SUBSTANCE ABUSE: A 2015 PRIMER - National Kidney
LEARNING OBJECTIVES:SUBSTANCE ABUSE:A 2015 PRIMERJane Kwatcher, MSW, LCSWMatt Stricherz, Ed.D.PsychologistDISCLOSURE We have no financial relationships related to thispresentation. The content will promote improvements in healthcareand does not promote a specific proprietary interest. Content for this session will be well-balanced,1) Understand the major changes to the DSM-5 withregard to diagnostic criteria for substance usedisorders.2) Identify the newer substances of abuse and theirimpact on patients on dialysis.3) Identify screening and assessment tools.4) Identify treatment plan interventions.DSM: WHY BOTHER? Be clear about what you need to know tohave a complete picture. Communicate with other professionalsabout patients in a standardized way.evidence-based and unbiased. We have not and will not accept any honoraria,additional payments or reimbursements from acommercial entity for participation in this activity.Understand the major changes to theDSM-5 (ICD) with regard to diagnosticcriteria for substance use disorders.CHANGES IN THE DSM-5DSM-IV-TR:DSM-5:Substance Dependenceand Substance Abuseare separate disorders.Criteria are provided forSubstance Use Disorders,accompanied by criteria forintoxication, withdrawal,substance/medicationinduced disorders, andunspecified substanceinduced disorders.1
CHANGES IN DSM-5CHANGES IN DSM-5, continued The use of the multi-axial process and the GAF are removed frompractice and not in the DSM-5. Disorders are renumbered using codes consistent with the ICD series. Substance Use Disorder with specifiers is now used instead ofAbuse or Dependence and with/without physiological dependence. A single continuum now has 9 to 11 criteria, with 2 criteria necessary “Recurrent legal problems” criterion for substance abusehas been deleted. A new criterion, craving or a strong desire or urge to use asubstance, has been added.to meet a diagnoses of Substance Use Disorder instead of a criterionbased dichotomy of Abuse (1 of 4 criteria) or Dependence (3 of 7criteria.)CHANGES IN THE DSM-5 Polysubstance Abuse is still not a diagnosisDIAGNOSTIC THRESHOLD CHANGE The threshold for Substance Use Disorder diagnosis inDSM-5 is set at two or more criteria of 11 listedcriteria. The threshold for the DSM-IV criteria of SubstanceAbuse was 1 of 4 criteria. The threshold for the DSM-IV Substance Dependencewas 3 of 7 criteria with 2 identifiers for physiologicaladdiction – tolerance and withdrawal Polysubstance Dependence and criteria for thediagnosis are no longer in the DSM-5 The WHODAS (series) replaces the GAF There are multiple forms and questions thatcomprise the WHODAS which are used to assessdisabilityDSM-IV (TR) Remission Specifiers were Early Full Remission Early Partial Remission Sustained Full Remission Sustained Partial Remission On Agonist Therapy In a Controlled EnvironmentDSM-5 Remission Specifiers include Early Remission Sustained Remission Past Diagnosis was metNo criteria met for at least 12 months (with exception ofcraving)In Controlled Environment meansoooo Past Diagnosis was metNo criteria for at least 3 months but less than 12 months(with exception of craving)in close supervision,substance free jails,in therapeutic communitieslocked hospitalsOn maintenance therapyOn agonist therapy2
WHO Disability Assessment Schedule 2.0(WHODAS 2.0)WHODAS 2.0 supersedes WHODAS IIand shows the following advantages: / WHODAS 2.0 covers 6 Domains ofFunctioning, including: Cognition – understanding & Tolerance - Withdrawal Specifiers Not considered if under medical supervisioncommunicatingMobility– moving & gettingaroundSelf-care– hygiene, dressing,eating & staying aloneGetting along– interacting withother peopleLife activities– domestic , leisure,responsibilities, work & schoolParticipation– joining incommunity activitiesCannabis UpdateA generic assessment instrument for health anddisabilityUsed