. SIX AIMS
      • Timely – reduces waits and sometimes harmful delays for those receiving and giving care
      • Efficient – avoids waste, including waste of equipment, supplies, ideas and energy
      • Equitable – care does not vary in quality due to personal characteristics (gender, ethnicity, geographic location, or socio-economic status)
    • 73. SIX CRITICAL PATHWAYS FOR ACHIEVING AIMS AND RULES
      • New ways of delivering care
      • Effective use of information technology (IT)
      • Managing the clinical knowledge, skills, and deployment of the workforce
      • Effective teams and coordination of care across patient conditions, services and settings
      • Improvements in how quality is measured
      • Payment methods conducive to good quality
    • 74.  
    • 75. MEDICAL AND SUBSTANCE-USE CONDITIONS
      • Pervasive
        • More than 33 million Americans treated annually
          • 20 % of all working age adults (18-54)
          • 21 % of adolescents
          • Millions more fail to receive care
      • Frequently intertwined
        • 15 - 40 % co-occurrence
      • Often influence general health
        • frequently accompany chronic illnesses
        • 20% of heart attack patients suffer from depression, tripling risk of death
        • associated with leading causes of outpatient visits; e.g., headache, fatigue and pain
    • 76. MENTAL, SUBSTANCE-USE, & GENERAL HEALTH
      • CONCLUSION
      • Improving care delivery and outcomes for any one of mental health, substance use, and general health disorders depends upon improving care and outcomes for the other two .
      • OVERARCHING RECOMMENDATION
      • Health care for general, mental, and substance-use problems and illnesses must be delivered with an understanding of the inherent interactions between the mind/brain and the rest of the body .
    • 77. CH 3. PATIENT CENTERED CARE RECOMMENDATIONS FOR CLINICIANS
      • Incorporate informed, patient-centered decision making throughout practices
      • To ensure informed decision making
      • Adopt recovery-oriented and illness self-management practices that support patient preferences for treatment
    • 78. CH 3. PATIENT CENTERED CARE RECOMMENDATIONS FOR CLINICIANS
      • Coercion should be avoided whenever possible.
      • When coercion is legally authorized, patient-centered care is still applicable and should be undertaken.
    • 79. CH 5. COORDINATING CARE RECOMMENDATIONS FOR CLINICIANS
      • Implement policies and incentives to continually increase collaboration among providers to achieve evidence-based screening and care of patients.
      • Clinical practices should transition along a continuum of evidence-based coordination models:
        • Formal agreements
        • Case management
        • Co-location
        • Integrated practices
    • 80. Core Components of Comprehensive Services Medical Mental Health Vocational Educational Legal AIDS/HIV Risks Financial Housing & Transportation Child Care Family Etheridge, Hubbard, Anderson, Craddock, & Flynn, 1997 ( PAB ). Continuing Care Case Management Urine Monitoring Self-Help (AA/NA) Pharmacotherapy Group/Individual Counseling Abstinence Based Intake Assessment Treatment Plans Core Treatment
    • 81. Substance Abuse is a Chronic Medical Condition
      • Type 1 Diabetes:
        • 30% to 50% relapse each year requiring additional medical care
        • Significant societal consequences
      • Hypertension and Asthma:
        • 50% to 70% relapse each year requiring additional medical care
        • Significant societal consequences
      • Alcohol and Other Drug Diseases.
        • 40% to 60% relapse each year
        • Significant societal consequences
        • Few patients receive treatment!
      McLellan, JAMA, 2000

    ×