Training physicians who care for adolescents and young adults. Richard Blondell MD ABAM-Foundation. with support from The Conrad N.

Transcription

1 Training physicians who care for adolescents and young adults Richard Blondell MD ABAM-Foundation with support from The Conrad N. Hilton Foundation

2 A request for a presentation for the pediatric grand rounds at the Children's Hospital of Buffalo

3 The request from WCHOB: What to do with certain patients? What should the pediatrician do if you suspect that a teenager is using drugs? if the parent is asking for certain drugs? when teenagers might be drinking more than they admit? for routine screening? to look for signs of injection because they use their feet? treat withdrawal from heroin? when a teenager asks for a refill of pain killers? to refer an young person to drug treatment?

4 Provide some practical treatment recommendations for the pediatricians in the audience who care for the types of patients described on the previous slide

5 Meet their request for advice Add in some SBIRT material Be interactive

6 This was not known before the presentation At least 3 pediatricians in the audience were also the parent of an adolescent who had an active substance use disorder.

7 An Addiction Medicine Patient Care Competency 5 Cases 5 Different Providers

8 Richard D. Blondell, MD University at Buffalo Addiction Medicine Pediatric Grand Rounds Women and Children's Hospital of Buffalo June 12, 2015

9 Richard D. Blondell, MD NO COMMERCIAL CONFLICTS Work Supported by an Educational Grant from The Conrad N. Hilton Foundation

10 Drugs Destroy Families

11 A 14-year-old is brought in to the office by her mother for bad moods.

12 Case 1: 14-year-old CC: Bad moods HPI: Depressed since her father died 6 months ago PMH: ADHD, treated with methylphenidate FH: Mother with breast CA, father with alcoholism SH: Lives with mother and step-father Occasional cigarette, denies EtOH & drug use School issues, mother requests Adderall PE: Unremarkable, difficult to engage QUESTIONS: What is the DDx? Any testing needed?

13 The audience members were asked to write down an answer to these questions What is the DDx? Any testing needed? with support from The Conrad N. Hilton Foundation

14 A 15-year-old presents for follow-up of knee pain following a sports injury.

15 Case 2: 15-year-old CC: Knee pain, F/U from Ortho Subjective: About 6 weeks previously, she had arthroscopic treatment of a meniscal tear. She was discharged from the care of orthopedics and was told to follow-up with her PCP for pain management. She is now having PT and requests a refill for a few Lortabs so I can take them after my PT session. Objective: Hair dyed blonde, slight effusion in left knee. Rx report: Hydrocodone/APAP 5/325, #30, refilled twice QUESTIONS: Any testing needed? Would you refill Rx?

16 The audience members were asked to write down an answer to these questions Any testing needed? Would you refill Rx? with support from The Conrad N. Hilton Foundation

17 A 16-year-old admits to binge drinking at an ER follow-up visit..

18 Case 3: 16-year-old CC: ER F/U, sprained ankle Subjective: On Saturday (2 days ago), she was at her junior prom, drank a couple of drinks afterwards, fell down, and twisted my right ankle. She was seen in the local ER where X- rays were negative, and she was told to follow-up with her PCP. She requests a prescription for a few Lortabs because ibuprofen is not cutting it. Objective: Lateral ankle with mild swelling and ecchymosis. Rx report: No Rx for controlled substance in past 6 months QUESTIONS: Any testing needed? Would you Rx opiates?

19 The audience members were asked to write down an answer to these questions Any testing needed? Would you Rx opiates? with support from The Conrad N. Hilton Foundation

20 A 17-year-old presents for a pre-college examination and disease prevention.

21 Case 4: 17-year-old CC: College physical HPI: No major complaints, but has questions about HPV, otherwise immunizations are up-to-date PMH: ADHD as child, minor injuries, otherwise [-] FH: Heart disease, diabetes, cancer, alcoholism SH: Lives with parents; will start local CC in fall. Smoker, social drinker, denies drug use PE: Cutter marks, 2 tattoos, body piercings QUESTIONS: Any testing needed? What advice to give?