across all diseases, including mental, neurologicaland addictive disordersShort, simple and easy to administer (5 to 20 minutes)Applicable in both clinical and general populationsettingsA tool to produce standardized disability levels andprofilesApplicable across cultures, in all adult populations StimulantsOpioidsSedative, Hypnotic, AnxiolyticsNOTE: There are Tolerance and Withdrawalcriteria for CANNABIS; there is no specifierfor “under medical supervision.”Caffeine Disorders Withdrawal is recognized and includes both New emphasis to practitioners based on Cannabis Intoxication includes perceptual About 85% of Americans consume caffeine Caffeine is in coffee, teas, energy drinks,psychological and physical symptomsdisturbances with auditory illusions withintact reality testing OR visual or tactileillusions without delirium It is acknowledged that extended cannabisuse in some persons can result in psychosesmarketed products vitamins, chocolate, cold-remedies,vitamins, analgesics, etc.Clearly delineated signs and symptomsfrom Intoxication through SubstanceInduced Disorder are found with caffeineuse3
ENERGY DRINKS: POST 2004 CHANGESAddictNon-Alcohol EnergyDrinksSubstance Use Disorder (SUD)The language we use matters!ChemicalDependenceAlcohol Based EnergyDrinksAlcoholicAbuseSubstance MisuseAfter repeated drug use, “deciding” touse drugs is no longer voluntary,becauseIndividuals with lower levels of self-control may beparticularly predisposed to develop Substance UuseDisorders long before the onset of actual substance useitself.DRUGS CHANGE THEBRAIN!SOURCE: NIDA. (2010). Drugs, Brains, and Behavior: The Science of AddictionER Visits (2011 – 2015 reports)Ten Classes of Substances 1, 400,000 non-medical use of prescription medication (2011)(Opiod pain relievers, anti-anxiety and sleep aids, andbenzodiazepine are common) 660,000425,000380,000210,00093,000 In 2013, 43,982 drug overdose deaths35,663 (81.1%) were unintentional5,432 (12.4%) were of suicidal intent,2,801 (6%) were of undetermined intent.alcoholcocainemarijuanaheroinstimulants AlcoholCaffeineCannabisHallucinogens(PCP and others) Inhalants Opioids Sedatives,hypnotics, andanxiolytics Stimulants Tobacco OtherNIDA 2009 /CDC 20154
DSM-5: Differential DiagnosisSubstance UseDisordersSubstance InducedDisorders Impaired controlSocial ImpairmentRisky oxicationWithdrawalOther substance/medication induceddisorders3 Items To Be Considered inEvery Diagnosis Direct Effects of the Substance Direct Effects of General Medical Conditions Disorders causes Distress/ImpairmentSocial, Occupational, RelationalSocial Impairment5) Failure to fulfill major role obligations atwork/school/home.6) Continued use of substance despite persistent orrecurrent social/interpersonal problems, caused orexacerbated by the effects of the substance.7) Important social/occupational/recreational activitiesmay be given up or reduced due to substance use.DSM-5 Diagnosis: Art or Checklist?SUBSTANCE USE DISORDERSImpaired Control1) Substance taken in larger amounts or over a longerperiod than intended.2) Significant amount of time spent obtaining/using/recovering from substance.3) In more severe disorders, nearly all daily activitiesrevolve around substance.4) Craving: intense desire for drug, especially inenvironment associated with previous use.Risky Use8) Recurrent substance use in situations in which it isphysically hazardous.9) Continues substance use despite knowledge of havinga persistent/recurrent physical or psychological problemthat is likely to have been caused or exacerbated by thesubstance.5
