Addictive Disorders in Medical Populations

Norman S. Miller, Mark S. Gold, Norman S. Miller, Mark S. Gold

• Publisher: Wiley
• Year: 2011
• Print ISBN: 9780470740330
• eBook ISBN: 9781119956303
• Edition: 1
• Topic: Psychology
• Subtopic: Addiction in Psychology
• Index: Psychology

This book has a much wider focus than traditional books written about drug and alcohol addictions. This unique book is written by medical specialists who diagnose, treat and research addictive disorders in their specialities. Thus, it meets the needs of the typical medical practitioner who wants to learn about and treat patients with addictive disorders in their practices. Because alcohol and drug problems are so prevalent and affect medical conditions profoundly, the medical specialist will improve their knowledge and skill to diagnose and treat addictive disorders in their specialties.

Drug and alcohol addictions occur commonly in medical populations; 25–50% of patients seen by primary care physicians have alcohol and drug disorders, with even higher prevalence in certain medical specialty populations. Drug use (including illicit drug use and actual or perceived misuse of prescribed medications), alcohol use, and what has been called unhealthy drinking are even more common in trauma centers and our society. Currently, there are no authoritative addiction texts that focus on the identification, intervention and management of either "addictive disorders in medical populations" or "medical complications in addiction populations".

Neurobiological progress in the field of addiction has been amazing and evidence-based treatments have developed at a phenomenal pace, with bench to office applications for tobacco, alcohol and drugs. Pharmacological and psychosocial treatments are described here in detail and in practical terms. The medical and mental complications of addiction are explained comprehensively throughout the text. Clinical considerations are the predominant theme, with the standards of clinical practice grounded in the most current research. The chapters include practical presentations of both clinical and research materials, with instruments for screening and assessment and treatment.

It will be useful for all those seeking information to help a patient or family with a tobacco, alcohol or drug problem. We hope this book can give answers and direction to the identification and management of addictions and their medical complications in patient populations.

Part One

Addictive disorders and medicine

1

Addictive disorders as an integral part of the practice of medicine

Norman S. Miller¹ and Mark S. Gold²

¹Department of Medicine, Michigan State University, East Lansing, Michigan 48824, USA and Department of Psychiatry, The University of Florida, Gainesville, FL 32611, USA

²Departments of Psychiatry, Neuroscience, Anesthesiology, Community Health & Family Medicine, University of Florida College of Medicine and McKnight Brain Institute, Gainesville, FL 32611, USA

1.1 OVERVIEW

The role of physician in the prevention and treatment of addictive disorders is growing in importance and magnitude. The public and managed care organizations are increasingly looking to physicians for leadership and advocacy for patients who have drug and alcohol addictions. The political climate and enormous need combine to make the role of physicians essential to prevention and treatment strategies for addictive disorders. Efforts by physicians in the past have been slow and obstructionist, partly because of moral views and lack of training in addiction problems and disorders. Physicians who were not prepared to confront patients about their addictions and non-physicians who could treat, but not communicate with the physicians, competed for the overall care of the patients. Frequently, patients had to bridge the gap at the expensive cost of delay in prevention and diagnosis of problematic use of alcohol and drugs.

Heretofore, physicians played a supporting role, or no role at all, in fostering and developing effective prevention and treatment methods for addictive disorders. The attitude of “see no evil, hear no evil, do no evil” no longer allows physicians to ignore common alcohol and drug problems in their patients. Increasingly, generalists are called upon to screen, detect, prevent, and treat alcohol and drug disorders in their populations.

The challenge to medical schools and resident training programs to provide education and clinical experience in addiction has never been greater or more pressing. In the past, despite the presence and affects of alcohol and drug-related disorders, medical schools and residency programs failed to competently teach screening, diagnosis and treatment of such disorders to students. Increasingly, medical students and residents became aware of the need and demonstrated interest in becoming knowledgeable and skilled in the prevention and treatment of alcohol and drug addiction. Both residency directors and curriculum deans affirmatively endorsed that assessment of deficiencies in training and education for alcohol disorders would lead to significant improvements in medical education for residents and medical students. As a result, medical schools and psychiatry residency programs (at least in the major university settings) are integrating addiction education and experience into their programs [1].

We have a large body of knowledge and basic skills in the prevention and treatment of addictive disorders. Considerable resources have been spent on research and development of clinic methods for prevention and treatment. The next step is to implement what is effective and useful to patients. The role of physicians will become apparent if they concentrate on what is effective in preventing and treating addictive disease [2].

