Chapter 10
Substance Abuse

Henry Francis, MD and
Victoria A. Cargill, MD, MSCE

I. Substance Use And Abuse  TOP

Substance use is more prevalent in the United States than is generally appreciated. Statistics described in the 2002 National Survey on Drug Use and Health (NSDUH) give the following picture on drug use in American men and women (SAMHSA, 2002). Approximately 46% of the American population will use an illegal drug in their lifetime. It is estimated from the NSDUH data that in the general population, 10.3% of men and 6.4% of women have used illegal drugs in the last month. Over the past year, 35 million Americans will have used an illegal drug. Only a fraction of drug-using persons are truly drug-dependent (also called drug-addicted). It is estimated that 7.1 million people meet the definition of illicit drug dependence, defined as compulsively continuing drug-seeking and drug-using behavior even in the face of negative consequences, including health, social, family, legal or work problems.

The general rates of legal drug dependence dwarf the amount of illegal drug addiction. In 2002, 120 million persons reported consuming alcohol in the last 30 days and 71.5 million persons used a tobacco product. At least 54 million of the alcohol consumers are dependent on alcohol through binge or very heavy drinking. The alcohol-dependent individuals are almost three times as numerous as the number of illegal drug users. In contrast to illegal drug use rates where almost twice as many men as women use illegal drugs, alcohol consumption rates are nearly equal for men and women in the general population. However, women were much less likely to be binge drinkers. It is important to note that rates of drug and alcohol use are equal in adolescent males and females (12–17 yr. old), suggesting a trend toward comparable substance use patterns for men and women. Regular use of cigarettes (nicotine dependence), was nearly equal for men and women.

Unfortunately, the majority of alcohol and/or drug dependent women and men, who could benefit from substance abuse–related emotional/psychologic and health treatment, never receive any form of therapeutic intervention. In 2002, only 7.5% of women who needed treatment for an alcohol problem and 20.4% of women who needed treatment for an illegal drug problem actually received care at a specialty facility for these problems.

This chapter will focus on drug and alcohol dependence as a disease, discuss associations with a variety of comorbid conditions, review the epidemiology of substance abuse in the United States, and outline ways to identify and treat substance abuse in women.

II. Epidemiology Of Substance Abuse  TOP

The frequency and danger of drug and alcohol dependence and behaviors of drug and alcohol use are greatly underestimated by the American public and health care professionals. The two commonly used legal drugs, alcohol and tobacco, are more frequently consumed than all the illegal drugs combined (Table 10-1). Marijuana and cocaine (including crack cocaine) are the most frequently used illegal drugs. Inhalants are used predominately by adolescents. A more recent trend in adolescents is to use club drugs like g-hydroxybutyrate, ecstasy (MDMA), Rohypnol, ketamine, methamphetamine, and LSD at all-night parties called “raves” or “trances.” Surprisingly, heroin, which is viewed as a highly prevalent drug, is actually one of the least favored drugs of preference in the U.S. population.

The rates of illicit drugs used vary slightly by ethnicity (Table 10–2) and in a major way by gender. Estimates for gender-specific drug use indicate that women are almost 50% less likely to use illicit drugs compared with men. The male-to-female illicit drug use rate relationship is consistent throughout all ethnic groups. Ethnic comparisons of drugs used demonstrated that the highest rates of drug use occur in young adults aged 18–25.

White American men and women have higher rates of alcohol use than African Americans or Hispanic Americans (Table 10-3). For all alcohol-using groups, alcohol consumption is highest in young adults (18–25 yr).

III. Substance Abuse And HIV  TOP

Substance abuse is a major risk behavior for acquisition of HIV infection. The most recent HIV/AIDS statistics in the US show that 26% of women living with HIV/AIDS at the end of 2002 were infected through injection drug use (IDU). Non-injection drug use (NIDU) is also associated with increased risk of HIV infection, most likely related to high risk sexual behaviors. Use of illicit drugs and alcohol abuse are generally associated with larger numbers of sexual partners, increased rates of STIs, decreased rates of condom use, increased likelihood of sex with an injection drug user and, for illicit drugs, increased risk of exchange of sex for money or drugs (Woods, 2000; Molitor, 1998; Word, 1997; Sanchez, 2002). Crack cocaine use has been associated with increased likelihood of engaging in anal sex (Gross, 2000). Although IDU-related HIV transmission is most closely related to sharing injection equipment, a significant portion of transmission is related to sexual behaviors. Even after controlling for other potential risk factors, HIV infection rates tend to be higher among individuals who abuse alcohol (Petry, 1999). Individuals who abuse one drug or alcohol are more likely to use/abuse other substances as well. Over half of cocaine-dependent and 17–50% of heroin-dependent individuals abuse alcohol and alcohol use is associated with needle sharing in both heroin- and cocaine-abusing persons (Petry, 1999).

While under the effects of these substances, individuals have impaired decision-making ability or a reduced ability to understand or evaluate their actions. Disinhibition with drug use is known to decrease compliance with safer sex precautions or drug paraphernalia hygeine. Sex and drug-related HIV risk behaviors are strongly associated in women. Women acquire HIV, hepatitis B and C, and STIs often through sexual partnerships with injection drug users.

Among HIV-infected women, substance abuse is common. Although learning that she is HIV-infected may provide a woman incentive for stopping drug or alcohol use in order to better care for herself, it may also be more difficult to curtail substance abuse because of feelings of despair and hopelessness about the diagnosis of HIV. HIV status did not affect use of heroin or cocaine in a large cohort of HIV-infected and high-risk HIV-uninfected women followed for over 6 years (Macalino, 2003). In HIV cohort studies, 40–80% of individuals consume alcohol and rates of alcohol dependence are increased (Kresina, 2002).