22 The audience members were asked to write down an answer to these questions Any testing needed? What advice to give? with support from The Conrad N. Hilton Foundation

23 An 19-year-old admitted for cellulitis develops opioid withdrawal.

24 Case 5: 19-year-old CC: My foot s infected. HPI: 5-year history of drug abuse, prior Narcan rescue, IV heroin for past 9 months, IV site infected PMH: ADHD, psych problems, chronic pain FH: Mother has drug issues, father died of alcoholism SH: Lives with boyfriend, unemployed Arrested last month, court pending PE: S/P I&D of abscess on dorsal surface of (L) foot Labs: Hepatitis C (+); urine HCG (+) QUESTIONS: How do you treat withdrawal? How would you refer for drug rehab?

25 The audience members were asked to write down an answer to these questions How do you treat withdrawal? How would you refer for drug rehab? with support from The Conrad N. Hilton Foundation

26 Etiology Genetic and Environmental

27 Risk Factors for Addiction Family History/Genetics OPRM1 - opioid receptor mu 1 DRD2 - dopamine receptor D2 5-HTTLPR - neurotransmitter serotonin gene Prenatal exposure: animal and human studies Early onset drinking: <14 yrs = 47%; > 21 = 10% Alcohol tolerance ADHD Depression/Anxiety disorders History of physical or sexual abuse

28 Epidemiology It s very common

29 Alcohol Use, th Graders 10 th Graders 12 th Graders Lifetime use Annual use Binge: past 2 weeks 27.8% 52.1% 68.2% 22.1% 47.1% 62.0% 5.12% 13.7% 22.1% Nackers AM, Weddle MC, Kototailo PK. Epidemiology of adolescent substance use. In: Essentials of Addiction Medicine, 2 nd Ed. Wolters Kluwer, 2015 (pages: )

30 Marijuana Use, th Graders 10 th Graders 12 th Graders Lifetime use 16.5% 35.8% 45.5% Annual use 12.7% 29.8% 36.4% (synthetic) (4.0%) (7.4%) (7.9%) Daily use 1.1% 4.0% 6.5% Nackers AM, Weddle MC, Kototailo PK. Epidemiology of adolescent substance use. In: Essentials of Addiction Medicine, 2 nd Ed. Wolters Kluwer, 2015 (pages: )

31 Cocaine Use, th Graders 10 th Graders 12 th Graders Lifetime use Annual use 1.7% 3.3% 4.5% 1.0% 1.9% 2.6% Nackers AM, Weddle MC, Kototailo PK. Epidemiology of adolescent substance use. In: Essentials of Addiction Medicine, 2 nd Ed. Wolters Kluwer, 2015 (pages: )

32 Any Illicit Drug Use, th Graders 10 th Graders 12 th Graders Lifetime use Annual use 20.3% 38.8% 50.4% 14.9% 31.8% 40.3% Nackers AM, Weddle MC, Kototailo PK. Epidemiology of adolescent substance use. In: Essentials of Addiction Medicine, 2 nd Ed. Wolters Kluwer, 2015 (pages: )

33 Non-Medical Use, th Graders 10 th Graders 12 th Graders OxyContin 2.0% 3.4% 3.6% hydrocodone 1.4% 4.6% 5.3% tranquilizers 2.9% 5.5% 7.7% Adderall 1.8% 4.4% 7.4% Ritalin 1.1% 1.8% 2.3% Nackers AM, Weddle MC, Kototailo PK. Epidemiology of adolescent substance use. In: Essentials of Addiction Medicine, 2 nd Ed. Wolters Kluwer, 2015 (pages: )

34 Natural History Addiction starts in adolescence

35 Addiction is a Pediatric Disease! Compton Arch Gen Psych 2007;64

36 Neurobiology Addiction is a brain disease

37

38 What I learned from gynecologists about addiction

39 We can't treat our way out of this addiction epidemic.

40 The Spectrum of Cervical Cancer Metastatic Vaccine Colposcopy Cone Hysterectomy Pelvic Surgery

41 The Spectrum of Addiction Dependent Prevention Education Advice Intervention Refer to treatment

42 Prevention

43 Prevention 1. Screen: ask about risk factors 2 Teach: educate about addiction risks 3. Do no harm: caution with Rx meds

44

45 SBIRT 1. Screening 2. Brief Intervention 3. Referral to Treatment

46 Screening

47 NIAAA & AAP SIMPLE QUESTIONS Do you have any friends who drink beer, wine, or any drink containing alcohol in the past year? In the past year, on how many days have you had more than a few sips of beer, wine, or any drink containing alcohol in the past year? NIH Publication No

