Hot Topics in Addiction Medicine. Timothy Fong MD 44 th Annual Family Medicine Refresher March 2017

Transcription

1 Hot Topics in Addiction Medicine Timothy Fong MD 44 th Annual Family Medicine Refresher March 2017

2 Financial Disclosures Speaker Bureau Indivior Research Support Constellation Health Onward

3 Hot Topics The Opiate Epidemic Marijuana Vaping In 2017 what should FP know and do? SBIRT practices FDA-approved meds

4 DSM-5 Review

5 Substance-Related and Addictive Disorders Substance Use Disorder Single, dimensional condition Craving / strong desire to use (new) Legal problems removed 11 symptoms

6 Substance Use Disorder 1. is often taken in larger amounts or over a longer period than was intended. 2. There is a persistent desire or unsuccessful efforts to cut down or control use. 3. A great deal of time is spent in activities necessary to obtain, or recover from its effects. 4. Craving, or a strong desire or urge to use 5. Recurrent use resulting in a failure to fulfill major role obligations at work, school, or home. 6. Continued use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol. 7. Important social, occupational, or recreational activities are given up or reduced because of use. 8. Recurrent use in situations in which it is physically hazardous. 9. use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol. 10.Tolerance, as defined by either of the following: 1. A need for markedly increased amounts of alcohol to achieve intoxication or desired effect. 2. A markedly diminished effect with continued use of the same amount of 11.Withdrawal, as manifested by either of the following: 1. The characteristic withdrawal syndrome for alcohol (refer to Criteria A and B of the criteria set for alcohol withdrawal). 2. is taken to relieve or avoid withdrawal symptoms. Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association. All rights reserved.

7 DSM-5 Updates Added: Cannabis Withdrawal Caffeine Withdrawal Tobacco Use Disorder Moved Gambling Disorder Not Added: Hypersexual Disorders

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9 Alcohol Use Patterns 90% Have ever drank 60% Current drinkers 21% At-risk drinking 5% Abuse 4% Dependence (past year) (past year) O Malley 2014

10 Latest Drinking Trends: NESARC III 14% met DSM-5 AUD criteria for the previous year, 8% sought treatment 29% met AUD criteria at some time in their life 20% percent sought treatment or 7.7 percent of those with a 12-month alcohol use disorder sought treatment.

11 Clinical assessment and diagnosis NIAAA Clinician s Guide

12 Alcohol Markers A breathalyzer in every office Urine drug screen Not routinely measured Urine monitoring Urine ETG (ethylglucuronide) Urine EtS (ethylsulfate) Blood Peth (Phosphatidylethanol)

13 Screening Questions How often did you have a drink last year How many drinks did you have on days that you were drinking? How many times in the last 12 months have you had more than 5 (4, if female) drinks in a single occasion?

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15 Marijuana Trends Since 2008, perception of harm among 12 th graders has decreased (softening) Heavy MJ use <18 results in 8-point drop in IQ Establishing MJ intoxication limits Environmental impact

16 Medical Marijuana Compassionate Use Act (1996) SB 420 (2003) Establishes ID Card and regulation Explosion ( ; 439 in LA) Crackdown (2010) 2013 accepted practice /rites of passage 2014: Recreational legalization

17 Headed toward Legalization? Blue Ribbon Committee: (Pathways Report: Policy Options for Regulating Marijuana in California) Lt. Governor Gavin Newsom Ballot Initiative 2016? Protect children and youth, ensure public safety, establish tax and regulation schemes that maximize revenue while eliminating the illicit market.

18 Marijuana Breathalyzer

19 E-Cigarettes

20 Smoking in California First state to enact Tobacco control program (1988) Smoke-Free workplace (1994) Indoor smoking bans Current smoking prevalence for adults 13.3% (2008) 22.7% (1988)

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22 Diagram of E-Cig *When heated, the cartridge that contains the liquid nicotine converts the contents into a vapor that the user inhales.

23 How does it work? Activated by inhaling the device - on detecting the airflow the heating element is activated releasing vapor. In addition to being tobacco free it contains varying amounts of nicotine and or propylene glycol.

24 E-Cigs are HUGE > 500 manufacturers Global Sales >$7 billion 3 rd generation technology Patchwork regulation + consumer demand + affordable product + slick marketing

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26 Increasingly Popular among Teens Monitoring the Future (2014) Past-month use: 8th graders is 8.7 percent 10th graders is 16.2 percent 12th graders is 17.1 percent

27 Facts about E-Cigs E-cigarette emissions can contain nicotine levels comparable to secondhand tobacco smoke which is potentially particularly problematic for children, pregnant women and persons with cardiovascular conditions.