The coexistence of substance abuse and HIV has a number of implications. The stigma and discrimination associated with drug and alcohol abuse, as well as the disorganization often seen in the lifestyle of those with active substance abuse, can lead to denial, delay in diagnosis of HIV, and reluctance to seek care. The signs and symptoms of drug and alcohol dependence, as the comorbidities associated with these conditions, may overlap with the signs and symptoms of HIV, further complicating and delaying early diagnosis and care. Such delays have been associated with increased morbidity and mortality in drug-using populations. The comorbidity associated with substance abuse, such as alcohol-induced liver cirrhosis or IDU-related hepatitis C, may accelerate HIV progression and/or significantly complicate HIV management. Active substance abuse is consistently associated with poor adherence to medical care and to antiretroviral medications. Individuals who are heavy alcohol users are one-fourth as likely to achieve virologic suppression on HAART as non-drinkers (Miguez, 2001). Both alcohol and methadone have potential drug-drug interactions with some antiretroviral agents, possibly increasing toxicity or decreasing effectiveness of ARV drugs.

Primary care providers are uniquely positioned to identify early indications of drug use-related HIV risks and signs of other comorbidities and to engage drug users in treatment at earlier stages of drug dependence. New and younger initiates to injection drug use engage in particularly high-risk behaviors for acquisition and transmission of infectious diseases and HIV (Carneiro, 1999). In primary care settings, interventions can be put in place to prevent further transmission (Anderson, 1996) of HIV or other infections. Misconceptions about the legal, social, and health implications of testing positive for HIV reduce early detection efforts, particularly among patients at high risk (Harvey, 1999).

IV. Comorbidity Related To Substance Abuse  TOP

Substance abuse is associated with a number of medical consequences and comorbid conditions, some of which are listed in Table 10-4. These conditions represent only a few of the many disease states either directly associated with substance abuse or exacerbated by substance abuse. Excessive alcohol use places women at risk for cirrhosis, epilepsy and dementia, psychiatric disorders, cardiomyopathy, peptic ulcer disease, pancreatitis, malnutrition, and malignancies. Intravenous drug use continues to be implicated in a number of infectious diseases, such as hepatitis and endocarditis, and smoking tobacco is the most common cause of lung cancer and airway diseases, and has been implicated in other malignancies such as cervical carcinoma (Waggoner, 1994).

The comorbid conditions related to substance abuse may delay diagnosis of HIV and complicate management of both HIV and substance abuse. Hepatitis C is a marker of poorer outcomes for HIV and has been associated with decreased survival and increased HIV progression. Some have postulated that HCV, rather than being the primary cause of poor outcomes, may be a marker of later access to care and injection drug use, based upon a cohort of 823 HIV infected patients with and without HCV co-infection. (Greub, 2000; Tedaldi, 2003; Sulkowski, 2002). Both HIV infection and alcohol abuse have been reported to accelerate hepatitis C-induced liver disease and when all three are present together, this effect may be magnified. End-stage liver disease has become the leading cause of death in specific patient populations with HIV infection, and coinfection with viral hepatitis and alcohol abuse appear to be the major risk factors for progression of liver disease and death (Kresina, 2002).

Treatment with highly active antiretroviral therapy (HAART) is associated with improved outcomes in patients with substance abuse and comorbidities such as hepatitis coinfection (Benhamou, 2001). This underscores the importance of timely identification and treatment of substance abuse and its sequelae, as well as HIV. In both substance abuse treatment programs and primary care clinics, strategies are needed to identify HIV and manage HIV and comorbid conditions associated with HIV and/or substance abuse or have established linkages into appropriate care.

V. Substance Abuse In Women  TOP

Women who use drugs and alcohol have different risk factors for initiating use, have accelerated progression to dependence (Zilberman, 2003), and have an increased vulnerability to the medical and psychosocial consequences of substance use as compared to men, and as such require different approaches for the diagnosis and management of drug use and its sequelae. Women need treatment plans and care sites that address their personal, social, and familial needs, but most addiction diagnosis and treatment paradigms have been based upon the experiences in treating male users. Family circumstances, stigma, community environment, social status, and the nature of her primary relationships all affect the treatment of substance abuse in women. Several studies suggest that women drug users are more socially isolated, depressed, and dependent upon partners than their male counterparts (Sanders-Phillips, 2002). Women who have experienced violence, whether sexual or physical, are more likely to use alcohol, as well as marijuana or crack cocaine (Fullilove, 1992; Miller, 2000). These women, often due to imbalances in the power of their relationships, as well as a past history of abuse, are less likely to insist upon condom use, placing themselves at risk for HIV and other STIs (Fenaughty, 2003; Amaro, 2000).

Underlying psychiatric conditions, such as depression or other psychiatric disorders, may influence initiation or continuation of substance use (“self-medicating” depression). The prolonged use of drugs or alcohol in this setting can exacerbate, rather than improve, these problems. Female drug and alcohol users as a group are more likely to suffer from depression and anxiety disorders than the general population or other medical groups. The strong association between drug use and alcohol abuse and mental health disorders is evident in environmental and genetic predisposition to addictive, impulsive, and compulsive behaviors and personality disorders. A conservative estimate is that over 50% of drug or alcohol-dependent women have one or more comorbid mental health conditions. Successful treatment of the drug or alcohol dependence is unlikely until their mental illness is treated.

Prevention intervention strategies for women with substance abuse must include both contextual relevance (eg, dealing with an IDU sexual partner) and real-world appropriate planning, such as condom use strategies in the setting of drug/alcohol intoxication. In addition to treatment of the underlying substance abuse and HIV, if present, treatment and prevention of comorbid conditions (eg, STIs, hepatitis C) are important, as these may facilitate sexual and perinatal transmission of HIV. Although they are growing in number, still relatively few treatment facilities accommodate women who are pregnant or have small children. Those sites that can address the medical, drug and alcohol use, and living circumstance challenges simultaneously will have the greatest appeal and utility for drug and alcohol-abusing women.