48 CeASAR & AAP CRAFFT C: ridden in a CAR R: use to RELAX A: ever use ALONE F: FORGET things F: FRIENDS ever tell you T: gotten into TROUBLE Arch Ped Adoles Med 2010; 156:607

49 Am Psych Assoc VALIDATED INSTRUMENTS Useful for research Often with quantitative scoring Many are automated Most are for adults TWEAK for pregnancy American Psychiatric Publishing, 2007

50 Brief Intervention

51 FRAMES Based on Motivational Interviewing

52 Feedback with concern I'm concerned about your drinking.

53 Reinforce Responsibility Only you can decide what to do.

54 Advise Action I recommend that you wait until 21

55 Menu of options You could continue to drink and risk your future I recommend that you wait until 21 to preserve your future Promise me that you will never drink and drive, or ride in car with a driver who has been drinking

56 Express Empathy I know that this is not an easy conversation to have It is not always easy to not do what your friends want you to do

57 Support Self-efficacy I think you are smart enough to think for yourself and use this information to make the right choice

58 Referral to Treatment

59 Offer Hope

60 Detox Management of Withdrawal

61 Buprenorphine Day 1: 4 mg in AM, 2 mg Q 4 hours PRN Day 2: 4 mg in AM, 2-4 mg at HS PRN Day 3: 4 mg in AM, 2 mg at HS PRN Day 4: 2 mg in AM PRN, 2 mg at HS PRN Day 5: 2 mg in AM PRN

62 Methadone Day 1: mg in AM, 5 mg Q 4 hours PRN Day 2: mg in AM, 5 mg at HS PRN Day 3: 5-10 mg in AM, 5 mg at HS PRN Day 4: 5 mg in AM PRN Day 5: 5 mg in AM PRN

63 Federal Regulations Buprenorphine requires special DEA permit Methadone requires DEA Schedule II permit - Only if hospitalized for another condition - Maximum of 5 days

64 The audience members now were told That the 19 y/o patient was an actual patient There were not 5 different patients There was only one patient, but 5 doctors The other 4 were the 19 y/o at younger ages We will review the cases in reverse order with support from The Conrad N. Hilton Foundation

65 An 19-year-old admitted for cellulitis develops opioid withdrawal.

66 Case 5 Recommendations 1. Detox 2. Perform a detailed intervention - FRAMES/motivational therapy - Show a video 3. Refer to treatment (Offer Hope)

67 The audience members now were told We will continue to review in reverse order We will look for red flags We will identify missed opportunities We will recognize teachable moments We will outline possible interventions with support from The Conrad N. Hilton Foundation

68 Case 4 A 17-year-old presents for a pre-college examination and disease prevention. PMHx : ADHD PSHx: Rx opiate exposure FHx: alcoholism SHx: smoker, drinker PE: cutter marks, tattoos

69 Case 4 Recommendations 1. Screening: Consider urine tox 2. Perform a Brief Intervention - FRAMES - Show a video/give printed info 3. Refer to treatment ( evaluation )

70 Case 3 A 16-year-old admits to binge drinking at her prom during an ER follow-up visit.. Drinking probably > HPI Injury while drinking Asking for Lortabs

71 Case 3 Recommendations 1. Screening: more questions, UDT 2. Perform an intervention - FRAMES - Show a video/give printed info 3. Refer to treatment (PCP follow-up)

72 Case 2 A 15-year-old presents for follow-up of knee pain following a sports injury. Bleach blonde Excessive Rx med use Asking for Lortabs

73 Case 2 Recommendations 1. Screening: more questions, UDT 2. Perform an intervention - FRAMES - Do no harm: no more opiates 3. Refer to treatment PRN

74 Case 1 A 14-year-old is bought into the office by her mother because of bad moods. HPI: Requesting Adderall PMHx : ADHD PSHx: Rx opiates FHx: alcoholism (father s death?) SHx: smoker, school problems PE: difficult to engage

75 Case 1 Recommendations 1. Make an accurate diagnosis - Detailed history of current substance use - Detailed history for abuse/neglect - Is the diagnosis of ADHD accurate? - Detailed family history of alcohol/drug issues - Nature of school problems - Consider urine toxicology 2. Consider referral for evaluation 3. Follow-up

