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

Medical Co-Morbidities in the Substance Using Patient

Adam J. Gordon, MD, MPH, FACP, FASAMUniversity of Pittsburgh School of Medicine

VA Pittsburgh Healthcare System

[email protected]

[email protected]

Wilford:Wilford:

mailto:[email protected]

mailto:[email protected]

ASAM’s 2008 Review Course

in Addiction Medicine

ACCME required disclosure of

relevant commercial relationships:

Dr. Gordon has nothing to disclose.

Medical Comorbidities

GOALS

• Understand that alcohol and drug use can become disorders, that are chronic medical conditions

• Understand the epidemiology and harm associated with alcohol and other drug use

• Understand the complex relationship between alcohol and other drug use with other disease processes


OUTLINE• Discuss the harm and other diseases

associated with the use of the “big three” substances:– Alcohol– Opioids– Cocaine

• Discuss (briefly!) the harm and other diseases associated with the use of “non-big-three” substances

• Discuss the complexity of defining and clinically dealing with co-morbidities

• Summarize and further discussion


BACKGROUND• Alcohol and other drug use patients who

present for treatment often have other medical problems

• These medical conditions are consequences – of both their current and their past high risk

behaviors– Injection or route of drug use– direct toxic effects of illicit drugs or caustic agents

• Clinicians should screen for and treat (or refer for treatment) common comorbid medical conditions


BACKGROUND

• Treating alcohol and other drug use in an office based settings provides a unique opportunity to integrate the delivery of substance abuse treatment with screening and management, increasing effectiveness and patient compliance

• Clinicians should know the common comorbid medical conditions found in alcohol and other drug use patients and promote preventive health care for these patients


ALCOHOL USE and DISORDERS:

HARM and MEDICAL CO-MORBIDITIES




Medical Harm of Hazardous Drinking• Hazardous drinking is

associated with an increased risk for:– All-cause mortality – Hypertension– Cardiomyopathy– Diabetes– Trauma– Stroke– More serious alcohol

disorders– Cancers

~particularly upper GI and breast cancers

Figured from Babor et al (World Health Organization), AUDIT Guidelines for Use in Primary Care, 2001


Brief Primer of Physical Exam Features for Alcohol Use

• Tachycardias • Tremor• Hypertension• Hepatosplenomegaly and a tender liver edge• Peripheral neuropathy• Spider angiomata• Conjunctival injection• Unexplained trauma


Some Associations with Hazardous Drinking

• Injuries• Infections• Gastritis and duodenitis• Hematologic effects• Early hepatic injury• Cardiac effects


Injuries

• Due to – Fights and homicide attempts– Auto accidents

~50% of injuries involve some alcohol consumption

– Drowning and other accidents– Suicide attempts

• Patient neglects injuries until the next day– Injuries not painful until the following day


Infections

• Heavy drinkers are more susceptible to pneumonia and other infections– Pneumococcal infections– Pseudomonas infections– Gram-negative infections

• Heavy drinkers have impaired immunity – Increased sequestration of neutrophils– Decreased fixed macrophage phagocytic capacity– Decreased white blood cell production– Decreased cell mediated immunity


Gastritis and Duodenitis

• Most commonly observed effects – Epigastric pain – Morning nausea and vomiting– Melena– Gastric Esophageal Reflux Disease (GERD)

• Eventually– Consequences of liver disease including varices

and portal hypertension


Hematologic Effects

• Macrocytosis – Due to direct cytotoxic effects– Due to vitamin deficencies

• Decreased platelets (may be down to 30,000 to 50,000)

• Anemia usually due to– Bleeding from gastrointestinal tract– Folic acid deficiency– Also remember other vitamin deficiencies


Hepatic Effects

• Alcoholic hepatitis in 10% to 15% of alcoholics– Increased liver enzymes and bilirubin– Enlarged tender liver– 80% can progress to cirrhosis– 20% result in liver failure

• Cirrhosis– 40% have a 5-year survival if they continue to drink– 77% have a 5-year survival if they stop drinking

• Liver cancer (also esophageal, laryngeal, and nasopharyngeal cancers)


Early Hepatic Markers • Increased gamma-glutamyl transpeptidase

(GGT) up to 3 times normal in 20% to 30% of heavy drinkers

• Liver enzymes– AST/SGOT > ALT/SGPT

• Production Problems– Coagulopathies in end stage alcoholic liver

disease

• Don’t forget the pancreas!– Acute and chronic pancreatitis– Complications:

~Diabetes, Steatorrhea, Pseudocyst


Cardiac Effects

• Increased blood pressure– From withdrawal – Without withdrawal

• Increased ischemic heart disease• Cardiomyopathy• Arrhythmias

– Especially tachyarrhythmias– Atrial flutter– Atrial fibrillation – “Holiday Heart”– Paroxysmal Atrial Tachycardia


Nervous System Effects

• Headaches• Sleep disorders• Wernicke syndrome• Korsakoff psychosis• Organic brain disease

– Cognitive– Memory

• Peripheral neuropathy


Nervous System EffectsC – Confusion O – OphthalmalplegiaA – AtaxiaT – Early Thiamine Deficiency (Wernicke’s)

R – Retrograde AmnesiaA – Anterograde AmnesiaC – Confabulation and meager ConversationK – Korsakoff Syndrome

(Also lack of INsight and Greater apathy)


Fetal Alcohol Spectrum• Growth retardation

– Head circumference, height, and weight less than tenth percentile

• Facial malformation– Palpebral fissure– Philtrum– Thin upper lip

• Neurodevelopmental delay– Intelligence– Boundaries– Memory – Aggression– Motor skills– Right/wrong


Fetal Alcohol Spectrum

• Defects occur before most women know they are pregnant

• No known safe level of drinking for pregnant women– Binging may be worse than daily drinking– The higher the blood level of alcohol, the greater

the chance of damage


Associations with Other Diseases

• There exist many diseases that co-exist with alcohol use disorders that may complicate the treatment of either disorder– HIV– Major Depressive Disorder– Hepatitis – Cirrhosis– (Social morbidities – homelessness)

• Emerging research is examining treatment modalities for co-morbid conditions


Alcohol Use of the Elderly• Of the 80% of elderly persons who have ever

consumed alcohol, two-thirds continue to drink, often at hazardous levels of consumption

• Of the elderly:– 15% drink alcohol at levels considered hazardous– 5% have diagnosis of abuse or dependence– many more drink sporadically in binge episodes

• The problem drinking elderly consist of :– 30% of the hospitalized elderly– 10% of the elderly primary care– 50% of the mentally ill elderly


Alcohol Use of the Elderly

• With mild alcohol consumption, compared to the non-elderly, the elderly are at increased risk for:– greater numbers of harmful medication

interactions– increased falls– more cognitive deficits– greater sleep impairments– increased sexual dysfunction– greater numbers of hip fractures– more psychiatric problems compared to younger

populations


Alcohol and Breast Cancer• More than 30 epidemiologic studies have evaluated a

possible association between alcohol intake and breast cancer

• Alcohol consumption is associated with a linear increase in breast cancer incidence in women over the range of consumption reported by most women (Smith-Warner)

• In a recent study of 70,000 women, a drink a day increased their risk by 10 percent, and more than three daily drinks by 30 percent (Lew)

• Women's Health Study, daily alcohol intake again was shown to modestly increase risk (Zhang)

– The relative risk for each 10 gram increase in daily alcohol intake was 1.11 (95% CI 1.03-1.20) for ER and PR+ cancer

Smith-Warner SA, JAMA 1998; Lew: Ameri. Assoc. for Cancer Research 2008; Zhang SM, Am J Epidemiol. 2007


Societal Costs of Alcohol DependenceTotal Cost: $184.6 BillionTotal Cost: $184.6 Billion

Harwood H, NIH Publication No. 98-4327 1998

$86,368 (47%)

$36,499 (20%)

$2,909(2%)

$15,963(9%)

$7,466* (4%)$24,093

(13%)$10,085

(5%)

$1,253(1%)

Specialty alcohol servicesMedical consequences (except FAS)

Medical consequences of FASLost future earnings due topremature deathsLost earnings due toalcohol-related illnessLost earnings due to FASLost earnings due to crime/victimsCrashes, fires, criminal justice, etc


OPIOID USE and DISORDERS:





Balloons, Bags, and Pills


New Prescription Drug Users

0

500

1000

1500

2000

2500

3000

New

Use

rs (

x 1

00

0)

Analgesics Tranquilizers Stimulants Sedatives

NSDUH, SAMHSA, 2005

Past Year Initiation of Non-Medical Use of Prescription-type Psycho-pharmaceuticsAge 12 or Older: In Thousands from 1965 to 2005