Pharmacological Criteria10) Tolerance: Markedly increased dose of substance isused to achieve desired effect, OR usual amount is usedbut with less of an effect.11) Withdrawal: Occurs when blood or tissueconcentrations of a substance decline in a person whohas maintained heavy use.Severity Qualifier of the DSM-5Substance Use DisorderMild:Moderate:Severe:SPECIFIERS2-3 symptoms4-5 symptoms6 or more symptomsSUBSTANCE INDUCED DISORDERSEarlyRemissionSustainedRemissionIn a ControlledEnvironmentSubstance-Induced Mental Disorder Clinically significant presentation of a mental disorderEvidence by History, labs (or related observable data)or by physical examinationCapable of producing observable mental disorder Onset is during or within 1 month of use Persists for substantial time after use (which onewould not expect)Not an independent mental disorderSubstance use preceded onset of disorderSubstance-Induced Disorders(related to DSM-5 Categories ofSubstance) WithdrawalIntoxicationMEDICATION INDUCEDDISORDER Psychotic DisorderBipolar DisorderDepressive DisorderAnxiety DisorderSleep DisorderDeliriumNeurocognitiveSexual Dysfunction6
SUBSTANCE EFFECTS:Intoxication MOOD SISTENTORTRANSIENTREALITYDISTORTIONS PSYCHOSIS BRAINCHANGES Reversible substance-specific syndrome due to recentingestion of a substance Behavioral/psychological changes due to effects on CNSdeveloping after ingestion:ex. Disturbances of perception, wakefulness, attention,thinking, judgment, psychomotor behavior andinterpersonal behavior Not due to another medical condition or mental disorder Does not apply to tobaccoc 2014 Kwatcher, StricherzClinical picture of intoxicationdepends on: Substance Dose Route ofadministration Duration/chronicity Individual degree of Time since last dose Person’s expectations of substance effectContextualvariables/triggersWithdrawal Substance-specific syndrome causing problematicbehavioral change due to stopping or reducingprolonged usePhysiological & cognitive componentsSignificant distress in social, occupational or otherimportant areas of functioningNot due to another medical condition or mentaldisordertoleranceSubstance-Induced Mental Disorder Potentially severe, usually temporary, butsometimes persisting CNS syndromes Context of substances of abuse, medications, or toxinsCan be any of the 10 classes of substancesCommonly Used Psychoactive SubstancesSUBSTANCEEFFECTSAlcohol(liquor, beer, wine)euphoria, stimulation, relaxation,lower inhibitions, drowsinessCannabinoids(marijuana, hashish)euphoria, relaxations, slowedreaction time, distorted perceptionOpioids(heroin, opium, many pain meds)euphoria, drowsiness, sedationStimulants(cocaine, methamphetamine)exhilaration, energyClub Drugs(MDMA/Ecstasy, GHB)hallucinations, tactile sensitivity,lowered inhibitionDissociative Drugs(Ketamine, PCP, DXM)feel separated from body, delirium,impaired motor functionHallucinogens(LSD, Mescaline)hallucinations, altered perceptionSOURCE: National Institute on Drug Abuse.7
Older Substances of AbuseStimulantsOpiatesCannabisHallucinogensNewer Substances of AbuseSedativesAlcoholNewer Substances of AbuseSYNTHETICSCANNABINOIDS Spice Incense K2 All synthetic marijuanaSYNTHETICSSynthetic CannabinoidsPSYCHEDELICSSTIMULANTS/CATHINONES Mescaline Imitators LSD and all imitators of LSD DXM and all relateddissociatives DMT, LSD, STP Bath Salts All synthetic amphetamines Designer amphetaminesSynthetic Cathinones(Stimulants)Synthetic HallucinogensDSM-5 Diagnosis: “Unspecified” or “OtherSubstance” use.JUST BECAUSE IT ISN’T ILLEGALTimeline of Synthetic Cannabinoidsand Spice ProductsTHAT DOESN’T MEANIT’S GOOD FOR YOUHELPS WITH REALITY FUNCTIONING OR TESTING ORPRODUCTIONCAN’T BE DEFINED AS HAVING SOME POSITIVE REASON FOR IT’SUSEIT CAN BE CONSIDERED BIO-GENICSOURCE: Fattore & Fratta. (2011). Frontiers in Behavioral Neuroscience, 5 (60), 1-12.8