VI. Impact Of Societal Perceptions And Beliefs  TOP

Numerous social, moral, personal, and situational beliefs adversely affect a substance-abusing woman’s health. Historically, U.S. society’s response to drug addiction is punitive, stigmatizing, and prejudiced against drug users and their families. The negative public sentiment surrounding illicit drug use is especially evident in criminal justice sentencing practices. Health providers often share these views of drug users as unreliable and noncompliant. Value-laden judgments may affect provider willingness to treat this population and influence the care provided and therapeutic regimens prescribed. Providers may also be reluctant to raise the subject of substance abuse treatment with patients because of misconceptions about the effectiveness of treatment.

Women with drug and alcohol abuse are more likely to experience poor health and are less likely to access services, receive treatment, or seek health care, partially because of the stigma of substance abuse. Suspicion, fear, and distrust of the health care system result in reluctance among drug users to disclose medically necessary information. Negative sanctions, such as mandatory HIV testing during pregnancy and incarceration of drug-using pregnant women for child abuse, have intensified fears about contact with the health system. For economically disadvantaged women with HIV and drug abuse problems, the fear of discrimination, retribution, loss of housing, or loss of children may become more important than seeking or engaging in health services (Sly, 1997) and may keep them from receiving personally tailored prevention messages.

Individuals who are drug or alcohol dependent, even though they may exhibit dysfunctional behavior, retain the right to be evaluated as individuals and to be treated with respect and equality, regardless of conflicts in values or beliefs between patient and care provider.

VII. Identification Of Substance Use/Abuse  TOP

A. DIAGNOSIS BY HISTORY

Identification of substance use can be a challenge, given the myriad of illnesses it can mimic. However, the biggest barrier to identification is denial. Given the stigma associated with substance use, as well as the stereotypes associated with substance use, health care providers must entertain the diagnosis in all patients. Substance use must be a diagnosis to be excluded in the differential diagnoses of many medical conditions. Table 10-5 lists clues to a possible alcohol and drug abuse diagnosis. These clues include erratic behavior, agitation, disorientation, doctor “hopping,” child custody loss, and frequent unexplained accidents.

The diagnosis of drug and alcohol dependence is made by taking a careful history of drug and alcohol use, as well as a directed medical and psychosocial history; performing a complete physical evaluation; and laboratory testing for the presence of drugs and/or alcohol, or for the complications of drug and alcohol abuse.

The most commonly used instruments to detect and assess drug and alcohol abuse are the CAGE survey, the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) alcohol/drug abuse/dependence diagnostic criteria, and the Addiction Severity Index.

If the provider cannot get a sense of the patient’s substance use from unstructured questions, the CAGE survey offers a nonthreatening alternative approach. The CAGE survey is a four-question format intended to be used in primary care and other non-substance abuse-related health care facilities.

1. Have you felt that you ought to Cut down on your drinking or drug use?
2. Have people Annoyed you by criticizing your drinking or drug use?
3. Have you ever felt bad or Guilty about your drinking or drug use?
4. Have you ever had a drink or used drugs first thing in the morning (Eye opener) to steady your nerves, get rid of a hangover, or to get the day started?

There are several other simple alcohol-screening instruments, including TWEAK, T-ACE, Michigan Alcoholism Screening Test (MAST), Alcohol Use Disorders Identification Test (AUDIT), and Rapid Alcohol Problems Screen (RAPS). TWEAK (an acronym for Tolerance, Worry about drinking, Eye-opener, Amnesia, and Cut down on drinking) and AUDIT perform better than CAGE in women (Bradley, 1998). Both TWEAK and T-ACE have been validated for alcohol screening in pregnancy (Russell, 1994).

Screening tests like these can be very useful for getting substance-addicted patients into a trajectory for substance abuse care. Otherwise, these patients may be seen in different parts of the health care system for other problems, while the substance abuse is not identified or addressed.

Some patients will come to medical attention because of substance intoxication or withdrawal. As with substance abuse in general, entertaining the diagnosis and recognizing the constellation of signs and symptoms is critical to recognition of intoxication and withdrawal syndromes. Alcohol intoxication may be characterized by inebriation, sedation, ataxia, and slurred speech. However, this extreme of behavior is witnessed in only a subset of patients. Of the 113 million Americans age 12 and older who reported alcohol use, 33 million reported binge drinking (meaning they drank 5 or more drinks on one occasion 5 or more days during the past 30 days) (SAMHSA, 1999). Alcohol withdrawal can vary from agitation to the more florid syndromes associated with delirium tremens. This includes labile blood pressure, autonomic instability, visual hallucinations, and death. It should be noted that delirium tremens may be fatal if untreated. The mortality may be as high as 35%, but with early recognition and treatment, that risk decreases to 5% (Grossman, 2001).

Opiate intoxication is associated with sedation, including somnolence or “nodding.” There has been a resurgence in heroin popularity, with an estimated 81,000 new heroin users in 1997 (SAMHSA, 1999). Opiate withdrawal is characterized by the loss of central nervous system depression. These signs include piloerection, vomiting, diarrhea, agitation, irritability, and sweating. Cocaine, and its alkaline cheaper form, crack, are highly addictive. Intoxication with cocaine is associated with euphoria, as well as profound hypertension (secondary to vasoconstrictive effects). Increased pulse rate and dilated pupils are also associated with cocaine intoxication. Cocaine/crack withdrawal is associated with irritability, agitation, and mood lability.

