Medical CoMorbidities in the Substance Using Patient

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Medical Co-Morbidities in the Substance Using
Patient
Wilford

• Adam J. Gordon, MD, MPH, FACP, FASAM
• University of Pittsburgh School of Medicine
• VA Pittsburgh Healthcare System
• gordona_at_upmc.edu
• adam.gordon_at_va.gov

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ASAMs 2008 Review Course in Addiction
Medicine

• ACCME required disclosure of
• relevant commercial relationships
• Dr. Gordon has nothing to disclose.

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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

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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

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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

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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

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ALCOHOL USE and DISORDERSHARM and MEDICAL
CO-MORBIDITIES

• Adam J. Gordon, MD, MPH, FACP, FASAM
• University of Pittsburgh School of Medicine
• VA Pittsburgh Healthcare System

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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
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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

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Some Associations with Hazardous Drinking

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

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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

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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

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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

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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

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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)

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Early Hepatic Markers

• Increased gamma-glutamyl transpeptidase (GGT) up
  to 3 times normal in 20 to 30 of heavy drinkers
• Liver enzymes
• AST/SGOT gt ALT/SGPT
• Production Problems
• Coagulopathies in end stage alcoholic liver
  disease
• Dont forget the pancreas!
• Acute and chronic pancreatitis
• Complications
• Diabetes, Steatorrhea, Pseudocyst

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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

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Nervous System Effects

• Headaches
• Sleep disorders
• Wernicke syndrome
• Korsakoff psychosis
• Organic brain disease
• Cognitive
• Memory
• Peripheral neuropathy

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Nervous System Effects

• C Confusion
• O Ophthalmalplegia
• A Ataxia
• T Early Thiamine Deficiency (Wernickes)
• R Retrograde Amnesia
• A Anterograde Amnesia
• C Confabulation and meager Conversation
• K Korsakoff Syndrome
• (Also lack of INsight and Greater apathy)

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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

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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

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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

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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

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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

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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
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Societal Costs of Alcohol Dependence
Total Cost 184.6 Billion
7,466 (4)
24,093 (13)
15,963 (9)
10,085 (5)
2,909 (2)
1,253 (1)
36,499 (20)
86,368 (47)
Harwood H, NIH Publication No. 98-4327 1998
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OPIOID USE and DISORDERSHARM and MEDICAL
CO-MORBIDITIES

• Adam J. Gordon, MD, MPH, FACP, FASAM
• University of Pittsburgh School of Medicine
• VA Pittsburgh Healthcare System

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Balloons, Bags, and Pills
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New Prescription Drug Users
Past Year Initiation of Non-Medical Use of
Prescription-type Psycho-pharmaceutics Age 12 or
Older In Thousands from 1965 to 2005
NSDUH, SAMHSA, 2005
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Opioid Withdrawal

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

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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

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Changing Route of Heroin Administration
Treatment Episode Data System, 1992-2000
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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

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Hepatitis B Clinical Course

• Early and mild viral hepatitis manifests with
  symptoms of hepatic inflammation and damage with
  elevated serum transaminases (gt 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

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Acute Hepatitis B Infection with Recovery
Symptoms
HBeAg
anti-HBe
Total anti-HBc
Titer
anti-HBs
IgM anti-HBc
HBsAg
0
4
8
12
16
24
28
32
52
100
20
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Weeks after Exposure
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Progression to Chronic Hepatitis B Infection
Titer
Weeks after Exposure
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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

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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

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Hepatitis C Acute Infection with Recovery
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Hepatitis C Progression to Chronic Infection
anti-HCV
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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)
• lt 40 years old when infected, male sex

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30 Year Progression of Chronic Hepatitis C
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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

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Hepatitis C Treatment in Drug Users

• Standard recommendation gt/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 345211-214, 2001

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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

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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

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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

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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

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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

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How Do They Get Hooked?
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COCAINE USE and DISORDERSHARM and MEDICAL
CO-MORBIDITIES

• Adam J. Gordon, MD, MPH, FACP, FASAM
• University of Pittsburgh School of Medicine
• VA Pittsburgh Healthcare System

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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

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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

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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

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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

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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

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Cocaine Physical Exam

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

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OTHER DRUG CO-MORBIDITIES(briefly!)

• Adam J. Gordon, MD, MPH, FACP, FASAM
• University of Pittsburgh School of Medicine
• VA Pittsburgh Healthcare System

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Indolealkylamine Hallucinogens (LSA/LSD, DMT,
Toads, Psilocybin, Psilocyn)
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Lysurgic Acid Diethylamide (LSD)
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Indolealkylamine Hallucinogens(LSA/LSD, DMT,
Toads, Psilocybin,Psilocyn)
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Phenethylamine Hallucinogens(Peyote, Mescaline,
MDMA)
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Ecstasy (MDMA)
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Sedatives and Designer Drugs
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Arylcyclohexylamine Hallucinogens(PCP)
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Marijuana
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ADDRESSING CO-MORBIDITIES TREATMENTS IN PRACTICE

• Adam J. Gordon, MD, MPH, FACP, FASAM
• University of Pittsburgh School of Medicine
• VA Pittsburgh Healthcare System

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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)
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SIX AIMS OF QUALITY HEALTH CARE

• Safe avoids injuries from care
• Effective provides care based on scientific
  knowledge and avoids services not likely to help
• Patient-centered respects and responds to
  patient preferences, needs, and values

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SIX AIMS

• Timely reduces waits and sometimes harmful
  delays for those receiving and giving care
• Efficient avoids waste, including waste of
  equipment, supplies, ideas and energy
• Equitable care does not vary in quality due to
  personal characteristics (gender, ethnicity,
  geographic location, or socio-economic status)

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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

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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

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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.

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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

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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.

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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

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Core Components of Comprehensive Services
Medical
Mental Health
Financial
Housing Transportation
Vocational
Educational
Child Care
Legal
Family
AIDS/HIV Risks
Etheridge, Hubbard, Anderson, Craddock, Flynn,
1997 (PAB).
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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