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OVERVIEW OF
ADDICTION MEDICINE
FOR PRIMARY CARE

Prepared by
CASAColumbia®

February 2014
Supporting Documents
1. Addiction Medicine: Closing the Gap between
Science and Practice (573 Pages)
2. Overview of Addict...
Outline
•

Importance of Topic

•

Universal Patient Education

•

Universal Screening

•

Diagnostic Evaluation

•

Brief...
IMPORTANCE OF TOPIC

© CASAColumbia 2014

4
Addiction & Risky Use
• Addiction: disease requiring
treatment
• Risky use:
• Substance use that
threatens health & safety...
Brain Disease
Tobacco/nicotine, alcohol & other drugs:
•All affect similar regions of the brain
•Common neurochemistry (e....
Brain Disease
Structural & functional
differences in brain:
•May result from continued
substance use
•May predispose certa...
Risk Factors
• Genetic
• Biological
• Psychological
• Environmental
• Age of first use

© CASAColumbia 2014

8
Treatment Barriers
• Misunderstanding of the disease
• Negative public attitudes & behaviors
• Lack of information on how ...
Continuum of Substance Use

© CASAColumbia 2014

10
Millions of People (2010)

© CASAColumbia 2014

11
Mortality
Addiction & Risky Use
Tobacco/nicotine, alcohol & other drugs:
•Estimated 580,000 deaths each year in the U.S.
•...
Morbidity
Addiction & Risky Use
Tobacco/nicotine, alcohol & other drugs:
•Cause, contribute to & exacerbate numerous
disea...
UNIVERSAL PATIENT
EDUCATION

© CASAColumbia 2014

14
Facts for Patients
• Health consequences are severe & deadly
• Quality of life suffers from disease impact
• Addiction & r...
Risk Reduction
• Recommend no tobacco/nicotine use
• Recommend guidelines for safe alcohol use
• Recommend no illicit drug...
UNIVERSAL SCREENING

© CASAColumbia 2014

17
Screen All Patients

for Tobacco/Nicotine, Alcohol & Other Drugs
• Screen routinely
• Be demographically &
culturally appr...
Integration into H&P
Addiction & Risky Use
Tobacco/nicotine,
alcohol & other drugs:
•Consider in HPI
•Include in PMH rathe...
Integration into H&P
Addiction & Risky Use

Tobacco/nicotine, alcohol & other drugs:
•Consider in ROS & PE
•Examples inclu...
Transition Tips
• Develop comfortable way to introduce topic
• Frame discussion within the context of medicine
• Emphasize...
Sample Transitions
“I would like to ask you some routine questions I
ask all of my patients.”
“Would you mind taking a few...
Screening: Tobacco/Nicotine
Positive Screen = in the past 30 days
any use of tobacco/nicotine

© CASAColumbia 2014

23
Screening: Alcohol
Positive Screen = in the past 30 days:
•Women: >1 drink/day
•Men: >2 drinks/day

© CASAColumbia 2014

2...
Screening: Alcohol
Positive Screen = in the past 30 days
any alcohol use for persons:
• <21
• Pregnant
• Taking meds which...
Screening: Alcohol
Positive Screen = in the past 30 days
any alcohol use:
• While driving, operating machinery or taking p...
Screening: Other Drugs
Positive Screen = in the past 30 days
any misuse of:
• Controlled prescription drugs
(e.g., not as ...
Screening: Other Drugs
Positive Screen = in the past 30 days
any use of:
• Illicit drugs
• Other substances for
the purpos...
DIAGNOSTIC EVALUATION

© CASAColumbia 2014

29
Diagnostic Evaluation
•All patients with
positive screens
•Determine: risky use
or addiction

© CASAColumbia 2014

30
Diagnosis of Addiction
• DSM-5 released May 2013
• Addiction = DSM-5 “Substance Use Disorder”
• Addiction diagnosed for a ...
Diagnostic Criteria
• 11 Criteria
• Mnemonic: “CHEW THAT COP”
Cut Down

Time

Craving

Health

Hazardous Use

Obligations
...
Diagnostic Criteria
• Cut Down: there is a persistent desire or unsuccessful
efforts to cut down or control use of the sub...
Diagnostic Criteria
• Time: a great deal of time is spent in activities necessary
to obtain the substance, use the substan...
Diagnostic Criteria
• Craving: craving, a strong desire or urge to use the
substance
• Obligations: recurrent use of the s...
Risky Use
= All positive screens
not meeting addiction criteria