After reading this chapter you will better be able to understand:

1. The clinical prevalence of addictive disorders in the general as well as special circumstance populations.

2. The role of the physician in the prevention and treatment of addictive disorders.

3. Methods to improve prevention and treatment of addictive disorders primarily through improving medical school education.

1.2 CLINICAL PREVALENCE

1.2.1 Prevalence of alcohol and drug dependence in the general population

Alcohol and drug dependence are among the most prevalent illnesses in American society. The Epidemiological Catchment Area study, which is a survey of mental health and substance-related disorders in nearly 20 000 adult Americans, found a 13.5% lifetime prevalence of alcohol addiction or dependence, and 7% of drug dependence [3]. Alcoholism and related illnesses are major causes of morbidity and mortality in patients in the United States. More than half of all accidental deaths, suicides, and homicides are alcohol or drug related [4]. A significant proportion of fetal anomalies can be attributed to the use of drugs or alcohol during pregnancy, with an estimated rate of 11% of illicit drug use among pregnant women [5]. The use of intravenous methods of administering illicit drugs has contributed to the increasing number of deaths from AIDS, according to data from the Centers for Disease Control and Prevention (CDC) [6].

1.2.2 Prevalence of multiple drug use and dependence in treatment

The use of multiple drugs and alcohol is extraordinarily common (e.g., alcohol and cocaine, heroin and cocaine, marijuana with alcohol or cocaine). The large overlap of the use of drugs and alcohol has had significant ramifications for diagnosis and treatment as they are traditionally practiced [7–11].

Research models for dependence on alcohol and drugs are affected by multiple use and dependence. In practice, one drug is frequently substituted for another, and the majority of individuals develop combined alcohol and multiple-drug dependence. The concurrent and simultaneous occurrences of multiple drug and alcohol dependence suggest a generalized susceptibility to the various types of dependence [12–15].

1.2.3 Prevalence in the medical population

Drug and alcohol addiction are among the most common disorders seen in medical practice. They are at least as common as hypertension [16]. Addiction is associated with a wide range of problems, including pancreatitis, liver disease, accidents, suicide, depression, and anxiety. 20–50% of inpatient hospitalizations may be attributed to substance use and addiction, and 25–50% of emergency room visits are alcohol use and addiction related [17–22].

Although addiction is an extremely common disorder, it remains inadequately diagnosed and treated by physicians. Of the 20% of patients seen in ambulatory care settings who are estimated to be addicted to substances, only 5% of these patients are diagnosed [23]. Physicians do not diagnose or treat substance use and addiction with the same frequency, accuracy, or effectiveness as they do other chronic medical diseases [24,25]. In a recent study, resident physicians correctly identified less than half of the patients with positive scores on a CAGE questionnaire, 22% of patients with an alcohol addiction history, and 23% of patients with a history of substance addiction [26,27].

1.2.4 Prevalence in family and workplace populations

The psychological and social costs of alcoholism and drug addiction are considerable to patients in medical practice. Alcoholism is a major cause of family dysfunction, including domestic violence and child abuse. Over 40% of adults report exposure to problem drinkers in their families [28]. Alcoholism is a major contributor to poor job performance and productivity loss. Data show that 15% of heavy alcohol users missed work because of illness or injury in the past 30 days, and 12% of heavy users skipped work because of drinking in the past 30 days [29].

1.3 CLINICAL DIAGNOSIS

Physicians must make the diagnosis of alcohol and drug dependence to develop an integrated approach to medical education about addiction. Physicians must diagnose patients who present with abnormal alcohol and drug use [30–32]. Physicians must ask routine screening questions to all patients they see and maintain a high index of suspicion for addictive diseases, especially in light of the extreme levels of denial often present in addicted patients. Physicians seeing patients in high-risk populations, such as emergency departments, prisons, and trauma units, must have an especially high index of suspicion. A family history is the best predictor of addiction in patients; therefore, questions about family history take on special importance in the detection of substance addiction or dependence. In addition, patients with chief or presenting complaints such as sleep disorders, “stress,” chronic dyspepsia, recurrent peptic ulcers, or recurrent trauma should also raise a physician's index of suspicion. Physicians must be taught to listen carefully for rationalization, minimization, and denial in patient's responses while observing their affective component associated with these complaints and responses [33].

