Chapter 13
Management Of Substance Abuse

Henry Francis, MD

Assessment of Substance Abuse Problems   TOP

What is the definition of a substance abuser?

A substance abuser is an individual who repeatedly uses an addictive substance or performs a certain behavior even with the knowledge of its negative health consequences. A person is drug dependent or addicted if he or she uses drugs repeatedly despite the social, interpersonal, or other problems associated with their use and has a physical or psychological tolerance to the drug and experiences withdrawal symptoms after the effects of the drug wear off. Long-term drug abuse can interfere with normal brain activity and metabolism and can become a chronic, relapsing condition characterized by compulsive drug craving and drug seeking. There are other kinds of addiction that may not involve the use of substances, such as gambling, sex, and eating-related disorders, all of which involve a range of dysfunctional behaviors with undesirable social, medical, and economic consequences (see Table 13-1).

How should primary care providers address substance use problems in their patients?

The first task is to consciously look for behavioral and physical signs of maladaptive drug use and to use a simple screening tool such as the CAGE examination (described below) to detect it. Common indicators of drug abuse are frequent absence from work or school, recurrent injuries, motor vehicle accidents, depression, anxiety, labile hypertension, sleep problems, sexual dysfunction, or abdominal symptoms. Physical signs of drug abuse such as tremor, liver disorders, and physical changes such as nasal irritation caused by cocaine are well known to health care providers.
The second task is to tell the patient his or her diagnosis of drug abuse or dependence. Providers are often concerned about upsetting a patient with a stigmatizing diagnosis. Giving a concise, objective description of clinical findings without making judgments is important. Common pitfalls for providers to avoid during this discussion are listed as the DEATH Glossary (Table 13-2).

Table 13-2. The DEATH Glossary
Common Pitfalls for Providers to Avoid when
Diagnosing Drug Abuse Problems

	Details are not relevant; talking with a person on drugs is not useful. The simple issue here is talking to the patient when he or she is sober, ie, has not taken a drug before the visit.
	Do not spend much time on how drug use started but focus on getting the person to treatment.
	Avoid arguing at all costs. No meaningful conversation will occur in an argument.
	Guilt and shame do not promote recovery from chemical dependency. Threats or evoking guilt will not promote successful therapy.
	Hedging hurts your credibility. Being ambivalent about giving the diagnosis will not help the patient. If the patient disagrees with you, unequivocally agreeing to disagree is a valid starting point for getting to successful recovery.

 

The third task before sending a patient to treatment is to try a brief intervention in the office. It has clearly been shown that brief interventions given in community centers, hospitals, and ambulatory clinics decrease the morbidity and mortality associated with drug abuse (see Suggested Resources). For physicians who have received training on buprenorphine treatment for opiate addicts, there is the added opportunity to treat opiate drug users in the private practice setting without referring the individuals to drug use centers (see section on Treatment of Substance Abuse below).

Why is substance abuse such a big issue in HIV care?

Injection drug use is estimated to be responsible for 25% of HIV transmission in the United States and is directly or indirectly responsible for 57% of HIV transmission to women. Less well appreciated is the fact that drug-using behaviors may be a significant HIV transmission risk factor for many men who do not inject drugs. In a recent study of men who have sex with men (MSM), up to 16% may have drug use as a risk factor for acquiring HIV (Chesney, 2003). The high degree of association between injection and noninjection drug use underscores the importance of primary care providers' being able to diagnose drug using behaviors.

Diagnosing drug or alcohol dependence or addiction is not an easy task. Many people who are addicted to alcohol or drugs attempt to conceal or deny that they have an addiction. In addition, diagnostic tests for drug dependence and addiction lack specificity and sensitivity. Although blood and urine tests are usually quite reliable at detecting recent drug use, individuals can be adept at avoiding being tested or at manipulating test results. See Table 13-3 for the duration of time substances are detectible in urine.

Are there tools to help providers assess patients for drug and alcohol use?