© CASAColumbia 2014

36
BRIEF INTERVENTION

© CASAColumbia 2014

37
Brief Intervention for Risky Use
• Medical approach to
reduce risky use
• Evidence-based from
research studies
• Effective...
Brief Intervention for Risky Use
• Personalize feedback about substance effects
• State concern & recommend behavior chang...
Brief Intervention for Risky Use
• Practice patient-centered care
• Ask open-ended questions
• Elicit responses from patie...
COMPREHENSIVE
ASSESSMENT

© CASAColumbia 2014

41
Comprehensive Assessment
• Severity of disease
• Need for medical management of withdrawal
• Route of administration for s...
Comprehensive Assessment
• History of substance use & previous treatment
• Comorbidities which may affect treatment
• Fami...
TREATMENT PLANNING

© CASAColumbia 2014

44
Patient Placement Criteria
American Society of Addiction Medicine

• Comprehensive set of guidelines
• For patients with a...
Treatment Settings
• Outpatient
• Intensive outpatient
• Partial hospitalization
• Non-hospital residential
• Hospital inp...
TREATMENTS FOR
ADDICTION

© CASAColumbia 2014

47
Treatments
• Medications
• Psychosocial
therapies
• Combinations
• Tailored for each
patient

© CASAColumbia 2014

48
FDA-Approved Meds
Tobacco/Nicotine
• varenicline (Chantix®)
• bupropion (Zyban®, Wellbutrin®)
• nicotine replacement thera...
FDA-Approved Meds
Alcohol
• acamprosate (Campral®)
• disulfiram (Antabuse®)
• naltrexone (ReVia®, Depade®,
Vivitrol®)

FDA...
FDA-Approved Meds
Opioids
• buprenorphine/naloxone
(Subutex®, Suboxone®, Zubsolv®)
• methadone (Methadose®)
• naltrexone (...
Psychosocial Therapies

Primary Individual or Group Therapies
• Motivational Interviewing (MI)
• Motivational Enhancement ...
Combined Treatment
• Medications &
psychosocial therapies
• Can increase retention
in treatment
• Can decrease relapse
rat...
Specialist Referral
Consider for Complex Cases
• Addiction medicine physicians
find a doctor near you
• Addiction psychiat...
DISEASE MANAGEMENT

© CASAColumbia 2014

55
Disease Management
• Chronic care model
similar to diabetes
• Transdisciplinary,
team-based care
• Patient-centered with
p...
Management Goals
• Maintain or improve patient functioning
• Control symptoms (e.g., craving)
• Address comorbidities
• Re...
Physician Role
• Coordinate care with team
• Provide/arrange psychosocial therapy
• Manage relevant medications
• Continue...
Physician Role
Assist with & coordinate
mutual support, e.g.:
Alcoholics Anonymous
(AA), LifeRing, Narcotics
Anonymous (NA...
Physician Role
Assist with & coordinate other support:
•Legal
•Educational
•Vocational
•Housing
•Parenting
•Childcare
© CA...
Acknowledgements
• Margot Cohen contributed much of the research
and writing for these materials.
• The following subject-...
Ending Addiction
Changes Everything

www.casacolumbia.org

© CASAColumbia 2014
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Overview of Addiction Medicine for Primary Care

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These slides provide an overview of the major elements required for effectively addressing addiction and risky use of addictive substances within the primary care setting. For more information, including a supplement guide with slide-by-slide background information, case studies and references please visit http://www.casacolumbia.org/health-care-providers/addiction-resources-tools

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Overview of Addiction Medicine for Primary Care