The DSM-IV criteria for drug dependence are developed for the 11 classes of commonly abused drugs (including alcohol) and include 7 major criteria (Table 10-6). DSM-IV criteria determine dependence by finding evidence of physical or psychologic dependence on a drug or tolerance to it, disruption of social life patterns, and disregard of the negative medical consequences of using drugs. A person is considered to be drug dependent if they fulfill 3 of the 7 criteria within a 12 month period.

The Addiction Severity Index (ASI) (NIH, 1995) is most commonly used to help health care givers assess the severity of the drug and/or alcohol addiction in persons who are already determined to have a drug use problem and for whom a treatment plan must be developed. The ASI is a detailed, 1-hr assessment of environmental, historical, physiologic, and drug-related factors contributing to that individual’s drug use. The specific areas of evaluation include drug and alcohol use, psychiatric problems, legal problems, family/social issues, and employment/ support concerns. Physical and psychologic signs of drug use and changes in medical and mental health status are also assessed. The data accumulated by ASI information is useful for developing treatment plans that include lifestyle change goals. The ASI is also a useful instrument for assessing progress at different follow-up points because it is time-based and yields quantitative composite scores for each problem area.

B. DIAGNOSIS BY LABORATORY AND CLINICAL EXAMINATION

Substance abuse disorders are erratically diagnosed on physical examination for a number of reasons including: 1.) caregivers’ lack of interest 2.) lack of awareness of drug use signs or 3.) the signs may be subtle. Most drug and alcohol-dependent persons have jobs and lead a “normal” life, without the stereotypic dysfunction of severe alcoholism or injection and noninjection drug use. Cocaine snorting can be suspected by seeing a damaged nasal mucosa; hypodermic marks or “tracks” suggest injection drug abuse, although the absence of visible marks does not rule this out. The single most useful examination is of the eyes. Nystagmus is often seen in abusers of sedatives/hypnotics or cannabis. Mydriasis is often seen in persons under the influence of stimulants or hallucinogens or in withdrawal from opiates. Miosis is a classic hallmark of opioid effect. Evidence of multiple minor (or past major) injuries can also be a clue to possible substance abuse.

Drugs may be detected in almost any fluid or tissue in the body. The most common samples for drug tests are urine, blood, saliva, hair, sweat, and breath (Wolff, 1999). Urine testing is the most available and useful testing format. There are test kits that can be used in offices and at home and require simple collection of a urine sample. Urine test limitations, however, are numerous. These limitations include the ability to detect only recent drug or alcohol use, as seen in Table 10-7. Adulterated urine samples and changes in the acidity of the urine may prevent quantification of illegal drugs in urine. Blood testing is available to many caregivers but is more expensive and more cumbersome than urine analysis. Blood testing is more accurate at quantitative detection of drugs in the user. Saliva may also be useful and correlates well with drug levels in the blood. Hair analysis is a more recent technology and may be a future tool for drug detection. It has the advantage of detecting drug use over a 1–3-mo period, depending on a person’s hair growth rate. The reasons that the test is not used widely are that cosmetic hair treatments, i.e., hair bleaching, may change drug level results, in addition to other factors such as hair pigmentation and hair growth rate. Sweat testing is another noninvasive test that is more useful for monitoring drug relapse during drug treatment. It is designed to continuously monitor a person’s drug use over a period of time by placing a special absorbant pad on the skin. The pad collects microscopic amounts of sweat produced by the body over time and is analyzed later for presence of drugs. Breath testing is commonly used to estimate the concentration of alcohol in an alcohol user and is a reliable reflection of blood alcohol.

Overall, the urine tests are the most reliable tests for clinicians to use. However, test results may be difficult to interpret for the inexperienced care giver because the results may be confounded by secondary drug exposures, chemical characteristics of the drugs to be detected, drug level variations in different body tissues and fluids, and test method variations. Drug testing properly used is a useful adjunct to clinical and behavioral drug use assessment and a useful but limited drug use screening tool. Drug tests should not be used as the sole criteria for detecting substance use but, properly used, they are helpful during drug therapy, and follow-up.

VIII. Treatment Readiness And Harm Reduction  TOP

Substance abusers vary in their readiness to change their behaviors. Providers who are attuned to the patient’s stage of readiness (precontemplative to action-oriented) will have the greatest success in facilitating behavior change (Prochaska, 1992). Motivating factors for treatment readiness in women are most commonly associated with difficulty in raising their children or in response to interventions by social services departments (Brady, 1999). Unlike men, women are more likely to express their treatment readiness in nonsubstance use settings, especially in mental health care sites (Lex, 1991). For that reason, drug and alcohol treatment readiness should be evaluated in all health care settings.

For persons who are not ready for addiction treatment, caregivers can provide harm reduction interventions, aimed at reducing the damaging effects or harm resulting from risk behaviors and practices such as the sharing of syringes and other drug injection equipment and/or unsafe sex practices resulting from the use of drugs and alcohol (Des Jarlais, 1995). Comprehensive strategies that can effectively target high-risk populations consist of a hierarchy of risk reduction approaches that, depending on the composition and needs of the populations being served, may include needle exchange programs or community outlets providing condoms (Sumartojo, 1996). Sexually transmitted infection prevention programs, education programs, social and work skills building programs, and health and drug/alcohol use treatment programs should be provided through community resources. Programs targeting drug- and alcohol-using populations and subpopulations are all useful in preventing diseases such as HIV, STIs, hepatitis, and tuberculosis and should eventually lead to encouraging the substance user to seek help in stopping drug or alcohol use (Needle, 1997).

A patient’s history and behavior may be more predictive of treatment readiness, potential for engaging in care and adhering to therapeutic regimens than provider judgments based on gender, race, or ethnic background. There is a direct relationship between patient adherence with substance abuse treatment and the quality of the patient-provider relationship; however, the lack of physician training in the care of injection and other drug or alcohol abusers and the negative attitudes about drug use pose significant barriers (Laine, 1998).