76 Summary Ask every patient about substance use (Screen) Advise by giving a clear message (Intervention) Assess willingness to make a change Assist those willing to change (Refer PRN) Arrange for follow-up

77 If you fail 70% of the time, they'll put you in the Hall of Fame lifetime batting average

78 Suggested Reading Principles of Addiction Medicine, 5 th Ed. Wolters Kluwer (Chapters ) Essentials of Addiction Medicine, 2 nd Ed. Wolters Kluwer (Chapters ) NIAAA Guide, NIH Publication No AHRQ Guide, AHRQ Publication No. 06-E015 NIDA Guide, NIH Publication No (A)

79 I am the face of addiction

80 If there was more time Demonstration role plays Have audience members practice FRAMES Break into small groups with a moderator o o Provide a clinical summary Provide a scripts for the doctor and patient with support from The Conrad N. Hilton Foundation

81 An Addiction Medicine Patient Care Competency 5 Cases 5 Different Providers

82 Richard D. Blondell, MD University at Buffalo Addiction Medicine Pediatric Grand Rounds Women and Children's Hospital of Buffalo June 12, 2015

83 Richard D. Blondell, MD NO COMMERCIAL CONFLICTS Work Supported by an Educational Grant from The Conrad N. Hilton Foundation

84 Drugs Destroy Families

85 A 14-year-old is brought in to the office by her mother for bad moods.

86 Case 1: 14-year-old CC: Bad moods HPI: Depressed since her father died 6 months ago PMH: ADHD, treated with methylphenidate FH: Mother with breast CA, father with alcoholism SH: Lives with mother and step-father Occasional cigarette, denies EtOH & drug use School issues, mother requests Adderall PE: Unremarkable, difficult to engage QUESTIONS: What is the DDx? Any testing needed?

87 A 15-year-old presents for follow-up of knee pain following a sports injury.

88 Case 2: 15-year-old CC: Knee pain, F/U from Ortho Subjective: About 6 weeks previously, she had arthroscopic treatment of a meniscal tear. She was discharged from the care of orthopedics and was told to follow-up with her PCP for pain management. She is now having PT and requests a refill for a few Lortabs so I can take them after my PT session. Objective: Hair dyed blonde, slight effusion in left knee. Rx report: Hydrocodone/APAP 5/325, #30, refilled twice QUESTIONS: Any testing needed? Would you refill Rx?

89 A 16-year-old admits to binge drinking at an ER follow-up visit..

90 Case 3: 16-year-old CC: ER F/U, sprained ankle Subjective: On Saturday (2 days ago), she was at her junior prom, drank a couple of drinks afterwards, fell down, and twisted my right ankle. She was seen in the local ER where X- rays were negative, and she was told to follow-up with her PCP. She requests a prescription for a few Lortabs because ibuprofen is not cutting it. Objective: Lateral ankle with mild swelling and ecchymosis. Rx report: No Rx for controlled substance in past 6 months QUESTIONS: Any testing needed? Would you Rx opiates?

91 A 17-year-old presents for a pre-college examination and disease prevention.

92 Case 4: 17-year-old CC: College physical HPI: No major complaints, but has questions about HPV, otherwise immunizations are up-to-date PMH: ADHD as child, minor injuries, otherwise [-] FH: Heart disease, diabetes, cancer, alcoholism SH: Lives with parents; will start local CC in fall. Smoker, social drinker, denies drug use PE: Cutter marks, 2 tattoos, body piercings QUESTIONS: Any testing needed? What advice to give?

93 An 19-year-old admitted for cellulitis develops opioid withdrawal.

94 Case 5: 19-year-old CC: My foot s infected. HPI: 5-year history of drug abuse, prior Narcan rescue, IV heroin for past 9 months, IV site infected PMH: ADHD, psych problems, chronic pain FH: Mother has drug issues, father died of alcoholism SH: Lives with boyfriend, unemployed Arrested last month, court pending PE: S/P I&D of abscess on dorsal surface of (L) foot Labs: Hepatitis C (+); urine HCG (+) QUESTIONS: How do you treat withdrawal? How would you refer for drug rehab?