  1. 1. OVERVIEW OF ADDICTION MEDICINE FOR PRIMARY CARE Prepared by CASAColumbia® February 2014
  2. 2. Supporting Documents 1. Addiction Medicine: Closing the Gap between Science and Practice (573 Pages) 2. Overview of Addiction Medicine for Primary Care: Supplement (30 Pages) 1. http://www.casacolumbia.org/addiction-research/reports/addiction-medicine 2. http://bit.ly/1eQNfRS © CASAColumbia 2014 2
  3. 3. Outline • Importance of Topic • Universal Patient Education • Universal Screening • Diagnostic Evaluation • Brief Intervention • Comprehensive Assessment • Treatment Planning • Treatments for Addiction • Disease Management © CASAColumbia 2014 3
  4. 4. IMPORTANCE OF TOPIC © CASAColumbia 2014 4
  5. 5. Addiction & Risky Use • Addiction: disease requiring treatment • Risky use: • Substance use that threatens health & safety • Does not meet addiction criteria • Both require medical care © CASAColumbia 2014 5
  6. 6. Brain Disease Tobacco/nicotine, alcohol & other drugs: •All affect similar regions of the brain •Common neurochemistry (e.g., dopamine) dopamine transporters © CASAColumbia 2014 6
  7. 7. Brain Disease Structural & functional differences in brain: •May result from continued substance use •May predispose certain individuals to addiction •May affect judgment & behavior © CASAColumbia 2014 7
  8. 8. Risk Factors • Genetic • Biological • Psychological • Environmental • Age of first use © CASAColumbia 2014 8
  9. 9. Treatment Barriers • Misunderstanding of the disease • Negative public attitudes & behaviors • Lack of information on how to get help • Limited availability of services • Conflicting time commitments • Insufficient social support • Privacy concerns & cost © CASAColumbia 2014 9
  10. 10. Continuum of Substance Use © CASAColumbia 2014 10
  11. 11. Millions of People (2010) © CASAColumbia 2014 11
  12. 12. Mortality Addiction & Risky Use Tobacco/nicotine, alcohol & other drugs: •Estimated 580,000 deaths each year in the U.S. •Approximately 20% of all deaths in the U.S. © CASAColumbia 2014 12
  13. 13. Morbidity Addiction & Risky Use Tobacco/nicotine, alcohol & other drugs: •Cause, contribute to & exacerbate numerous diseases •Examples include cardiovascular disease, cancers, cerebrovascular disease, respiratory disease, cirrhosis, pancreatitis, HCV, HIV/AIDS, STDs, birth defects, depressive disorders, anxiety disorders © CASAColumbia 2014 13
  14. 14. UNIVERSAL PATIENT EDUCATION © CASAColumbia 2014 14
  15. 15. Facts for Patients • Health consequences are severe & deadly • Quality of life suffers from disease impact • Addiction & risky use are preventable •Known risk factors should be reduced •Interventions can lower risky use •Addiction is treatable © CASAColumbia 2014 15
  16. 16. Risk Reduction • Recommend no tobacco/nicotine use • Recommend guidelines for safe alcohol use • Recommend no illicit drug use • Consider H&P when prescribing controlled drugs • Assure medications taken only as prescribed • Remain vigilant for signs & symptoms • Offer evidence-based medical care early © CASAColumbia 2014 16
  17. 17. UNIVERSAL SCREENING © CASAColumbia 2014 17
  18. 18. Screen All Patients for Tobacco/Nicotine, Alcohol & Other Drugs • Screen routinely • Be demographically & culturally appropriate • Use sensitive, nonjudgmental tone & language © CASAColumbia 2014 18
  19. 19. Integration into H&P Addiction & Risky Use Tobacco/nicotine, alcohol & other drugs: •Consider in HPI •Include in PMH rather than SH •Include in FH © CASAColumbia 2014 19
  20. 20. Integration into H&P Addiction & Risky Use Tobacco/nicotine, alcohol & other drugs: •Consider in ROS & PE •Examples include vital signs; HEENT (pupils, injection, nasal mucosa, breath); CV (endocarditis); RESP (smoking effects); DERM (needle tracks, infections, yellow finger stains); MSE (cognition, memory, affect) © CASAColumbia 2014 20
  21. 21. Transition Tips • Develop comfortable way to introduce topic • Frame discussion within the context of medicine • Emphasize medical consequences • Consider language (e.g., “disease of addiction”) • Normalize the subject (e.g., “routine questions”) • Integrate into preventive care © CASAColumbia 2014 21
  22. 22. Sample Transitions “I would like to ask you some routine questions I ask all of my patients.” “Would you mind taking a few minutes to talk with me about your use of tobacco/nicotine, alcohol & other drugs?” “It is important to know that you can prevent a lot of health & related problems by addressing the use of tobacco/nicotine, alcohol & other drugs.” © CASAColumbia 2014 22