IX. Treatment Of Substance Abuse  TOP

A. TREATMENT PROGRAMS

The most effective treatment programs are comprehensive, multidimensional, and can be effectively delivered in outpatient, inpatient, and residential settings. In addition to behavioral (counseling, cognitive therapy, or psychotherapy) and/or pharmacologic therapies, the patient may need other medical services, family therapy, family planning, violence prevention, parenting instruction, vocational rehabilitation, and social and legal services (Table 10-8).

Treatment programs should also provide repeated assessments for HIV, hepatitis B and C, tuberculosis, and other infectious diseases, as well as noninfectious diseases like diabetes and hypertension, and counseling and referral for relevant mental health treatment.

The most successful treatment occurs when the environmental, social, behavioral, medical, and addiction problems are found early and treated over a long period of time (more than a year). Though it would be desirable to detect and treat drug use and alcohol abuse early after onset, when patterns of use are more easily treated or modified (Coates, 1998), most drug treatment modalities target more advanced stages of dependence, when medical or legal interventions are needed. Most patients do not seek treatment until symptoms and associated consequences are severe. Women’s drug use problems tend to occur at an older age of onset and develop more rapidly than in men. Women also often learn of their HIV infection and other comorbid conditions much later than men. The late diagnosis of drug use and other diseases may result in shorter survival. The confluence of factors that complicate health care for female substance abusers underscores the importance of early engagement and retention of women in care.

Effective treatment of drug dependence produces reductions in drug use by 40–60%, significant decreases in criminal activity during and after treatment, and increases in full-time employment. Effective treatment also reduces risk of HIV transmission (as well as other infectious diseases) by a reduction in risky behavior. Methadone treatment programs have consistently been linked to lower rates of HIV infection (Metzger, 1993). Similarly harm reduction interventions also play an important role in decreasing risky behavior. In a prospective study of 259 untreated injection drug users, syringe exchange programs demonstrated a two to six-fold decreased odds of HIV risk behavior. These findings were most pronounced for those individuals without other sources of syringes (Gibson, 2002). Establishing accessible care in primary care settings offers countless opportunities to initiate prevention and treatment interventions targeted to adults, adolescents, and other population groups at risk for drug and alcohol abuse and associated problems. Easy health access for women is particularly important because their motivation for drug use/alcohol abuse is most often to cope with negative mood or anxiety (McCaul, 1999). Providers should be accessible and should monitor individual triggers for stress and levels of stress sufficient to produce drug use complications or relapse.

B. PHARMACOLOGIC INTERVENTIONS

Today even the most severe physical withdrawal symptoms can be managed with appropriate pharmacologic treatments, reducing the complications of physiologic dependence in the treatment of drug dependence. Drugs for alcohol and sedative-hypnotic dependent persons are important for controlling and preventing serious medical consequences of drug withdrawal while other medications like methadone can help stabilize a patient and facilitate a return to productive functioning. Other important pharmacologic interventions include the treatment of comorbid conditions common in drug and alcohol abusing populations. Use of antidepressants in psychiatrically impaired substance abusers is as important as therapies directed to the effects of the drugs of abuse.

The pharmacologic treatments for drug use are well known but not well understood by many health caregivers. Several classes of medications may be used to treat, modulate, or prevent drug use.

Opiate Addiction

Opiate agonist drugs like methadone, 1-a-acetyl-methadol (LAAM) and buprenorphine are used as opiate substitutes for opiate-dependent persons. These three drugs, used to treat addiction, block the ability of the illicit drugs to attach to opiate receptors, therefore decreasing a person’s craving for the drug without causing euphoria. This is the most misunderstood medical approach to addiction treatment. Although methadone, LAAM, and buprenorphine are addictive, they are successful in helping addicts to stop their negative and harmful behaviors associated with drug use and begin to concentrate on developing the skills to discontinue drug use entirely. It is the drug craving that is associated with drug use relapse and criminal behavior and it is its prevention that makes substitution medications work successfully as part of a drug treatment program. Methadone suppresses withdrawal for 24 hr (four to six times the duration of the effects of heroin) and decreases or eliminates drug craving; it is not sedating, can be dosed once a day, and can be administered orally. Furthermore, it is medically safe even when used continuously for 10 years or more.

LAAM is a newer synthetic opiate resembling methadone. LAAM can block the effects of heroin for up to 72 hr with minimal side effects when taken orally. Its long duration of action permits dosing just three times per week, thereby eliminating the need for daily dosing and take-home doses for weekends.

Buprenorphine is a partial opioid agonist which has recently been approved by FDA for office-based and program-based treatment of opiate addiction. Some of the advantages of using buprenorphine are milder withdrawal symptoms, lower risk of overdose, and availability to patients in the offices of physicians trained and certified in the use of the medication. If used in the proper dosage, buprenorphine is as effective as methadone or LAAM.

These substitution medications are not a cure for drug dependence but important adjuncts to care. It has been shown that while an opiate user is on methadone, she is much less likely to commit a crime and more likely to succeed in completing a drug treatment program. When combined with behavioral therapies or counseling and other supportive services, these pharmacologic approaches are highly effective for treating heroin addiction, particularly in those with long-term dependence and repeated prior treatment failures.

Antagonist medications like naloxone and naltrexone block the effects of morphine, heroin, and other opiates. As antagonists, they are especially useful as antidotes. Naltrexone, with a duration of action ranging from 1 to 3 days depending on the dose, blocks the pleasurable effects of heroin and is useful in treating some highly motivated individuals, such as professionals who do not want to lose their jobs. It is also successful in preventing relapse by former opiate dependent individuals released from prison on probation.