Experts in addiction medicine use a combination of behavioral and clinical testing to diagnose drug abuse. There are 9 commonly used drug-use screening tests: Addiction Severity Index (ASI), Alcohol Dependence Scale, Alcohol Use Disorders Identification Test (AUDIT), CAGE (see below), Clinical Institute Withdrawal Assessment for Alcohol, Revised (CIWA-Ar), Drinker Inventory of Consequences (DrInC), Michigan Alcohol Screening Test (MAST and SMAST), Problem Oriented Screening Instrument for Teenagers (POSIT), and Self-Administered Alcoholism Screening Test (SAAST) (American Society of Addiction Medicine, 1998). Six of them are specifically designed to detect alcohol use.

Which screening tests are most useful in primary care practice?

The CAGE test is a non-threatening quick screening test for detecting drug use in adults (see Table 13-4) and the POSIT test useful for screening adolescents aged 12-19. The questions below are designed to assess key substance-using behaviors. The letters in CAGE correspond to important emotions or behaviors indicative of drug use.

Table 13-4. The CAGE Indicators of Drug Use

	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, to get rid of a hangover, or to get the day started?

 

The Problem Oriented Screening Instrument for Teenagers (POSIT) examination is a 139 item yes/no questionnaire for assessing adolescent risk factors in substance abuse, physical health, mental health, family and peer relationships, educational and vocational status, social skills, leisure and recreation, aggressive behavior, and delinquency. A nonexperienced provider can conduct the test in 20 to 25 minutes. The questionnaire is available free in English and Spanish from the National Clearinghouse for Alcohol and Drug Information by mail at P.O. Box 2345, Rockville, MD 20847-2345 or by telephone at 1-800-729-6686.

What would provide a more in-depth assessment of drug and alcohol use?

Two detailed evaluations of drug and alcohol use are the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) and Addiction Severity Index (ASI) for alcohol or drug use. The DSM-IV defines the diagnostic criteria for substance dependence as a maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by 3 or more of the following, occurring at any time in the same 12-month period:

1. Presence of drug withdrawal symptoms
2. Escalation of drug doses
3. Persistent inability to reduce or control drug use
4. Increased time spent obtaining drugs
5. Personal and business activities reduced by drug use
6. Development of drug tolerance
7. Knowing drug use's negative health and personal effects, yet continuing to use drugs
   

Treatment of Substance Abuse Problems   TOP

What should you do before referring a person for treatment?

The decision to refer a person for drug abuse treatment should come after the provider has detected a substance use problem, conducted initial evaluations to determine the degree of drug use and physical harm done by the drug use, and provided brief interventions to stop drug abuse. After the diagnosis and brief interventions (if appropriate), the provider should refer the patient to a drug treatment system or an addiction physician.

What role does the primary care provider's attitude play in successful drug abuse treatment?

Drug abuse treatment is successful if the provider addresses his or her own biases about addiction, understands the factors contributing to addiction, provides appropriate pharmacologic and behavioral care, and recognizes that drug addiction is a chronic disease problem. Many drug abuse treatment failures are associated with hostile or unsupportive providers whose behaviors are based on the assumption that drug use is voluntary. Since successful drug abuse therapy depends on adherence to treatment regimens, any factors that facilitate adherence will foster successful treatment outcomes. The patient's perception that the primary care provider is nonjudgmental and supportive is an essential factor in successful therapy.

How can the primary care provider enhance the success of drug abuse treatment?

The primary care provider must prevent or treat exogenous factors that negatively affect successful drug abuse therapy. We now recognize significant environmental (social), genetic, biologic, and behavioral factors that facilitate drug addiction:

Environmental factors Common factors are family or sibling drug use, poverty, poor education, and homelessness. Patient referral to social services and family referral into drug treatment will facilitate the patient's therapy.

Genetic factors Ten percent of drug users have multifactorial genetic predispositions to drug use. Many patients have significant severe drug use problems requiring care from addiction specialists as soon as possible.

Biologic factors Many patients have preexisting mental health problems such as depression and attention deficit and hyperactivity disorder (ADHD) which, if recognized and treated, may prevent or modulate drug use.

Behavioral risk factors For adolescents, peer pressure is a common cause of drug use. Early education by parents and the primary care physician about drug use are very important for preventing drug use by adolescents.