  23. 23. Screening: Tobacco/Nicotine Positive Screen = in the past 30 days any use of tobacco/nicotine © CASAColumbia 2014 23
  24. 24. Screening: Alcohol Positive Screen = in the past 30 days: •Women: >1 drink/day •Men: >2 drinks/day © CASAColumbia 2014 24
  25. 25. Screening: Alcohol Positive Screen = in the past 30 days any alcohol use for persons: • <21 • Pregnant • Taking meds which interact with alcohol • With certain specific medical conditions (e.g., liver disease, hypertriglyceridemia, pancreatitis) © CASAColumbia 2014 25
  26. 26. Screening: Alcohol Positive Screen = in the past 30 days any alcohol use: • While driving, operating machinery or taking part in other activities that require attention, skill or coordination • In situations that could cause injury or death (e.g., swimming) © CASAColumbia 2014 26
  27. 27. Screening: Other Drugs Positive Screen = in the past 30 days any misuse of: • Controlled prescription drugs (e.g., not as prescribed) • Other medications for nonmedical reasons (e.g., intoxicating effects, getting high, etc.) © CASAColumbia 2014 27
  28. 28. Screening: Other Drugs Positive Screen = in the past 30 days any use of: • Illicit drugs • Other substances for the purpose of intoxicating effects, getting high, etc. © CASAColumbia 2014 28
  29. 29. DIAGNOSTIC EVALUATION © CASAColumbia 2014 29
  30. 30. Diagnostic Evaluation •All patients with positive screens •Determine: risky use or addiction © CASAColumbia 2014 30
  31. 31. Diagnosis of Addiction • DSM-5 released May 2013 • Addiction = DSM-5 “Substance Use Disorder” • Addiction diagnosed for a 12-month period: • Mild addiction: 2-3 symptoms • Moderate addiction: 4-5 symptoms • Severe addiction: 6 or more symptoms © CASAColumbia 2014 31
  32. 32. Diagnostic Criteria • 11 Criteria • Mnemonic: “CHEW THAT COP” Cut Down Time Craving Health Hazardous Use Obligations Excessive Use Activities Personal Withdrawal* Tolerance Problems * not all substances © CASAColumbia 2014 32
  33. 33. Diagnostic Criteria • Cut Down: there is a persistent desire or unsuccessful efforts to cut down or control use of the substance • Health: use of the substance is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance • Excessive Use: the substance is often taken in larger amounts or over a longer period than was intended • Withdrawal* * not all substances © CASAColumbia 2014 33
  34. 34. Diagnostic Criteria • Time: a great deal of time is spent in activities necessary to obtain the substance, use the substance or recover from its effects • Hazardous Use: recurrent use of the substance in situations in which it is physically hazardous • Activities: important social, occupational or recreational activities are given up or reduced because of use of the substance • Tolerance © CASAColumbia 2014 34
  35. 35. Diagnostic Criteria • Craving: craving, a strong desire or urge to use the substance • Obligations: recurrent use of the substance resulting in a failure to fulfill major role obligations at work, school or home • Personal Problems: continued use of the substance despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of its use © CASAColumbia 2014 35
  36. 36. Risky Use = All positive screens not meeting addiction criteria © CASAColumbia 2014 36
  37. 37. BRIEF INTERVENTION © CASAColumbia 2014 37
  38. 38. Brief Intervention for Risky Use • Medical approach to reduce risky use • Evidence-based from research studies • Effective for risky use involving tobacco/nicotine, alcohol & other drugs • Only 5-10 minutes needed per patient encounter © CASAColumbia 2014 38
  39. 39. Brief Intervention for Risky Use • Personalize feedback about substance effects • State concern & recommend behavior change • Discuss patient’s strengths & possible barriers • Negotiate plan & provide follow-up care © CASAColumbia 2014 39
  40. 40. Brief Intervention for Risky Use • Practice patient-centered care • Ask open-ended questions • Elicit responses from patient on risks/benefits • Facilitate realization of how life can be improved • Support patient’s motivation with empathy © CASAColumbia 2014 40
  41. 41. COMPREHENSIVE ASSESSMENT © CASAColumbia 2014 41
  42. 42. Comprehensive Assessment • Severity of disease • Need for medical management of withdrawal • Route of administration for substances • Likelihood of continued use/relapse © CASAColumbia 2014 42
  43. 43. Comprehensive Assessment • History of substance use & previous treatment • Comorbidities which may affect treatment • Family & social support for treatment • Impact of home environment • Housing, child care, employment & legal issues • Readiness & willingness for treatment • Need for tailored treatment (age, gender, sexual orientation, other) © CASAColumbia 2014 43