Alcohol Addiction

Antabuse (disulfiram) is used in the context of alcohol abuse treatment to cause negative effects when the patient consumes alcohol. The drug interferes with alcohol metabolism, causing the production of acetaldehyde, a noxious chemical that causes severe flushing, nausea, and vomiting. The effectiveness of therapy is dependent on patient adherence to a daily medication dose. Acamprosate (Putzke, 1996) is a newer drug currently used in Europe that increases alcohol abstinence and decreases craving by affecting g-aminobutyric acid and glutamate brain receptors. Naltrexone also has been found to decrease alcohol craving and relapse. It was approved in 1994 by the FDA for the treatment of alcohol dependence (Volpicelli, 1992; Anton, 1999).

Cocaine Addiction

There are no effective medications for treating cocaine addiction but in some cases treating comorbid mental health problems may improve chances of stopping cocaine use in the cocaine or crack-dependent person. Pharmacologic therapies have been specifically targeted at decreasing the dysphoric effects of cocaine withdrawal. Unfortunately, studies examining antidepressant medications targeting numerous neuron targets and multiple generations of antidepressant medications such as fluoxetine, sertraline, maprotilene, phenelzine, trazodone, and lithium have not proven successful in assisting a person to permanently stop cocaine or crack use (McCance, 1997). Dopaminergic agents such as bromocriptine, amantadine, haloperidol, bupropion, and others have also not been proven to be effective. However, in studies using desipramine, carbamazine, and bupropion, the mental health effect of these drugs was clinically helpful for a patient’s successful drug cessation in drug treatment programs (Kranzler, 1999).

Detoxification

Detoxification is used either to prevent serious medical or psychologic complications of drug withdrawal from alcohol or sedative hypnotics or to ease the symptoms of withdrawal from the other drugs that do not have withdrawal syndromes with any significant morbidity or mortality (all other drugs of abuse) (Prater, 1999). In either case, detoxification protocols are not treatments for drug use but are part of a drug use treatment strategy.

Detoxification of alcoholics and sedative hypnotic users will prevent severe and sometimes fatal complications of drug withdrawal. For alcoholics, chlordiazepoxide (Librium) sedation is an important part of patient therapy. In most persons with alcohol dependence detoxification with a benzodiazepine can be completed on an outpatient basis with supportive care. However, about 10% of alcohol-dependent persons will have sufficiently severe withdrawal symptoms, histories of withdrawal complications, or other comorbid illnesses that require in-patient management. If a woman is pregnant, Librium should not be used. Alternative medications, especially for persons with severe liver disease are lorazepam (Ativan) and oxazepam (Serax). In conjunction with the sedatives, thiamine to prevent Wernicke-Korsakoff syndrome and clonidine or β-blockers to control noradrenergic symptoms may be helpful. Withdrawal from sedative hypnotics is characterized by severe, chronic anxiety, which may need long-term controlled, tapering doses of sedatives. Carbamazine (Tegretol) and valproic acid have also been used to control anxiety in sedative-hypnotic patients (Eickelberg, 1998).

Detoxification for other types of drug abuse is useful for diminishing the symptoms of drug withdrawal but does not have any long-lasting beneficial effect on the drug user. For example, clonidine (Gold, 1979) and lofexidine (Bearn, 1996) are used in this way because they decrease the adrenergic symptoms of opiate withdrawal. These measures are short term and do not address the true underlying problems of drug use. Even though the effects of detoxification are only short term, it is one of the few drug use interventions reimbursable in most health systems (O’Brien, 1997).

New Pharmacologic Approaches

The combined use of antagonist-agonist medications has been evaluated for drug treatment, with the biologic objective of preventing activation of opiate receptors and other drug use–related cell receptors. Research has found that treating nicotine-addicted persons with mecamylamine prevents smoking relapse (Rose, 1994). This may be a useful adjunct therapy for persons in tobacco cessation programs.

Anticraving medications are used to prevent a person from wanting to take the drug. The biology and psychology of craving and its prevention are not well understood but it has been proven to be effective in treating addiction to nicotine. Bupropion (Wellbutrin, Zyban), an antidepressant medication, has been successfully used to treat cigarette craving (Ferry, 1999).

Vaccines against addictive drugs are intended to block the binding of illicit drugs to their cellular receptors. Although no vaccines are currently available for human use, there is evidence that a vaccine against cocaine may be possible to develop. Much future research is planned in this area.

C. COGNITIVE/BEHAVIORAL INTERVENTIONS

Behavioral and cognitive interventions are a vital part of drug and alcohol addiction treatment and prevention. Cognitive-behavioral therapies are based on the assumption that learning processes play an important role in the development of drug use and dependence and therefore are important in efforts to reduce use and dependence. Behavioral methods are employed to identify high-risk relapse situations, extinguish triggers to drug use, develop self-monitoring of use behavior, and establish competing coping responses. By learning to recognize situations conducive to substance use, patients can develop individual coping strategies to avoid circumstances that place them at risk for relapse. Perhaps the single most important factor for short- and long-term relapse prevention is the learning and application of individual coping skills. Avoidance of other drug users and drug use environments are key tools for maintaining abstinence. Brief interventions with as little as 5 minutes of education and counseling about safe drinking guidelines, the consequences of alcohol on health, the patient’s medical status, and the improvements that may occur if alcohol use is stopped or reduced, have been shown to be effective in reducing alcohol consumption and its medical and social consequences in general medical settings and may be of use in HIV clinics as well (Petry, 1999). Five to 15 minute interventions have also been shown to be effective in increasing smoking cessation rates (Dolan-Mullen, 1999).

There are at least 11 research-validated therapies using a variety of behavioral, social, and incentive-based systems to treat drug use (NIH, 1999). The objectives of the different programs include removing patients from stressful environments to get care (short-term and long-term residential homes), providing alternatives to pharmacologic treatment (outpatient drug-free programs), and providing community-specific interventions (community-based programs for drug users and recently released criminals). There are several psychotherapy programs, based on the patient’s willingness to recognize drug use as a problem and to stay off drugs, with or without incentives.