Opioid Withdrawal

• Severe flu-like symptoms including shaking chills• Anxiety• Hyperactivity• Drooling• Lacrimation/Tearing• Rhinorrhea/Runny nose• Anorexia• Nausea• Vomiting• Diarrhea• Myalgias• Muscle spasms


Street Stuff

• Sold in “stamp bags” and “balloons”• A opioid user will maintain a steady supply of

opioids - not a binge addiction• Combination of abuse is important

– Can be combined with a stimulant (ala speedball)– Rarely with a depressant


Changing Route of Heroin Administration

0%

20%

40%

60%

80%

100%

1992 1993 1994 1995 1996 1997 1998 1999 2000

Injection Inhalation Smoking Oral Other

Treatment Episode Data System, 1992-2000


Hepatitis B

• DEFINITION– Hepatitis B (HBV) is a blood borne viral pathogen

• EPIDEMIOLOGY– Estimated 1.25 million chronically infected in U.S.– Approximately 300,000 new cases per year– Transmission by blood borne, sexual, or perinatal – Approximately 50% of active injection drug users

have serological evidence of prior exposure to HBV


Hepatitis B – Clinical Course• Early and mild viral hepatitis manifests with

symptoms of hepatic inflammation and damage with elevated serum transaminases (> 10-20x normal)

• Chronic viral hepatitis manifests as chronic liver disease with portal hypertension and poor hepatic synthetic function

• Likelihood of developing chronic infection is related to age:– 80 to 90% of infants infected develop chronic disease – only 2 -10% of infected adults progress to chronic disease

Medical ComorbiditiesWeeks after Exposure

Titer

Symptoms

HBeAg anti-HBe

Total anti-HBc

IgM anti-HBc anti-HBsHBsAg

0 4 8 12 16 20 24 28 32 36 52 100

Acute Hepatitis B Infection with Recovery


Weeks after Exposure

Titer

IgM anti-HBc

Total anti-HBc

HBsAg

Acute(6 months)

HBeAg

Chronic(Years)

anti-HBe

0 4 8 12 16 20 24 28 32 36 52 Years

Progression to Chronic Hepatitis B Infection


Hepatitis C - Epidemiology

• Hepatitis C (HCV) is the most common bloodborne infection in the U.S.– 1.8% of the U.S. population are infected– Of the 3.9 million people in the U.S. who are infected,

2.7 million are chronically infected

• At least 30,000 new infections (cases) annually• Morbidity and mortality

– Chronic liver disease – HCV-related: 40% - 60% – Deaths HCV chronic disease/year: 8,000-10,000– Most common reason for (~40%) liver transplants


Hepatitis C - Epidemiology

• In some series, greater than 90% of injection drug users have antibodies to HCV

• HCV is more prevalent and more infectious than HIV– with 170,000,000 infected with HCV worldwide– In injection drug users, infection results from

contact with contaminated needles, syringes, paraphernalia

– Blood and blood products are more infectious than saliva, vaginal secretions, or semen


Symptoms +/-

Time after Exposure

Tite

ranti-HCV

ALT

Normal

0 1 2 3 4 5 6 1 2 3 4YearsMonths

HCV RNA

Hepatitis C: Acute Infection with Recovery


anti-HCV

Symptoms +/-

Time after Exposure

Tite

r

ALT

Normal

0 1 2 3 4 5 6 1 2 3 4YearsMonths

HCV RNA

Hepatitis C: Progression to Chronic Infection


CHRONIC Hepatitis C: Clinical Course• Symptoms: 50% of patients report chronic

fatigue and abdominal discomfort• Serum transaminases:

– Persistently elevated - 43% – intermittently elevated - 42% – normal - 15%

• Risk factors for disease progression:– alcohol use, hepatitis B virus, HIV (modifiable

risks)– < 40 years old when infected, male sex


Acute hepatitis C

Chronic hepatitis C

Cirrhosis

< 20%Hepatic failure

< 20%HCC (30 years)

>85% (10 years)

20% - >50% (20 years)

30 Year Progression of Chronic Hepatitis C


Hepatitis C: HIV Co-infection

• 30% of HIV positive patients in the U.S. are co-infected with HCV

• In HIV infected injecting drug users, the prevalence of HCV is 50 to 90%

• HIV has a significant effect on progression of liver disease in HCV-infected patients

• Must balance hepatotoxicity of HIV therapy with need to treat HIV in HCV-infected patients, while HIV therapy can worsen the symptoms of HCV