What is the role of drug detoxification in drug abuse treatment?

Drug detoxification is the transitional therapy between identifying drug abuse and beginning a comprehensive program to treat it. The objective of drug detoxification is to facilitate a safe drug withdrawal process in supportive surroundings. Detoxification is not a treatment or cure for drug addiction; it is an intervention to get a person to the stage of comprehensive drug abuse therapy. Two common medical interventions to modulate symptoms are benzodiazepines in alcohol withdrawal and clonidine in opiate withdrawal.

What are the components of a comprehensive drug abuse treatment plan?

Effective drug abuse treatment encompasses a combination of behavioral and pharmacologic therapies to treat the individual's particular substance abuse problems and needs. Drug use medication is only one element of successful, comprehensive drug treatment, which includes addressing the individual's medical, psychological, social, vocational, and legal problems (see Table 13-5). Behavioral drug abuse prevention and treatment programs are provided in residential settings and in prisons. These programs may provide medications to treat drug abuse, medical treatment for coexisting illnesses, and /or behavioral interventions using a number of personal, family, and community interventions. The most important community interventions are the 12-step or self help programs such as Narcotics Anonymous, Cocaine Anonymous, and Alcoholics Anonymous.

What should you do after the patient has completed a drug treatment program?

The primary care provider's task in assuring successful drug addiction treatment is to treat drug abuse as a chronic disease. Drug abuse treatment is effective if provided correctly and consistently. Approximately 50% of alcoholics, 60% of opiate addicts, 55% of cocaine addicts, and 30% of nicotine (cigarette) addicts are successfully treated. Note the success rate is generally lower for the legal addictive drugs, which may be because of ready access to those substances. For the illicit drug addictions, success occurs only if the drug abuse therapy is given on a continual basis for the lifetime of the patient. Drug use studies have clearly shown that drug abusers will relapse as any patient would who has a chronic disease. In direct comparisons, drug-addicted patients are actually less likely to relapse into addiction and are more adherent to their medication than persons with diabetes mellitus or hypertension.

How do you use maintenance medications in treating drug abuse?

Maintenance treatment medications, important adjuncts to comprehensive drug abuse and dependence treatment, are used in the same way the nicotine patch is used for cigarette smokers. The medications help stabilize the drug user by reducing drug craving and thereby reducing high-risk behaviors associated with acquiring illicit drugs to attain the drug-induced high. Medication is used most effectively by patients who have good social support and higher education levels and are highly motivated to get off illicit drugs.

What are the common medications used in drug abuse treatment?

Use of medications to treat illicit drug use is limited because most of the approved medications are for opiate addiction and alcohol abuse. Effective opiate addiction medications are divided into 2 classes: opiate agonists and opiate antagonists. Opiate agonists are used to substitute for the opiate without causing the euphoria associated with drug abuse. The opiate agonists include methadone, L-alpha-acetyl-methadol (LAAM), and buprenorphine, which has recently been approved for medical use in the United States (Johnson, 2000). The other class is the opiate antagonists, the most important of which is naltrexone. Buprenorphine, actually a partial agonist-antagonist, may be used by physicians who undergo an 8-hour training course on how to use the medication. This medication has the highest potential for providing care in the private practice setting. Details for obtaining buprenorphine training and certification are available at the Office of Substance Abuse and Mental Health Administrations website, in the addiction treatment section under office-based therapies.

How do you detect, manage, and prevent relapse?

After the patient has been treated and is off drugs, the responsibility of the primary care physician does not end. The most common complication after patients have stopped using drugs is relapse. Four points to remember: 1) relapse should be expected to occur in most users; 2) on average 3-4 episodes may occur before complete abstinence; 3) relapse is not a treatment failure; it is a time to intensify treatment; and 4) the primary care provider is critical in preventing episodes of relapse. The most critical issues for the primary care provider to keep track of in the detection and prevention of relapses are to:

• Provide close followup.
• Do not make medical care dependent on drug abstinence.
• Recognize missed appointments as a sign of relapse and need for followup.
• Encourage and monitor the drug treatment/sobriety program of the patient.
• Treat comorbid psychiatric conditions aggressively.
• Identify drug use trigger points with the patient and discuss how to avoid them.
• Develop a plan to identify and manage relapse early.
• Make every effort to keep communication open and nonjudgmental.
  