28 Facts about E-Cigs E-cigarettes emit volatile organic compounds, like benzene and toluene; heavy metals, like nickel and arsenic; tobacco specific carcinogens; Manufacturing standards are not universally regulated (contaminants!)

29 Facts about E-Cigs Has the potential to undo decades of de-normalization of smoking in California by making it appear that smoking is acceptable.

30 Facts about E-Cigs Have NOT been shown to be superior to placebo or existing FDA-products for smoking cessation Potential is there but no proof.

31 Facts about E-Cigs Long-term health effects of e-cigarette use are unknown and although the industry marketing of the product implies that these product are harmless, the vapor that e-cigarettes emit is not purely water vapor. (Same claims as tobacco)

32 Abused Opiates Prescription Pills Heroin

33 Opioid Sales, Deaths & Addiction Treatment National Vital Statistics System, ; Automation of Reports and Consolidated Orders System (ARCOS) of the Drug Enforcement Administration (DEA), ; Treatment Episode Data Set,

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35 Overdose Education and Naloxone Distribution (OEND) ~20,000 deaths / yr Naloxone (injectable and nasal spray) Reverses opiate overdoses In early 2015, California law allows pharmacists to distribute naloxone directly to patients

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37 Naloxone Formulations Generic Injection Solution: 0.4 MG/1 ML, 1 MG/1 ML Evzio Injection Solution: 0.4 MG/0.4 ML Narcan Nasal Spray: 4 MG/0.1 ML

38 FDA-Approved Medications Drugs of Abuse Brand Name Generic Name Alcohol Antabuse Disulfiram Vivitrol Naltrexone Revia Campral Naltrexone Acamprosate

39 FDA-Approved Medications Drug of Abuse Brand Name Generic Opiates Suboxone, Zubsolv Buprenorphine/ Naloxone Methadone Revia Vivitrol Naltrexone Naltrexone

40 FDA-Approved Medications Drug of Abuse Brand Name Generic Name Nicotine Nicotine Replacement Therapies Chantix Patches, Lozenge, Inhalers, Gums Varenicline Zyban Bupropion

41 FDA-Approved Medications Addictive Disorder Brand Generic Name Name Cocaine - - Methamphetamine - - Marijuana - - Gambling - - Sexual Addictions - -

42 What is SBIRT? Public health approach to the delivery of early intervention and treatment services for people with substance use disorders Developed by SAMHSA ~ 2004

43 What is SBIRT? Screening: quickly assesses the severity of substance use and identifies appropriate level of treatment Brief Intervention increases insight, awareness and motivation toward change Referral to Treatment provides access to specialty care

44 The Value of SBIRT Brings behaviors into the light Gives providers an opportunity to educate and change risky behaviors Can provide a wake-up call Feasible to screen in primary care Integrate care The 6 th vital sign?

45 What SBIRT Can t Do Not likely to change behaviors of severe and complex cases Dually diagnosed Severely mentally ill Unclear how well it works with different drugs of abuse

46 SBIRT Reimbursement Commercial Insurance CPT Alcohol and/or substance abuse structured screening and brief intervention services; 15 to 30 minutes $33.41 CPT Alcohol and/or substance abuse structured screening and brief intervention services; greater than 30 minutes $65.51

47 SBIRT Reimbursement Medicare G0396 G0397 Alcohol and/or substance abuse structured screening and brief intervention services; 15 to 30 minutes; $29.42 Alcohol and/or substance abuse structured screening and brief intervention services; greater than 30 minutes $57.69

48 Essential Office Tools

49 LASBIRT.com

50 Controlled Substance Utilization Review and Evaluation System (CURES)

51 Proper Drug Disposal (DEA/FDA) 1. Medicine Take Back Programs 2. Transfer to DEA-authorized collection sites 3. Dispose in Trash Mix with unpalatable substance, seal, throw, de-identify 4. FLUSH Controlled Substances!

52 Treatment Referrals SAMHSA Treatment Locator HELP NIDA Clinical Trials Network American Academy of Addiction Psychiatry American Society of Addiction Medicine

53 Contact Information Timothy Fong MD UCLA Addiction Medicine Clinic (appts) (office) uclagamblingprogram.org