Hepatitis C: Treatment in Drug Users• Standard recommendation: >/=6 months

“clean”• Arguments for not treating: poor adherence,

side effects, re-infection, non-urgent treatment – but data supporting these arguments are lacking, some drug users may do well

• Treatment should be based on individual risk-benefit assessments– Edlin BR et al. NEJM 345:211-214, 2001


Hepatitis C: Treatment in Drug Users

• The 2002 NIH Consensus Guideline on the Treatment of HCV is available at – Active injecting drug use should not exclude

patients from HCV treatment– HCV treatment of active injecting drug users

should be considered on a case-by-case basis– Web site: http://www.guideline.gov


HIV/AIDS: Epidemiology

• Approximately 1.1 million cases in the US • 0.7 - 34% (median 15%) seroprevalence

entering substance abuse treatment• IV Drug Use (IVDU) associations

– From 1993-1999 IVDU persons living with AIDS jumped from 48,244 to 88,540

– 15-20% long-term IVDUs infected (43% of women AIDS)

– 25% of the approximately 40,000 new HIV infections/year through IVDU


HIV/AIDS: Treatment in Drug Users

• High risk for non-receipt of antiretrovirals:– 2-3 times as likely not to be on antiretroviral

treatment if not in SA treatment

• High risk for non-adherence:– 1998 CDC guidelines recommend delaying

HAART until active opioid use has been addressed


Tuberculosis: Epidemiology• Worldwide, approximately 2 billion people

(1/3 of world population) are infected with M. tuberculosis

• Since the HIV pandemic began in the U.S. in the mid-1980s, there has been increased concern about TB since it is more common in this population

• Tuberculosis is also more common in alcohol users and injection drug users in general and in patients with alcohol use disorders


Opioid Dependence is Costly

• Medical Costs• Mental illness

• An environmental and disease stressor• Co-morbid interactions

• Trauma and infections• Hepatitis and HIV

• Medical Cost• $20 billion per year total costs• $1.2 billion per year health care costs


How Do They Get Hooked?

COCAINE USE and DISORDERS:





Cocaine• Cocaine is a product of the alkaloid extract

from leaves of the Erthroxylon plant originally grown in the Andes Mountains of western South America

• Evidence of use in 500 AD - coca leaves in tombs in Bolivia and Peru

• Cocaine was used by Sigmund Freud • William Halsted used cocaine for anesthesia

in 1884 • Today, cocaine is still used (sparingly) as a

local anesthetic in the upper respiratory tract in concentrations of 4%


Cocaine• As many as 20 million people in the United States

have used cocaine at least once in their lifetime• In New York City, cocaine use is extremely prevalent

and in one survey 26% of people sustaining fatal injuries had evidence of cocaine metabolites in their urine or blood

• Of pregnant women, an estimated 11% are substance abusers and cocaine is the most commonly abused drug other than alcohol

• Cocaine has increasingly been associated with criminal behavior


Street Stuff• Cocaine exists in many forms

– Powder– Freebase– Rock (crack)

• Crack is convenient– The soft mass that develops becomes hard when

dry– The crack can then be smoked (potent!)– Usually it is smoked in a glass pipe or regular pipe

or by mixing it with tobacco or marijuana– Crack is thought to be termed by the sound of

cocaine crystals ‘popping” when smoked


Cocaine Intoxication• Clinically significant maladaptive behavioral or

psychological changes that developed during, or shortly after, use of cocaine.

• Two (or more) of the following developing during or shortly after cocaine use:– Tachycardia or bradycardia– Pupillary dilation– Elevated or lowered blood pressure– Perspiration or chills– Nausea or vomiting– Evidence of weight loss– Psychomotor agitation or retardation– Muscular weakness, respiratory depression, chest pain, or

cardiac arrhythmias– Confusion, seizures, dyskinesias, dystonias, or coma


Morbidity and Co-morbidity of Cocaine• Can be deadly in intoxication

– Mainly due to adrenergic stimulus~Think that you are injecting epinephrine into the blood

– Morbidity can occur secondary to social consequences as well as direct effects

• Long term– Cardiac - cardiomyopathy, hypertension, arrythmias– Pulmonary – if smoked– Renal – rhabdomyolysis and “tea colored urine”– Cerebral – TIAs and strokes


Cocaine Physical Exam

• Track marks (injection use)• Burnt lips/face/hair• Hand findings• Look for nasal perforation or hyperemic nares

OTHER DRUG CO-MORBIDITIES(briefly!)