Medical and Pain Management Issues   TOP

What exactly do drugs do to the brain?

Researchers continue to explore the variety of functional and structural changes that occur in the brain during drug use. Drug dependencies have been linked to disturbances in the dopaminergic pathways of the mesolimbic reward system, which lies deep in the brain. This system interconnects the ventral tegumentum to the nucleus accumbens with other connections to the limbic system and orbitofrontal cortex (Leshner, 1997). Disturbances in these areas are responsible for the behavioral changes and drug craving that characterize the drug-addicted person. Brain imaging studies have suggested that the changes in the brain are chronic, even after the person stops consuming drugs and may cause the relapses of most drug users.

What are the common medical problems of patients who inject drugs?

Patients who inject drugs often have comorbid clinical conditions, which are listed below with specific recommendations.

Mental health problems Treat early. Depression is the most common problem.

Hepatitis C Screen all drug users for hepatitis C and B and treat when indicated. Consult a specialist in HIV/AIDS and hepatitis C for coinfected patients. Screen for depression before initiating therapy for hepatitis C. Treating hepatitis is important for preventing hepatotoxicity associated with ART.

Sexually transmitted diseases Screen regularly and provide safe sex education. Like other people, drug users often do not stop having sex even if they are infected with multiple diseases.

Tuberculosis Past tuberculosis exposure is common in injection drug users (as many as 30% are PPD positive); they should be screened for TB.

Skin and soft tissue infections Cellulitis and skin abscesses are very common in injection drug users. The practice of "skin popping" markedly increases the risk of abscess formation.

Noninfectious health problems Treat accordingly. Drug users and alcoholics have multiple health problems that should be treated aggressively. The fewer medical problems patients have, the more likely they are to adhere to the treatment plan.

Common problems to be aware of:

• Drug interactions (between medications and between medications and illicit drugs)
• Diabetes mellitus and hypertension
• Social environment (housing, child care)
• Pain management

How do you manage pain in opiate-addicted patients?

It is incorrect to assume that individuals addicted to opiates or any other kind of drug should receive less pain medication because they are addicted. They should receive pain therapy based on the diagnosed cause of the pain just like nonaddicted patients. The therapeutic approach differs according to whether the pain is acute or chronic.

How should you treat acute pain in a person diagnosed as a drug abuser?

Appropriate actions to take for drug-abusing patients in acute pain related to a recent diagnosable injury involve managing the pain:

1. Determine the source of the pain.
2. Provide pain medication that relieves the symptoms. Opiates may be used if they are what will stop the pain.
3. Give the medication in regularly scheduled doses. This prevents undesirable drug-seeking behaviors resulting from treatment on an as-needed (PRN) basis.
4. If pain is persistent or the cause is unclear, check for underlying psychiatric problems or an undetected source of pain.
5. If opiates are used, taper the doses slowly to avoid drug withdrawal.

How should you treat chronic pain in a person diagnosed as a drug abuser?

If the pain is chronic, the treatment strategies shift to not only finding the source of the pain, but also to using the entire spectrum of pain-relieving strategies with or without nonopiate pain medication (see Table 13-6). One exception is a patient with cancer-associated pain, for whom any effective medication (potentially addictive or not) is appropriate.

HIV/AIDS Issues   TOP

Can HIV transmission be prevented in active substance abusers?

A comprehensive HIV prevention strategy in a primary care practice includes interventions to provide drug treatment, to take care of mental health problems, and to prevent HIV transmission during drug use and sexual activity. The primary care provider should routinely screen for drug abuse and treat or refer for treatment as quickly as possible. This is particularly important for adolescents who are at high risk for HIV, hepatitis B and C, and other infections. One study has shown that once adolescents start injecting drugs, over 90% will become infected with hepatitis C within 18 months. The provider should also counsel patients who are actively using drugs not to share needles with others and to take advantage of programs that distribute clean needles. Programs use the needle distribution strategy as a first step to engage individuals who can then be encouraged to accept medical and drug abuse treatment services.