1.3.1 Risk assessment by physicians

Physicians should be able to detect patients in environments that pose a risk for the development of substance dependence. Categories of vulnerability to the use of alcohol, tobacco, and other drugs should be learned by every physician. Family environment includes family conflict, poor discipline style, parental rejection of the child, lack of adult supervision or family rituals, poor family management or communication, sexual and physical abuse, and parental or sibling modeling for use of alcohol, tobacco, and other drugs. School environment involves lack of school bonding and opportunities for involvement and reward, unfair rules, norms conducive to use of drugs, and school failure because of poor school climate. Community environment pertains to poor community bonding; community norms that condone alcohol, tobacco, and other drug addiction; disorganized neighborhoods; lack of opportunities for positive youth involvement; high levels of crime and drug use; endemic poverty; and lack of employment opportunities. Peer factors include bonding to peer groups whose members use alcohol, tobacco and other drugs or engage in other delinquent behaviors [34].

1.3.2 Physical examination and laboratory testing

The physical examination may be helpful in detecting alcohol or drug dependence. Information about intoxication, withdrawal, or alcohol-related or drug-related organ damage and disease may yield important information about the adverse complications of addictive illness. Although no specific finding is pathognomonic of alcoholism, a physician's use of physical findings may be valuable in penetrating denial and convincing patients of the significant extent of their alcohol and drug use. Laboratory tests, such as urine toxicology screen, macrocytic red cell indices, or for serum glutamic-oxabacetic transaminase and serum glutamic-pyruvic transaminase, may also be helpful. None of these, however, is of the same degree of importance and specificity as a thorough history for addiction with every patient [33].

1.4 CLINICAL COMORBIDITY

Substance addiction disorders have been associated with serious problems including violence, injury, disease, and death. In 2006, the CDC reported 13 470 injury deaths from alcohol-impaired motor vehicle crashes in the United States; this was almost 32% of all traffic-related deaths for that year [35]. It has been estimated that one in every four deaths can be attributed to the use of alcohol, tobacco, or some other form of drug. For example, tobacco use alone has been linked to 90% of lung cancer cases, 75% of emphysema cases, and 25% of ischemic heart disease cases [36].

1.5 TREATMENT OF MEDICAL DISORDERS ASSOCIATED WITH ALCOHOL AND DRUG USE AND ADDICTION

1.5.1 Physician intervention

Physicians should know how to provide simple interventions to eliminate or decrease substance misuse before it becomes dependence or addiction. Studies have shown that brief, empathic interventions by physicians can decrease the consumption and adverse effects of addictive substances by 20–50% [34,37–39]. Physicians should be taught that messages which state that the attainment of the goal of reducing alcohol-related problems is the patients' responsibility and which encourage abstinence are powerful modifiers of patients' behavior toward alcohol and drugs.

Physicians should be well versed in using prevention strategies for those patients at risk of substance addiction or dependence. Counseling patients about the health risks and dangers of substance misuse or addiction can be extremely effective in reducing their occurrence. The education of patients about the long-term and short-term consequences of substance misuse and addiction, including the severe risks encountered by drinking and driving, is fundamental to interventions by physicians. Physicians should be aware that many patients' peers probably do not approve of substance misuse and addiction, including the severe risks encountered by drinking and driving, is fundamental to interventions by physicians. Physicians should be aware that many patients' peers probably do not approve of substance use as a healthy activity, which may prove to be an effective deterrent. Physician communication and physician availability as a source of confidential information about addictions are key to successful interventions. Open discussion between patient and physician of issues relating to the health effects of alcohol and drugs can be extremely helpful [30,32].

1.5.2 Requirements of physicians for diagnosing and treating addictive disease

A physician specialist in the treatment of alcoholism and other drug addictions must:

• Possess a current MD or DO license.
• Be able to recognize and diagnose alcoholism or other drug dependencies at both early and late stages and possess sufficient knowledge and communication skills to prescribe a full range of treatment services for alcohol and other drug addiction patients, their families, or significant others.
• Demonstrate a functionally positive attitude toward addicted patients, their families, and indicated significant others.
• Be knowledgeable in addiction treatment and be able to intervene to get patients and their families or significant others into treatment for their needs.
• Be able to provide, refer, and support standard addiction treatment methods for alcohol and drug addictions.
• Be able to recognize and manage the medical and psychiatric complications of alcohol and other drug addictions.
• Be able to recognize and manage the signs and symptoms of withdrawal from alcohol and other drugs of addiction.
• Possess sufficient knowledge and communications skills concerning alcohol and other drug addictions to provide consultation, teach lay and professional people, and provide continuing education in this field.