Synthetic Cannabinoids (Spice)“Designer” Psychoactive Substances Mainly abused by smoking (alone or withmarijuana); may also be prepared as an herbalinfusion for drinking. The five active chemicals most frequentlyfound in “Spice” products have been classifiedby the DEA as Schedule I controlledsubstances, making them illegal to buy, sell,or possess.SOURCE: NIDA. (2012). NIDA DrugFacts: Spice (Synthetic Marijuana).SOURCE: http://www.drugs-forum.com.SyntheticsSpice, K2, Spice, Incense, Fake Weed, YucatanFire, Genie, Skunk, Moon Rocks, Zohai, BlackMambaSynthetic marijuanaFactors Associated with SpiceProducts’ Popularity Cannabis vs. Synthetic Cannabinoid IntoxicationMost symptoms are similarto cannabis intoxication:They induce psychoactive effects They are readily available in retail stores andonlineThe packaging is highly attractiveThey are perceived as safe drugsThey are not easily detectable in urine and bloodsamples (parolees, probationers, military, etc)SOURCE: Fattore & Fratta. (2011). Frontiers in Behavioral Neuroscience, 5(60), 1-12. TachycardiaReddened eyesAnxiousnessMild sedationHallucinationsAcute psychosisMemory deficitsSymptoms not typically seenafter cannabis intoxicationbut seen after syntheticcannabis intoxication: tationViolent behaviorComaSOURCES: Hermanns-Clausen et al. (In Press), Addiction; Rosenbaum et al. (2012). Journal of MedicalToxicology; Forrester et al. (2011). Journal of Addictive Disease; Schneir et al. (2011). Journal of EmergencyMedicine9
Clinical Symptoms of Synthetic Cathinone Use inPatients Admitted to the Emergency Department(N 236)Agitation82%Combative/Violent 36%Confusion34%Myoclonus/Movement disorders19%Hypertension17%Chest pain17%CPK elevationsMollies, Ecstasy, MDMA9%SOURCE: Spiller et al. (2011). Clinical Toxicology, 49, 499-505.Psychological DangersBath SaltsHallucinations / PsychosisExtreme Paranoia / Violent BehaviorSuicidal IdeationAgitation / Intense CravingPhysical DangersChest PainsYounger UsersHallucinogenic EffectIncreased Blood PressureIncreased heart rateHeart attack/ StrokeDeath or serious injury10
DissociativesA class of hallucinogen which reduce or block signalsto the conscious mind from other parts of the brain.What is DXM?Non-opiod anti-tussiveDextromethorphan is a psychoactive drugfound in common over the counter coughmedicines.Produce hallucinogenic effects, which may includesensory deprivation, dissociation, hallucinations, anddream-like states or trances.SOURCE: NIDA. (2001). NIDA Research Report Series: Hallucinogens and Dissociative Drugs.Syrup, Purple Drank, Sizzurp, Lean, Drank, Barre,Purple Jelly, Texas Tea, TsikuniPrescription strength cough syrup with codeine andpromethazine, typically mixed with Sprite orMountain Dew, with a Jolly Rancher thrown in forsweetness.Effect is mild euphoria and dissociative feeling.Challenges with Chromatography ScreeningKrokodil“Krokodil’ — A Designer Drug from Across the Atlantic, with SeriousConsequences. Thekkemuriyi DV et al. Am J Med 2013 Oct 15 .” Lack of availability of the reference standard for new drugs Variable quality of reference standards Lack of purity and labeled internal standards Chemical similarity of newdrugs within a class requiresgreat care with identification Sensitivity (correctly IDsthe drug)DEADLYSOURCE: Logan et al. (2012). Journal of Forensic Sciences, 57(5), 1168-1180.11
Salvia Divinorum Salvia Diviner’s Sage Sage of the SeersKhat (not synthetic) Pronounced “cot” This stimulant drug is native to East Africa and Southern Arabia Catha edulis (Khat) is derived from a shrub Cathinone, an illegal drug, is one of Khat’s chemicals. Cathinone is ascheduled 1 drug. The drug produces a mild euphoria and is highlyaddictive Khat goes by many names depending on the country of use, gat. chat,jimma, jaad, and quaat. Khat is generally chewed and the dried leavescan be used to make teaSOURCE: NIDA. (2011). NIDA DrugFacts: Khat.68Why People Use Psychoactive SubstancesWhy Start?Peer PressureMedicalExperimentalWhy Continue?Reward system activation: Regions of thebrain are more active when engaged inpleasurable activities, hence, additionalstimulation is sought.Relieve stress/painFunction betterHave fun/relaxCope with mental healthdisordersSOURCE: NIDA. (2010). Drugs, Brains, and Behavior: The Science of Addiction .Effects on CKD PatientAll drugs taken in excess have in common the directactivation of the brain reward system, which isinvolved in the reinforcement of behaviors and theproduction of memories.They may produce such an intense activation ofthe reward system that normal activities may beneglected.What does it mean for you?c12