When is an active substance abuser ready for HIV treatment?

The most important clinical decision for successful treatment of drug-abusing patients with HIV is deciding when they are ready -- both substance abuse treatment and antiretroviral therapy (ART). Patients fall into 3 categories: those who do not want treatment, those who are ambivalent, and those who want treatment. For patients who do not want treatment, the provider should continue to be available with information on HIV and drug abuse treatment until they are ready to consider treatment. For those who are ambivalent about treatment, time is well spent during several clinical visits discussing the health issues of AIDS and drug abuse until they are ready for treatment. For patients who are ready for treatment the next step is to assess what factors will affect their adherence (see Chapter 7: Adherence to HIV Therapies). History of injection drug use, race, gender, age, socioeconomic status, level of education, and occupation are poor predictors of medication adherence. Accurate predictors of adherence are:

• The patient's health beliefs
• Ease of access to health care providers
• Familiarity with the treatment setting
• Existence of a social support system
• Perceived support from clinical staff members
• Simplicity of medication regimens

Interaction with providers and ambiance of the treatment setting account for almost half of the support factors needed to encourage drug users to adhere to treatment regimens. This pattern is true for active drug users, with the possible exception of persons addicted to crack cocaine.

Difficult economic and social situations, including unemployment and unstable housing, may make adherence to clinical treatment plans for both drug addiction and HIV even more difficult to follow. For these reasons some drug abuse treatment centers provide residential treatment to minimize outside influences on drug use. Also, methadone clinics provide an ideal opportunity for rehabilitated substance users to receive adherence support for ART through directly observed therapy (DOT) at the clinic.

What immunizations should drug abusers with HIV receive?

Because of the higher risk of tetanus in injection drug users, tetanus boosters should be given when due. Pneumococcocal and influenza vaccines are recommended for all patients with HIV. Drug abusers with no antibodies to hepatitis A and hepatitis B should be immunized. Hepatitis A can be fatal in individuals with hepatitis C.

Are there important drug interactions between antiretrovirals and medications for drug treatment?

A common problem in treating patients with HIV who are drug users is the drug interactions between medications. Studies have shown that interactions of methadone and antiretroviral medications are linked to CYP450 3A4 sites in the liver. The most significant interactions are between methadone and nevirapine (NVP) or efavirenz (EFV), which precipitate rapid drug withdrawal symptoms (see Table 13-7). Methadone programs should be alerted when methadone patients are started on efavirenz or nevirapine, as dose escalation of methadone will probably be required. When methadone and didanosine (ddI) are coadministered the uptake of didanosine may be lowered requiring a higher dose of didanosine (See Drug Tables 7 and 8 in the Pocket Guide). Other interactions caused by drugs such as abacavir (ABC) and all the PIs except indinavir (IDV), though pharmacologically measurable, are not clinically apparent and standard doses are appropriate. Potential interactions between illicit drugs and HIV medications are less well understood. Methamphetamine products have been associated with sudden death in individuals on protease inhibitors. Anecdotal reports describe how selective serotonin reuptake inhibitor (SSRI) antidepressant medications may produce side effects that mimic drug withdrawal and may decrease AIDS medication adherence.

¬ = decreases methadone blood levels
x = indeterminate effect
↑ = increases methadone blood levels

Source: Adapted from Gourevitch MN, Friedland GH. "Interactions between methadone and medications used to treat HIV infection: a review." Mt Sinai J Med 2000 67:429-436.

Why are HIV and drug abuse both such noticeable issues now?

HIV and substance abuse are both significant public health problems that merit the attention of public health officials and policymakers. Today, an estimated 40 million people worldwide are living with HIV. Of these, 2 to 3 million people are injection drug users. In the United States, approximately a third of HIV/AIDS cases are related to injection drug use. Research shows that use of drugs, injected or not, can affect decisionmaking - particularly about engaging in unsafe sex - that can endanger the health of the drug user and of others. Substance abuse is a double-edged sword because it increases an individual's risks for continuing drug use while also increasing the likelihood of exposure to HIV and other bloodborne infections. Infectious diseases that are more prevalent among injection drug users than in the general population are HIV, other STDs, including hepatitis B and C, and tuberculosis. Prevention and early treatment of drug abuse and drug-related diseases are critical public health measures to reduce the spread of new infections.