General physicians must possess:

• The ability to competently obtain a history and perform a physical examination on patients with addictive disorder (this presumes an ability and willingness to hospitalize patients if necessary).
• An understanding of the medical, psychiatric, and social complications of addictive disorder (this presumes a knowledge of self-help groups, such as AA, Narcotics Anonymous, and Al-Anon, and presumes a knowledge of special groups for professionals).
• A positive attitude which is essential in establishing a relationship with patients in the treatment of alcoholism and drug addiction.
• A knowledge of the spectrum of this disease and the natural progression if untreated.
• A knowledge of the medical and psychiatric effects and organ damage attributable to alcoholism or other drug addictions (this presumes a knowledge of, and ability to prescribe, treatment).
• A knowledge of the classifications of drugs of addiction and their pharmacology and biochemistry (this presumes maintenance of current knowledge in this field and knowledge and skill in one or more methods of teaching and learning).
• A knowledge and skill in standard addiction treatment to prevent relapse and recurrence of adverse consequences of addictive disorders [40].

1.5.3 Abstinence-based method

Controlled studies have found significant results in treatment outcomes in abstinence-based programs, particularly when combined with referral to Alcoholics Anonymous (AA). The first randomized clinical trial of abstinence-based treatment showed significant improvement in drinking behavior compared with that of a more traditional form of treatment [41]. A total of 141 employed alcoholics were randomized to the abstinence-based program (Hazelden type) (n = 74) or to traditional-type treatment (n = 67). The abstinence-based treatment was significantly more involving, supportive, encouraging to spontaneity, and oriented to personal problems than was the traditional-type treatment. The one-year abstinence rate was significantly greater for the abstinence-based treatment; in addition, dropout rates were 7.9% for the abstinence treatment group and 25.9% for the traditional treatment group, respectively [42].

In another controlled study, 227 workers newly identified as alcoholics and cocaine addicts were randomly assigned to one of three treatment regimens: compulsory inpatient treatment, compulsory attendance at regimens; compulsory inpatient treatment, compulsory attendance at AA meetings; and a choice of options (i.e., inpatient, outpatient, or AA meetings). Inpatient backup was provided if needed [43]. On seven measures of drinking and drug use, the hospital group had significantly greater abstinence at a one-year and two-year follow-up. Those assigned to AA had the lowest abstinence rates, and those allowed to choose either an inpatient or outpatient program or AA had intermediate results. The programs for inpatient and outpatient treatment were abstinence based with eventual referrals to AA at discharge [43].

Previous evaluation studies of large populations of patients (>9750 subjects) enrolled for abstinence-based methods have shown favorable outcomes for addiction treatment. The populations consisted of multiply-dependent patients, including those with alcohol, prescription drug, cannabis, stimulant, cocaine, and opiate dependence (DSM-III-R Substance Dependence). The overall abstinence rates at one year were 60% for inpatients and 68% for outpatients (57% of the cases were contacted for inpatients, 62% for outpatients) [44,45]. However, abstinence rates were increased to 88% for inpatients and 93% for outpatients who participated in continuing care following discharge. At one-year follow-up, only 8% were attending continuing care after discharge in the inpatient treatment programs, and 17% were attending the outpatient programs. Moreover, abstinence rates after discharge were 75% for inpatients and 82%for outpatients who were regular attendees at AA. Accordingly, 46% and 51% of those discharged from the inpatient and outpatient programs, respectively, were attending AA at least once per week. Abstinence rates at one year for nonattendees at AA were 49% and 57%, respectively. Significant outcomes on other variables were reported, such as improved psychosocial functioning and employment and legal histories for those completing the treatment programs in these studies [44–46].

According to survey results [47] (1992) conducted by AA, recovery rates achieved in the AA fellowship were:

1. Of those sober in AA less than a year, 41% remain in the AA fellowship for an additional year [47].

2. Of those sober more than one year and less than five years, 83% remain in the AA fellowship for an additional year

3. Of those sober five years or more, 91% remain in the AA fel...

Table of contents

• Cover
• Title page
• Copyright
• List of Contributors
• Preface
• Acknowledgments
• Part One: Addictive Disorders and Medicine
• Part Two: Assessment and Diagnosis
• Part Three: Addictive Disorders and Clinical Diseases
• Part Four: Management of addictive disorders in selected populations
• Part Five Treatment of Addictive Disorders
• Index