95 Etiology Genetic and Environmental

96 Risk Factors for Addiction Family History/Genetics OPRM1 - opioid receptor mu 1 DRD2 - dopamine receptor D2 5-HTTLPR - neurotransmitter serotonin gene Prenatal exposure: animal and human studies Early onset drinking: <14 yrs = 47%; > 21 = 10% Alcohol tolerance ADHD Depression/Anxiety disorders History of physical or sexual abuse

97 Epidemiology It s very common

98 Alcohol Use, th Graders 10 th Graders 12 th Graders Lifetime use Annual use Binge: past 2 weeks 27.8% 52.1% 68.2% 22.1% 47.1% 62.0% 5.12% 13.7% 22.1% Nackers AM, Weddle MC, Kototailo PK. Epidemiology of adolescent substance use. In: Essentials of Addiction Medicine, 2 nd Ed. Wolters Kluwer, 2015 (pages: )

99 Marijuana Use, th Graders 10 th Graders 12 th Graders Lifetime use 16.5% 35.8% 45.5% Annual use 12.7% 29.8% 36.4% (synthetic) (4.0%) (7.4%) (7.9%) Daily use 1.1% 4.0% 6.5% Nackers AM, Weddle MC, Kototailo PK. Epidemiology of adolescent substance use. In: Essentials of Addiction Medicine, 2 nd Ed. Wolters Kluwer, 2015 (pages: )

100 Cocaine Use, th Graders 10 th Graders 12 th Graders Lifetime use Annual use 1.7% 3.3% 4.5% 1.0% 1.9% 2.6% Nackers AM, Weddle MC, Kototailo PK. Epidemiology of adolescent substance use. In: Essentials of Addiction Medicine, 2 nd Ed. Wolters Kluwer, 2015 (pages: )

101 Any Illicit Drug Use, th Graders 10 th Graders 12 th Graders Lifetime use Annual use 20.3% 38.8% 50.4% 14.9% 31.8% 40.3% Nackers AM, Weddle MC, Kototailo PK. Epidemiology of adolescent substance use. In: Essentials of Addiction Medicine, 2 nd Ed. Wolters Kluwer, 2015 (pages: )

102 Non-Medical Use, th Graders 10 th Graders 12 th Graders OxyContin 2.0% 3.4% 3.6% hydrocodone 1.4% 4.6% 5.3% tranquilizers 2.9% 5.5% 7.7% Adderall 1.8% 4.4% 7.4% Ritalin 1.1% 1.8% 2.3% Nackers AM, Weddle MC, Kototailo PK. Epidemiology of adolescent substance use. In: Essentials of Addiction Medicine, 2 nd Ed. Wolters Kluwer, 2015 (pages: )

103 Natural History Addiction starts in adolescence

104 Addiction is a Pediatric Disease! Compton Arch Gen Psych 2007;64

105 Neurobiology Addiction is a brain disease

106

107 What I learned from gynecologists about addiction

108 We can't treat our way out of this addiction epidemic.

109 The Spectrum of Cervical Cancer Metastatic Vaccine Colposcopy Cone Hysterectomy Pelvic Surgery

110 The Spectrum of Addiction Dependent Prevention Education Advice Intervention Refer to treatment

111 Prevention

112 Prevention 1. Screen: ask about risk factors 2 Teach: educate about addiction risks 3. Do no harm: caution with Rx meds

113

114 SBIRT 1. Screening 2. Brief Intervention 3. Referral to Treatment

115 Screening

116 NIAAA & AAP SIMPLE QUESTIONS Do you have any friends who drink beer, wine, or any drink containing alcohol in the past year? In the past year, on how many days have you had more than a few sips of beer, wine, or any drink containing alcohol in the past year? NIH Publication No

117 CeASAR & AAP CRAFFT C: ridden in a CAR R: use to RELAX A: ever use ALONE F: FORGET things F: FRIENDS ever tell you T: gotten into TROUBLE Arch Ped Adoles Med 2010; 156:607

118 Am Psych Assoc VALIDATED INSTRUMENTS Useful for research Often with quantitative scoring Many are automated Most are for adults TWEAK for pregnancy American Psychiatric Publishing, 2007