Indolealkylamine Hallucinogens (LSA/LSD, DMT, Toads, Psilocybin, Psilocyn)


Lysurgic Acid Diethylamide (LSD)


Indolealkylamine Hallucinogens(LSA/LSD, DMT, Toads, Psilocybin,

Psilocyn)


Phenethylamine Hallucinogens(Peyote, Mescaline, MDMA)


Ecstasy (MDMA)


Sedatives and Designer Drugs


Arylcyclohexylamine Hallucinogens(PCP)


Marijuana

ADDRESSING CO-MORBIDITIES TREATMENTS IN PRACTICE




CROSSING THE QUALITY CHASM• “Quality problems occur

typically not because of failure of goodwill, knowledge, effort or resources devoted to health care, but because of fundamental shortcomings in the ways care is organized”

• Trying harder will not work: changing systems of care will!

a new HEALTH system for the 21st century (IOM, 2001)


SIX AIMS OF QUALITY HEALTH CARE

1. Safe – avoids injuries from care

2. Effective – provides care based on scientific knowledge and avoids services not likely to help

3. Patient-centered – respects and responds to patient preferences, needs, and values


SIX AIMS

4. Timely – reduces waits and sometimes harmful delays for those receiving and giving care

5. Efficient – avoids waste, including waste of equipment, supplies, ideas and energy

6. Equitable – care does not vary in quality due to personal characteristics (gender, ethnicity, geographic location, or socio-economic status)


SIX CRITICAL PATHWAYS FOR ACHIEVING AIMS AND RULES • New ways of delivering care• Effective use of information technology (IT)• Managing the clinical knowledge, skills, and

deployment of the workforce• Effective teams and coordination of care

across patient conditions, services and settings

• Improvements in how quality is measured • Payment methods conducive to good quality



MEDICAL AND SUBSTANCE-USE CONDITIONS

• Pervasive– More than 33 million Americans treated annually

~20 % of all working age adults (18-54) ~21 % of adolescents ~Millions more fail to receive care

• Frequently intertwined– 15 - 40 % co-occurrence

• Often influence general health – frequently accompany chronic illnesses– 20% of heart attack patients suffer from depression, tripling

risk of death– associated with leading causes of outpatient visits; e.g.,

headache, fatigue and pain


MENTAL, SUBSTANCE-USE, & GENERAL HEALTH

CONCLUSION• Improving care delivery and outcomes for any one of

mental health, substance use, and general health disorders depends upon improving care and outcomes for the other two.

OVERARCHING RECOMMENDATION• Health care for general, mental, and substance-use

problems and illnesses must be delivered with an understanding of the inherent interactions between the mind/brain and the rest of the body.


CH 3. PATIENT CENTERED CARERECOMMENDATIONS FOR CLINICIANS

• Incorporate informed, patient-centered decision making throughout practices

• To ensure informed decision making• Adopt recovery-oriented and illness self-

management practices that support patient preferences for treatment


CH 3. PATIENT CENTERED CARERECOMMENDATIONS FOR CLINICIANS

• Coercion should be avoided whenever possible.

• When coercion is legally authorized, patient-centered care is still applicable and should be undertaken.


CH 5. COORDINATING CARE RECOMMENDATIONS FOR CLINICIANS

• Implement policies and incentives to continually increase collaboration among providers to achieve evidence-based screening and care of patients.

• Clinical practices should transition along a continuum of evidence-based coordination models:– Formal agreements – Case management – Co-location – Integrated practices


MedicalMedicalMental Mental HealthHealth

VocationalVocational

EducationalEducational

LegalLegalAIDS/HIV AIDS/HIV RisksRisks

FinancialFinancial

Housing & Housing & TransportationTransportation

Child Child CareCare

FamilyFamily

Continuing Care

Case Management

Urine Monitoring

Self-Help(AA/NA)

Pharmacotherapy

Group/Individual Counseling

AbstinenceBasedIntake

Assessment

Treatment Plans

CoreCoreTreatmentTreatment

Etheridge, Hubbard, Anderson, Craddock, & Flynn, 1997 (PAB).

Core Components of Comprehensive Services


Substance Abuse is a Chronic Medical Condition

• Type 1 Diabetes: – 30% to 50% relapse each year requiring additional medical

care– Significant societal consequences

• Hypertension and Asthma: – 50% to 70% relapse each year requiring additional medical

care– Significant societal consequences

• Alcohol and Other Drug Diseases. – 40% to 60% relapse each year– Significant societal consequences– Few patients receive treatment!

McLellan, JAMA, 2000

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