  44. 44. TREATMENT PLANNING © CASAColumbia 2014 44
  45. 45. Patient Placement Criteria American Society of Addiction Medicine • Comprehensive set of guidelines • For patients with addiction & comorbidities • For placement, continued stay, transfer & discharge • Typically utilized under the supervision of an addiction physician specialist © CASAColumbia 2014 45
  46. 46. Treatment Settings • Outpatient • Intensive outpatient • Partial hospitalization • Non-hospital residential • Hospital inpatient © CASAColumbia 2014 46
  47. 47. TREATMENTS FOR ADDICTION © CASAColumbia 2014 47
  48. 48. Treatments • Medications • Psychosocial therapies • Combinations • Tailored for each patient © CASAColumbia 2014 48
  49. 49. FDA-Approved Meds Tobacco/Nicotine • varenicline (Chantix®) • bupropion (Zyban®, Wellbutrin®) • nicotine replacement therapy (e.g., patch, gum, lozenge, inhaler, nasal spray) • combinations FDA Prescribing Information (01/18/2012): bupropion FDA Prescribing Information (02/19/2013): varenicline Cahill K, et al. Pharmacological interventions for smoking cessation: an overview & network meta-analysis. Cochrane Database Syst Rev. 2013 May 31;5:CD009329. © CASAColumbia 2014 49
  50. 50. FDA-Approved Meds Alcohol • acamprosate (Campral®) • disulfiram (Antabuse®) • naltrexone (ReVia®, Depade®, Vivitrol®) FDA Prescribing Information (01//30/2012): acamprosate UpToDate Prescribing Information: disulfiram UpToDate Prescribing Information: naltrexone © CASAColumbia 2014 50
  51. 51. FDA-Approved Meds Opioids • buprenorphine/naloxone (Subutex®, Suboxone®, Zubsolv®) • methadone (Methadose®) • naltrexone (ReVia®, Depade®, Vivitrol®) FDA Prescribing Information (12/22/2011): buprenorphine (Subutex ®) FDA Prescribing Information (12/22/2011): buprenorphine/naloxone (Suboxone ®) FDA Prescribing Information (07/03/2013): buprenorphine/naloxone (Zubsolv ®) FDA Prescribing Information (02/04/2008): methadone UpToDate Prescribing Information: naltrexone © CASAColumbia 2014 51
  52. 52. Psychosocial Therapies Primary Individual or Group Therapies • Motivational Interviewing (MI) • Motivational Enhancement Therapy (MET) • Cognitive Behavioral Therapy (CBT) • Community Reinforcement Approach (CRA) • Contingency Management (CM) • Couples/Family Therapy NIH: National Institute on Drug Abuse: Treatment Information © CASAColumbia 2014 52
  53. 53. Combined Treatment • Medications & psychosocial therapies • Can increase retention in treatment • Can decrease relapse rates © CASAColumbia 2014 53
  54. 54. Specialist Referral Consider for Complex Cases • Addiction medicine physicians find a doctor near you • Addiction psychiatrists find a doctor near you Addiction medicine physician: http://www.abam.net/find-a-doctor Addiction psychiatrist: https://application.abpn.com/verifycert/verifyCert.asp?a=4 © CASAColumbia 2014 54
  55. 55. DISEASE MANAGEMENT © CASAColumbia 2014 55
  56. 56. Disease Management • Chronic care model similar to diabetes • Transdisciplinary, team-based care • Patient-centered with patient as part of team © CASAColumbia 2014 56
  57. 57. Management Goals • Maintain or improve patient functioning • Control symptoms (e.g., craving) • Address comorbidities • Reduce relapse • Prevent replacement addiction • Provide support services © CASAColumbia 2014 57
  58. 58. Physician Role • Coordinate care with team • Provide/arrange psychosocial therapy • Manage relevant medications • Continue patient education • Address comorbidities • Monitor progress • Adjust treatment as needed © CASAColumbia 2014 58
  59. 59. Physician Role Assist with & coordinate mutual support, e.g.: Alcoholics Anonymous (AA), LifeRing, Narcotics Anonymous (NA), Secular Organizations for Sobriety, SMART Recovery, Women for Sobriety © CASAColumbia 2014 59
  60. 60. Physician Role Assist with & coordinate other support: •Legal •Educational •Vocational •Housing •Parenting •Childcare © CASAColumbia 2014 60
  61. 61. Acknowledgements • Margot Cohen contributed much of the research and writing for these materials. • The following subject-matter experts served as external reviewers for these materials: Kevin Kunz, M.D., M.P.H., Frances Levin, M.D., David Lewis, M.D., Michael Miller, M.D., Charles O’Brien, M.D., Ph.D. • Funding was provided by The Joseph A. Califano, Jr. Institute for Applied Policy. © CASAColumbia 2014 61
  62. 62. Ending Addiction Changes Everything www.casacolumbia.org © CASAColumbia 2014

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