Let's talk about something that may be
difficult for patients to bring out and describe,
but is critically important for their care
and is also important for USMLE and
that’s substance use disorders.
Let’s start with a little case here.
We’ve got a 19-year-old young man.
He’s here for his routine wellness visit.
And so, what does the United States Preventive
Services Task Force recommends screening in him
when we talk about potential substances for abuse.
Is it, A, marijuana or should we be
screening for prescription drug abuse?
How about screening for
heroin use or alcohol use?
USPSTF recommends only screening for alcohol
use among these different substances.
So, let’s talk about alcohol use disorders.
They’re very common.
7% of American adults have
some alcohol use disorder.
It’s the third leading preventable cause of death.
And so, therefore,
we recommend screening for alcohol use
and brief interventions for problem drinking.
Now, CDC has a pretty liberal
definition of problem drinking.
So, men up to –
should be drinking up to
four drinks per day.
Other organizations would say that really
two drinks per day is the maximum limit for men,
but certainly five drinks a day
would be too many
and a total of 14 drinks per week.
Women have a more strict threshold
because they don't have the
alcohol dehydrogenase that men do,
so therefore they should be drinking,
at the maximum, three drinks per day.
But some organizations again would say,
actually one drink per day should
be the maximum for women
and less than seven drinks per week.
So, what about treatment for alcohol use disorders?
There are some medications available that
you should be aware of in clinical
practice before your exam.
Acamprosate and naltrexone are both
more effective than placebo
in improving alcohol use disorders and
improving rates of abstinence from alcohol,
with a pretty low number needed to treat.
I think that treatment of
substance use disorders is a real challenge.
Rates of relapse in terms of drinking, smoking,
whatever substance you’re talking about are fairly high.
So, a number needed to
treat between 11 to 20 is fairly low.
Disulfiram is a classic drug that promotes
a severe reaction in terms of nausea and vomiting
when patients take alcohol after disulfiram,
but that’s not been proven to be as effective.
So, really, these newer drugs –
well, and naltrexone has been around a long time,
just now used for alcohol use disorders.
They are better choices for patients.
Acamprosate requires three times a day dosing,
whereas naltrexone is a little bit easier to take.
Acamprosate should be avoided in severe renal illness,
whereas naltrexone unfortunately
shouldn't be used in hepatitis and cirrhosis,
which is pertinent because so many patients with
alcohol use disorders have hepatitis and cirrhosis.
And just keep in mind too that,
while disulfiram and alcohol almost
always equals nausea and vomiting,
nausea and vomiting are still very common with
both acamprosate and naltrexone too.
Those are the most common side effects.
So, for other substance use disorders,
beyond tobacco and alcohol, there is no –
there are no screening recommendations,
even though we know that
the use of substances among
adolescents is fairly high.
Nearly half of 12th graders have used
some illicit substances in the past year.
And then, overall, worldwide,
over 22 million adolescents and adults have
either substance abuse or substance dependence.
Terrible outcomes associated with substance use.
Let’s talk about marijuana use,
and that's really undergone a
revolution in the United States as the –
there's been this wave of
legalization across the country.
How has that affected use among adults?
We see both rates of use and disorder going up.
And disorder means that the patients either have –
they’re dependent upon marijuana
or they’ve had some adverse reaction
due to taking marijuana.
And the rates of both have gone up.
That’s due to the legalization.
Also due to the –
and the increase in the disorder is
probably due to the increased potency
of today's marijuana versus the marijuana of
10 years ago or 10 years before that.
It’s generally a more potent product.
Interestingly though, in that same period,
we’ve actually seen a stabilization of
marijuana use among high school students
and the use actually decreased during that
legalization period between 1998 and 2013.
Still over 38% or so had tried marijuana.
Use before age 13 is a real problem because
it's when it's used before age 15 that marijuana
is associated with its worse effects on cognition
and also as a gateway drug for other
substances such as opiates and amphetamines.
And you can see the current use in the past month
was about 22% among high school students.
Just to focus on adolescents for a minute
because these really are to me a significant high risk group.
Substance use in this group tends to have longer-lasting,
more durable and negative effects on health
versus a use among adults.
So, alcohol use,
most US adolescents
had used alcohol in the past month.
Use of hallucinogens and
ecstasy is still fairly rare,
but, boy, watch prescription drugs.
That's the big riser,
particularly in the past 10 years is that
adolescents are using a lot more prescription drugs
and misusing those drugs than previous.
This includes drugs, of course,
like opiates, but also benzodiazepines
and stimulant drugs too.
And it’s worth noting that
the rates of prescription
drug overdose during that period,
certainly among adolescents,
but this is among all US citizens,
vastly outweigh those of illicit drug overdose.
So, it's much more –
the emergency department sees a lot more
prescription drug versus
illicit drug overdose these days.
And that's a real shame and
something we need to change.
So, one question that has excellent sensitivity
in detecting substance abuse or misuse
is how many times in the past year
have you used an illegal drug
or used a prescription medication
for non-medical reasons.
You don't have a lot of time in clinical practice.
If you had to choose
one question, this would be it.
Some advocate routine screening with urine
testing for potential drugs for abuse,
and that’s actually not recommended widely
because it doesn't start the
conversation the right way.
And it's not an enlistment of a
partnership between patient and clinician.
So, I generally try to discourage use
and national organizations do too.
In counseling subjects,
when you find a substance use disorder,
definitely you want to keep it objective,
use motivational interviewing techniques,
help the patient understand
how that substance may be standing
as a barrier in their own lives,
maybe it's related to their family
or their social obligations,
maybe it’s something related to school or work,
but try to find what motivates them
and then use that as a tool
to help them to move towards abstinence,
hopefully, or at least cutting back
because the goal in general for
substance abuse is abstinence,
but now there's more of an acceptance
of harm reduction techniques
and a great example
would be avoiding needle sharing
among patients with IV drug abuse.
That's a critically important public health goal.
It’s going to reduce risks of hepatitis and HIV,
but the goal for the individual patient is
abstinence because drugs like heroin can ruin lives.
So, what do you do for patients with heroin
addiction and addiction to other opiates?
Buprenorphine with naloxone for overdose rescue is a great
regimen that can reduce the use of opioid abuse overall.
Now, it does require special training
and getting waivers in order to
prescribe buprenorphine specifically.
You have to commit to a
long-term treatment regimen,
and so this is not for
somebody who's the casual user,
these are for patients with a
stronger history of opioid abuse.
But it’s something that can be initiated at home.
They don't have to be an inpatient to use it.
And using naloxone now has become more regular
and given to patients in kits, such that they can –
if there is a case of overdose
related to the use of buprenorphine
or when it's mixed with drugs,
other opiates or heroin,
then naloxone can be an
absolute lifesaver in the field,
particularly for low resource populations
like homeless populations.
Methadone is an older drug,
but still can be effective for those
with chronic opioid addiction.
It reduces opioid abuse and the associated
risk of harm such as overdose.
Naltrexone is generally less effective overall in terms
of the prevention of opioid abuse in the long run.
It also has a risk of hepatotoxicity and requires
routine monitoring of liver function tests,
which can be hard in a population with a high use of
substances just because follow-up can be erratic.
So, with that,
that just walks you through
some of the more common substances,
things you might see on your examination
as well as the treatment of substance abuse.
Hope it was helpful.