119 Brief Intervention

120 FRAMES Based on Motivational Interviewing

121 Feedback with concern I'm concerned about your drinking.

122 Reinforce Responsibility Only you can decide what to do.

123 Advise Action I recommend that you wait until 21

124 Menu of options You could continue to drink and risk your future I recommend that you wait until 21 to preserve your future Promise me that you will never drink and drive, or ride in car with a driver who has been drinking

125 Express Empathy I know that this is not an easy conversation to have It is not always easy to not do what your friends want you to do

126 Support Self-efficacy I think you are smart enough to think for yourself and use this information to make the right choice

127 Referral to Treatment

128 Offer Hope

129 Detox Management of Withdrawal

130 Buprenorphine Day 1: 4 mg in AM, 2 mg Q 4 hours PRN Day 2: 4 mg in AM, 2-4 mg at HS PRN Day 3: 4 mg in AM, 2 mg at HS PRN Day 4: 2 mg in AM PRN, 2 mg at HS PRN Day 5: 2 mg in AM PRN

131 Methadone Day 1: mg in AM, 5 mg Q 4 hours PRN Day 2: mg in AM, 5 mg at HS PRN Day 3: 5-10 mg in AM, 5 mg at HS PRN Day 4: 5 mg in AM PRN Day 5: 5 mg in AM PRN

132 Federal Regulations Buprenorphine requires special DEA permit Methadone requires DEA Schedule II permit - Only if hospitalized for another condition - Maximum of 5 days

133 An 19-year-old admitted for cellulitis develops opioid withdrawal.

134 Case 5 Recommendations 1. Detox 2. Perform a detailed intervention - FRAMES/motivational therapy - Show a video 3. Refer to treatment (Offer Hope)

135 Case 4 A 17-year-old presents for a pre-college examination and disease prevention. PMHx : ADHD PSHx: Rx opiate exposure FHx: alcoholism SHx: smoker, drinker PE: cutter marks, tattoos

136 Case 4 Recommendations 1. Screening: Consider urine tox 2. Perform a Brief Intervention - FRAMES - Show a video/give printed info 3. Refer to treatment ( evaluation )

137 Case 3 A 16-year-old admits to binge drinking at her prom during an ER follow-up visit.. Drinking probably > HPI Injury while drinking Asking for Lortabs

138 Case 3 Recommendations 1. Screening: more questions, UDT 2. Perform an intervention - FRAMES - Show a video/give printed info 3. Refer to treatment (PCP follow-up)

139 Case 2 A 15-year-old presents for follow-up of knee pain following a sports injury. Bleach blonde Excessive Rx med use Asking for Lortabs

140 Case 2 Recommendations 1. Screening: more questions, UDT 2. Perform an intervention - FRAMES - Do no harm: no more opiates 3. Refer to treatment PRN

141 Case 1 A 14-year-old is bought into the office by her mother because of bad moods. HPI: Requesting Adderall PMHx : ADHD PSHx: Rx opiates FHx: alcoholism (father s death?) SHx: smoker, school problems PE: difficult to engage

142 Case 1 Recommendations 1. Make an accurate diagnosis - Detailed history of current substance use - Detailed history for abuse/neglect - Is the diagnosis of ADHD accurate? - Detailed family history of alcohol/drug issues - Nature of school problems - Consider urine toxicology 2. Consider referral for evaluation 3. Follow-up

143 Summary Ask every patient about substance use (Screen) Advise by giving a clear message (Intervention) Assess willingness to make a change Assist those willing to change (Refer PRN) Arrange for follow-up

144 If you fail 70% of the time, they'll put you in the Hall of Fame lifetime batting average

145 Suggested Reading Principles of Addiction Medicine, 5 th Ed. Wolters Kluwer (Chapters ) Essentials of Addiction Medicine, 2 nd Ed. Wolters Kluwer (Chapters ) NIAAA Guide, NIH Publication No AHRQ Guide, AHRQ Publication No. 06-E015 NIDA Guide, NIH Publication No (A)

146 I am the face of addiction

147 Women and Children s Hospital of Buffalo Grand Rounds, June 12, Richard D. Blondell, MD Director, National Center for Addiction Training Professor and Vice Chair for Addiction Medicine Department of Family Medicine University at Buffalo 77 Goodell St., Suite 220 Buffalo, NY UB SOM phone UB SOM FAX ECMC phone Clinic phone Clinic FAX blondell@buffalo.edu