The 12-step self-help groups/meetings are important nonmedical, behavioral drug use intervention and prevention activities used by 10–15 million Americans in 500,000 or more groups (Goldsmith, 1989). These meetings emphasize fellowship and provide support for maintaining abstinence from alcohol, other drugs, or addictive behaviors like overeating. These programs are not intended to replace medical and behavioral drug use treatments but are meant to add to their effectiveness. The largest 12-step groups are Alcoholics Anonymous; Narcotics Anonymous, for all drug users including alcoholics; Al Anon, to support family and friends of alcoholics and drug users; and Overeaters Anonymous (Chappel, 1999). In 1976, Women for Sobriety was established as a 12-step program to help women, when it was recognized that Alcoholics Anonymous did not address adequately the specific needs of alcohol-dependent women (Katkulas, 1996). Rational Recovery, a self-help group based on cognitive/behavioral principles, is also available in many large cities.

X. Predictors Of Drug Treatment Retention And
The Durability Of Treatment Gains  TOP

Predictors of treatment retention include high motivation, legal pressure, receiving psychologic counseling while in treatment, no prior violations of the law, and an absence of other psychologic problems (NIDA, 1998). Specific characteristics, such as injection drug use, age, race, socioeconomic status, level of education, and occupation do not predict adherence to drug treatment programs. The most accurate predictors of drug program retention and medication adherence are health care beliefs, health care access, familiarity of the treatment setting, availability of case management social support, and perceived support from the clinical staff.

Provider and patient recognition of the chronic nature of drug addiction and the need for long-term treatment is essential to successful and durable addiction care. It has also been shown that lasting reductions in drug use are greater for patients who remain in treatment for a minimum of 3 mo or longer (Simpson, 1997) and are treated with a combination of medical, behavioral and cognitive treatments.

Available treatment options continue to expand, providing therapeutic combinations that, when appropriately matched to patients’ specific treatment needs, can increase the patient’s chances of staying drug-free (McLellan, 1997). Treatments taking care of a patient’s specific social and personal needs increase an individual’s chances of successfully completing the treatment program and have improved posttreatment outcomes. Treatment for women that is woman-focused and targets the unique needs of women, including their children; interpersonal, cultural, and contextual issues; and employment and housing considerations are also known to increase effectiveness (Metsch, 1995). Participation in these programs enables women with children to develop stronger life and social skills to ensure stable independent living practices (Hughes, 1995).

XI. Relapse  TOP

Drug addiction is a chronic disease characterized by periodic drug use relapses. Although many treated persons relapse, it is wrong to conclude that treatment has failed or that the individual is hopeless. Like diabetes, hypertension, or other chronic diseases, the individual with a substance abuse problem will need frequent and long-term follow-up to maintain a drug-free state. Not surprisingly, simultaneous treatment for concurrent medical, mental health, and drug use problems offers significantly higher rates of success. The interventions that successfully address comorbidity maximize linkages between school, community, clinic, and other health service delivery systems. Woman-focused HIV prevention interventions include overcoming gender, cultural, and power barriers that increase risks, such as learning negotiation strategies for gaining partner acceptance for condom use, dealing with parenting responsibilities, and resolving interpersonal conflicts. The relative success and durability of approaches that have multiple and mutually reinforcing outcomes depend on coordination among professional and material resources in a rational, systematic, and cost-effective manner.

Treatment should be judged by the same criteria used for other chronic disease interventions: Will it help lengthen the time between relapses, ensure the individual can function in society, and minimize long-term physical damage?

XII. Substance Abuse In Pregnancy  TOP

It is difficult to determine the true prevalence of substance abuse by pregnant women. Stigma, criminal laws regarding child endangerment, and denial all contribute to the epidemiologic conundrum. Cross-sectional studies at large urban centers, given the high-risk populations served, may overestimate community drug use health problems. In 1990, a Centers for Disease Control and Prevention study in Rhode Island revealed a statewide prevalence of illicit drug use of 7.5% (CDC, 1990). A cross-sectional study in Florida revealed that 15% of unselected women had evidence of recent drug or alcohol use on urine toxicologic screening (Chasnoff, 1990). Punitive approaches to the problem of substance abuse during pregnancy risk threatening privacy rights. These approaches further serve as deterrents to health-seeking behavior, and may further threaten the health of women and children.

The sequelae of substance use in pregnancy is beyond the scope of this chapter, however, a few specific drugs will be highlighted.

Smoking tobacco during pregnancy is associated with increased perinatal mortality, bleeding complications in pregnancy, low birth weight infants and preterm delivery and a possible increase in behavioral and learning problems among school-aged children whose mothers smoked during pregnancy (ACOG, 1997; Milberger, 1996). It is estimated that there could be as much as a 10% reduction in fetal and infant deaths if all pregnant women stopped smoking (Kleinman, 1988).

Alcohol use in pregnancy is associated with risk of fetal alcohol syndrome. This congenital syndrome is characterized by three findings: growth retardation, facial abnormalities, and central nervous system dysfunctions. Skeletal abnormalities and structural cardiac defects are also seen in the fetal alcohol syndrome, but it is the performance deficits that are most obvious. Decreased IQ, fine motor dysfunction, and hyperactivity are all common findings (ACOG, 1994).

Cocaine use in pregnancy poses maternal as well as fetal hazards. Some of these stem from the intense vasoconstriction associated with cocaine (malignant hypertension, cardiac arrhythmias, and cerebral infarction). Cocaine has been associated with premature rupture of membranes, preterm labor and delivery, growth retardation, cognitive development delays, and placental abruption. There are also documented cases of in utero fetal cerebral infarction (MacGregor, 1987).