• Substance abuse and addiction involve compulsive drug-seeking behavior that interferes with an individual's ability to function normally in many aspects of daily life. Substance abuse and mental health problems often occur together and, unless treated, can lead to chronic social and medical consequences.
• Accurate and reliable diagnosis of substance abuse or dependence is not a perfect science. Screening techniques, in concert with a thorough medical history and evaluation, are important in detecting and correctly diagnosing a substance abuse-related disorder.
• HIV transmission is preventable in people who use drugs. For drug users and the community at large, drug addiction treatment is disease prevention.
• Hepatitis C is extremely common in patients with a past or current history of injection drug use. All patients with hepatitis C should be vaccinated against hepatitis A and B if serologic studies show no prior exposure.
• The clinical issues to be addressed are to treat comorbid conditions as soon as possible, treat drug use and HIV aggressively, and be aware of common drug interactions seen in patients treated for drug use and HIV simultaneously.

Suggested Resources   TOP

"Brief Interventions and Brief Therapies for Substance Abuse." Treatment Improvement Protocol (TIP) Series 34. Rockville, MD: Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment; 1999. DHHS Publication No. (SMA) 99-3353. Accessed 1/04.

Klein MB, Lalonde RG, Suissa S. "The impact of hepatitis C virus coinfection on HIV progression before and after highly active antiretroviral therapy." J Acquir Immune Defic Syndr. 2003;33:365-372.

WEBSITES

American Society of Addiction Medicine. Accessed 11/03.

National Institute on Drug Abuse. Accessed 11/03.

Erowid (detailed biochemical and other information on drugs). Accessed 11/03.

Office on National Drug Control Policy. Accessed 11/03.

Substance Abuse and Mental Health Services Administration (drug abuse statistics, clinical treatment information). Accessed 11/03.

References   TOP

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association Press; 1994.

American Society of Addiction Medicine. "Screening Instruments." In: Graham AW, Schultz TK, Mayo-Smith MF, Ries RK, Wilford BB, eds. Principles of Addiction Medicine. Chevy Chase MD: American Society of Addiction Medicine; 1998:1283-1286.

Chesney MA, Koblin BA, Barresi PJ, et al. "An individually tailored intervention for HIV prevention: baseline data from the EXPLORE Study". Am J Public Health. 2003;93:933-938.

Gourevitch MN, Friedland GH. "Interactions between methadone and medications used to treat HIV infection: a review." Mt. Sinai J Med. 2000;67:429-436.

Hyman SE, Malenka RC. "Addiction and the brain: the neurobiology of compulsion and its persistence [Review]." Nat Rev Neurosci. 2001;2:695-703.

Johnson RE, Chutuape MA, Strain EC, Walsh SL, Stitzer ML, Bigelow GE. "A comparison of levomethadyl acetate, buprenorphine, and methadone for opioid dependence." New Engl J Med. 2000;343:1290-1697.

Leshner, AL. "Addiction is a brain disease, and it matters." Science. 1997;278:45-47.

McLellan AT. "Have we evaluated addiction treatment correctly? Implications from a chronic care perspective." Addiction. 2002;97:249-252.

O'Brien CP. "A range of research-based pharmacotherapies for addiction." Science. 1997;278:66-70.

Principles of Drug Addiction Treatment: A Research-Based Guide. Bethesda, MD: National Institute on Drug Abuse; 1999. NIH Publication 99-4180. Accessed 1/04.

Principles of HIV Prevention in Drug-Using Populations: A Research-Based Guide. Bethesda, MD: National Institute on Drug Abuse; 2002. NIH publication 02-4733. Accessed 1/04.

Samet JH, Rollnick S, Barnes H. "Beyond CAGE. A brief clinical approach after detection of substance abuse." Arch Intern Med. 1996;156:2287-93.