SCREENING VERSUS ASSESSMENT Screening often provides the beginning states of communicationSCREENING AND ASSESSMENTabout substance use change There are MANY best practices and public domain instruments forscreening or assessment Screening needs to be SIMPLE, EFFECTI VE, SUPPORTIVE Screening answers a “Yes” or “No” question Disclosure of use is therapeutic A positive screen leads to an AssessmentGETTING A HISTORYBASIC SUBSTANCE USE HISTORYWhy is it so hard?/ assumptions? I’m embarrassed/uncomfortable.I don’t know how to ask.He’ll think I am accusing him.I won’t understand what she’s talking about.It doesn’t really matter for dialysis.CAGE-AID – “Adapted to Include Drugs”1) Have you ever felt you needed to Cut down on your drinking or druguse?2) Have people Annoyed you by criticizing your drinking or drug use?Substances usedAge at initiationAge of last useHighest period of usePhysiological and psychological adverse reactionsPositive use reactionsCAGE-AID SCORING4 questions, positive score on 2 or more is clinicallysignificant and indicates: 0 for no1 for yes3) Have you ever felt Guilty about your drinking or drug use?4) Have you ever felt you needed to drink or use a substance first thing inthe morning (Eye-Opener) to steady your nerves or to get rid of ahangover?-need for more evaluation-look at frequency-quantity-heaviest and/or daily use13
More Practice TipsPractice Tips for the SW Binges: don’t qualify as problematic unless they createsocial/occupational problems– and are more appropriatelylooked at as occasional recreational use Identify the switch from pleasure to obsessional useIdentify the family historyIs there Early Onset - high and heavy frequency of use andinherent high toleranceHigh Lethality with some substance use Perceptions and report of self-use is rarelyaccurate -- USE Collaterals Serum, Hair, Urine for Drugs of Abuse - ExcellentCollateraloutgrow itUser Patterndependence don't developproblemWe usually inherit the disorder into our care after it iswell entrenched in the patient’s life.TREATMENT AND INTERVENTIONEarly identification and active intervention are key.Types of Treatment Emergency RoomOutpatientResidentialMedically supervised withdrawal12 step groups, etc.TREATMENT:WHAT – WHERE – HOW – WHEN Can be voluntary or involuntary or coercive Can be used to treat the following: Cravings, Dependence, Abstinence, Emergency Management,Risk ReductionCan be most appropriate in the Emergency Roomor in a medically supervised or monitoredwithdrawal settingSome placements are legally set to be a jail setting14
ABSTINENCE:WHAT – WHERE – HOW – WHEN Support (12 step generally NA – AA – CA) Outpatient Individual or Group Residential Inpatient Sober living houses – Transitional living houses Minimum use housesINTERVENTION American Public Health Strategic Brief InterviewSymptom Targeted InterventionMotivational InterviewingRisk reductionGoal identificationTreatment OutcomesCraving: Such a strong urge to take drug itoverpowers all other thoughts. Used as apredictor for relapse.BRAINSTORM Causes? Referral needs? The reality? Interdisciplinary TeamAwareness of prescription meds Answer?CASE 1CASE 2 55 yr. old married Caucasian male Professionally employed, Ph.D. Dialyzes early a.m., four years on dialysis Frequently misses treatments Ongoing outbursts with staff, reports 48 year old Native FemaleWorks part-time; doesn’t miss workDialyzes in the evening, TTSHas had problems within the past 6 monthsHas been hitting thigh on objects in the work-place, hasbruisesHas nicked her hand when using scissors, needs band-aidsIs seen as quite “clumsy” by co-workersWent through substance treatment 5 years agoproblems with co-workers History of depression with intermittenttherapy15