Opiate addiction during pregnancy also poses serious risk to the mother as well as the fetus. Newborn infants of narcotic-addicted mothers are at risk for several complications, including the potentially fatal narcotic withdrawal syndrome. Withdrawal syndromes may appear 24 hr after birth, but may be delayed as long as 10 days after birth (Levy, 1993).

Beyond the medical ramifications for the mother and the fetus, substance abuse in pregnancy raises the specter of the legal system. There have been at least 200 women, in 30 states, criminally prosecuted for using illicit drugs or alcohol during pregnancy (Jos, 1995). Actions such as these have the potential to turn the provider into a law enforcement officer, and ultimately to drive away from prenatal care the very women who most need it. The conundrum of substance abuse in pregnant women and how society can best approach the problem continues. Providers should focus on screening and assessment of substance abuse and referral of pregnant women with drug and/or alcohol abuse into care and treatment.

XIII. Antiretroviral Therapy In Substance Abusers  TOP

There is often a lack of compassion toward people who have contracted HIV through stigmatized behavior, such as drug use (Hajela, 1998). Such sentiments are compounded by perceptions about adherence among drug users and the threat to public health associated with nonadherence leading to multidrug-resistant strains of HIV or other infectious diseases (Gourevitch, 1996). These assumptions may lead to blanket denial of appropriate antiretroviral therapy to individuals with a past or current history of substance abuse.

Although active substance abuse (including alcohol, cocaine, and heroin) is associated with nonadherence, patient readiness for antiretroviral therapy must be carefully assessed on an individual basis, and those who have been treated for drug dependence may be even more adherent than the general population or other medical groups. However, drug users are less likely to receive care, and injection drug users are among those least likely to receive antiretroviral therapies even when these treatments are available and free (Shapiro, 1999). Demographic characteristics of patients, including race/ethnicity, sex, age, and socioeconomic status are generally not predictive of medication adherence, although depression and low literacy have been associated with poorer adherence to HAART (Stone, 2001). Another challenge in the management of HIV infection in a substance-abusing woman is to recognize the potential for drug interaction between methadone, as well as street drugs, and antiretroviral therapies. The clinical experience in this area is limited; however, there are well-recognized drug interactions between certain antiretroviral therapies and methadone. Of the nucleoside reverse transcriptase inhibitors, only abacavir has been associated with an increase in methadone clearance. Both nevirapine and efavirenz are associated with significant decreases in the methadone level with opiate withdrawal a common consequence. As this increases the potential for heroin relapse, it is essential that this potential outcome be discussed with patients in advance of the prescribing of these therapies, with a clear plan to address this possibility with the patient’s drug treatment provider (ie, increasing methadone dose). Alterations in methadone levels have been seen with the protease inhibitors; however lopinavir/ritonavir has been associated with decreases in methadone levels and subsequent opiate withdrawal (see Table 10-9).

With newer ARV agents and dosing schedules allowing once-a-day antiretroviral regimens, the possibility of directly observed therapy (DOT), particularly in the setting of methadone clinics, offers a practical solution to concerns about adherence for patients in these settings.

XIV. Criminal Justice Settings  TOP

Women are the fastest growing segment of the prison population, and their drug-related crimes are increasingly more serious (FBI, 1997). Criminal justice reports show that substance use is implicated in the incarceration of 80% of men and women in state, federal, and local prisons. Persons either violated drug laws, stole property to buy drugs, have a history of substance abuse or addiction, or engaged in some combination of these (Maruschak, 1997). The more prior convictions an individual has, the more likely s(he) is to be drug dependent.

The most serious offense for 40% of women in state and federal prisons is the violation of drug laws. The enactment of mandatory sentencing policies has been associated with a 10-fold increase in the number of women incarcerated for drug crimes between 1986 and 1996.

Statistics show alcohol present in 31% of crimes, a combination of alcohol and other drugs in 16%, and other drugs alone 9%. A recent study confirms that alcohol has a high association with violent crime: twenty-one percent of violent felons in state prisons committed their crimes while under the influence of alcohol alone.

State officials have estimated that 70–85% of inmates need some level of substance abuse treatment; however, only about 13% actually receive treatment (Harlow, 1997). Those individuals with substance abuse histories are also more likely to have a history of physical and sexual abuse (National Minority AIDS Council, 1997). Criminal justice reports attribute the overwhelming majority of AIDS cases among inmates to injection drug use, with an incidence of new AIDS cases among inmates 17 times higher than that in the general population.

Inmates who have received appropriate treatment in prison are 50–60% less likely to be arrested again during the first 18 mo after release. For each offender who successfully completes treatment and returns to the community as a sober citizen with a job, it is estimated that reduced crime and arrest, prosecution, and incarceration costs, health care savings, and potential earnings accrue in the first year after release (Califano, 1998). One study found that total savings can exceed costs by a ratio of 12 to 1; another found that for every $1 invested in drug treatment, there is a return of up to $7. Levels of criminal activity have also been shown to decline by two thirds from the period before treatment to a comparable period after treatment.

XV. Conclusion  TOP

Drug and alcohol abuse have strong associations with HIV and other comorbid medical and psychiatric problems. Substance abuse may increase risk for HIV and other STI acquisition/transmission; may delay identification of HIV and entry into care; and may complicate management of HIV and other disorders. Women with substance abuse problems have special needs and require unique approaches to management. Health care providers should screen all women (including pregnant women) for drug and alcohol use/dependence and be knowledgeable about appropriate referrals and linkages. HIV prevention and treatment interventions should be part of comprehensive substance abuse treatment services and all HIV-infected women with drug and/or alcohol abuse problems should have access to substance abuse treatment.

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