ALCOHOL AND DRUG CONSEQUENCESQUESTIONNAIRE (ADCQ)From: Appendix B—Screening and AssessmentInstrumentsEnhancing Motivation for Change in SubstanceAbuse Treatment.Treatment Improvement Protocol (TIP) Series, No.35.Center for Substance Abuse Treatment.Rockville (MD): Substance Abuse and MentalHealth Services Administration (US); 1999. NCBIBookshelf. A service of the National Library ofMedicine, National Institutes of Health.Websites SAMHSA –Substance Abuse and Mental Health Services Administrationwww.samhsa.govNIDA – National Institute of Drug Abusewww.drugabuse.govAAAP – American Academy of AddictionPsychiatry www.aaap.orgASAM – American Society of AddictionMedicine www.asam.org Centers for Disease Control and Prevention.National Vital Statistics System mortality data.(2015) Available from tmlSpecial thanks to the professionals and agencies below forpermission to use slides from their research and trainingprojects on synthetic substances Jane C. Maxwell, Univ of Texas Beth Rutkowski, Mednet UCLA Thomas E. Freese, Mednet UCLA Gulf Coast ATTC: http://www.atcnetwork.org/gullfcoastPacific Southwest ATTC:http://www/psattc.org16
2 CHANGES IN DSM-5 The use of the multi-axial process and the GAF are removed from practice and not in the DSM-5. Disorders are renumbered using codes consistent with the ICD series. Substance Use Disorder with specifiers is now used instead of Abuse or Dependence and with/without physiological dependence. A single cont
Latin Primer 1: Teacher's Edition Latin Primer 1: Flashcard Set Latin Primer 1: Audio Guide CD Latin Primer: Book 2, Martha Wilson (coming soon) Latin Primer 2: Student Edition Latin Primer 2: Teacher's Edition Latin Primer 2: Flashcard Set Latin Primer 2: Audio Guide CD Latin Primer: Book 3, Martha Wilson (coming soon) Latin Primer 3 .
III. Statewide Trends in Substance Abuse Part 1: Demographics of People in Substance Abuse Treatment In fiscal year 2012, there were 105,189 total admissions to substance abuse treatment 81.2% of people in substance abuse treatment were white, and 7.1% were black, approximately reflecting the relative proportions of these races in the population.
The Case for a Coordinated Substance Abuse Prevention Plan This Substance Abuse Prevention Plan for Hancock County brings together an assessment of our current situation and proposes six major goals addressing a diverse range of concerns: Underage Drinking Illegal drug use High risk substance abuse Prescription Drug Abuse
Substance abuse is a long standing problem in child welfare (awareness could explain some increase) Child Welfare and Substance Abuse agencies generally don't work together Standardized screening indicates that 43% of the parents associated with a foster care placement meet criteria for substance abuse or substance dependence
Prevalence of Substance Misuse & Abuse (2011) 20.6 million persons ( 12 years) classified as 'substance dependence' or 'substance abuse' in past year (8% of population) 14.1 million - alcohol 3.9 million - illicit drugs . Substance Dependence or Abuse in the Past Year among
Center for Substance Abuse Treatment. Substance Abuse Treatment: Group Therapy. Treatment Improvement Protocol (TIP) Series, No. 41. HHS Publication No. (SMA) 15-3991. Rockville, MD: Substance Abuse
associated with substance abuse. One study shows that 84 percent of individuals with ASPD also have some form of substance abuse during their lifetimes (104). Other psychiatric conditions that may be associated with substance abuse are depression, anxiety disorders, manic-depression, and s
Rockville, MD: Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, 2009. Originating Office . Office of Program Analysis and Coordination, Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, 1 Choke Cherry Road, Rockville, MD 20857 HHS
