Welcome! Today we ll discuss some of the important relationships between mental and physical health that clinicians may encounter as they apply the

Transcription

1 Welcome! Today we ll discuss some of the important relationships between mental and physical health that clinicians may encounter as they apply the SBIRT process in practice. 1

2 We ll start by considering some of the most common mental disorders that occur concurrently with substance use both risky drinking that is the focus of the SBIRT process, and also substance use disorders. In that context, we ll review common screening tools for anxiety and depression which are often valuable in planning more comprehensive assessment and treatment of concurrent conditions. We ll also review the health effects of alcohol and think about substance intoxication that may require medical attention and specialized treatment. 2

3 Let s start with the important relationship between substance use and psychiatric illness. Alcohol and drugs may be used to deal with distressing symptoms of mental disorders, but they can also trigger the onset of mental illness and make existing symptoms worse. 3

4 People who have a mental disorder and also use substances are at high risk for having a downward spiral in their health. As a result, assessing and treating both conditions at the same time is essential. Building a strong base of objective data to support symptom presentation including standardized scale scores, lab values, and physical assessment findings is essential to adequately treat both conditions. For most people with co occurring substance and mental disorders, integrated treatment that offers health, mental health, and substance use treatment in the same clinic is optimal. That way they get the best of primary care and specialty treatments working as a team. 4

5 Both clinical and sub clinical depression is widely associated with substance use, particularly drinking. Of importance, the relationship goes both ways. Drinking can lead to depression, and Depression can lead to drinking. And it s not just drinking. Use of other substances, including both prescription and illicit drugs, may also be used to self medicate the distressing thoughts and feelings that clinical depression can trigger. If you suspect a client has depressive symptoms along with substance use, be sure to assess their depression symptoms using a standardized scale. Reference: Depression and the Connection to Substance Abuse ( treatment/co occurring disordersoverview/depression drug abuse/) 5

6 The Patient Health Questionnaire 2 item and 9 item scales are widely used in clinical settings to assess depressive symptoms. Just like we use the 2 item Annual screen for substance use, the PHQ 2 can be used to detect clinical depression since it rates the two hallmark symptoms of clinical depression: loss of ability to experience pleasure in usual activities and prominent dysphoria or sadness, feeling blue and down. The PHQ 9 is equally easy to use and score, making it another popular alternative. 6

7 Each symptom is rated on a four point scale. First you total the columns, then add the column totals to get a total score of 0 to 27. A score of 10 or greater indicates clinically significant depression depression that deserves further assessment and treatment. The PHQ 9is just the first step toward a more comprehensive assessment and decisions about treatment. However, quantifying the number and intensity of depressive symptoms can help guide decision making about possible treatments, which can include medications, psychosocial therapies, and increased physical activity for those with milder depressions. 7

8 Like depression, anxiety related disorders can be the reason for substance use, but also worsens symptoms of anxiety related disorders. For example, individuals with PTSD may experience temporary relief from distressing symptoms of the disorder when drinking alcohol, but ultimately alcohol will intensify their anxiety symptoms. 8

9 When you detect anxiety related symptoms in a client that is using a substance, we highly recommend that you quantify them using a standardized scale. A good starting point is the GAD 7, which will give you a foundation for understanding the frequency and intensity of anxiety related symptoms. 9

10 The GAD 7 is scored just like the PHQ 9, and uses similar cut points that can help direct treatment decisions. There are many additional anxiety scales, including ones that are more targeted for specific syndromes. Which tool or tools you use in practice should be guided by the population you serve. The main point is to clarify the contributing roles of anxiety and depression in substance use and make sure that both conditions are adequately treated. 10

11 Several studies have shown a strong connection between ADHD and substance use. This evidence suggests that adolescents with ADHD are at a higher risk to start using alcohol during their teenage years. Of equal importance, ADHD is a predictor of alcohol and substance use as an adult. In short, there are many reasons to include substance use in discussions with youth who have ADHD. Reference: ADHD and Substance Abuse ( adhd/adhd andsubstance abuse is there a link#1) 11

12 The risks of substance use continue into adulthood for individuals with ADHD. In adults, substances are often used to improve their mood or to sleep better. Of note, substance use is also common among individuals with undiagnosed ADHD or those who have not received treatment. Reference: ADHD and Substance Abuse ( adhd/adhd andsubstance abuse is there a link#1) 12

13 Individuals with serious and persistent mental disorders are also more likely to use alcohol and drugs. As noted earlier, alcohol or drugs may be used to reduce distressing symptoms, including psychotic symptoms like auditory hallucinations. If you are treating individuals with existing mental disorders like ADHD, bipolar disorder, schizophrenia, and personality disorders, think carefully about the potential that they are also using one or more substances and work toward concurrent treatment of both conditions. References: Bipolar Disorder and Addiction ( disorder andaddiction/) Schizophrenia: What About Substance Abuse? ( abuse schizophrenia) Borderline Personality Disorder and Addiction ( personality disorder and addiction/) 13

14 With a dual diagnosis substance use disorder and a mental disorder treatment can be a challenge. As noted earlier, collaborative, integrated approaches to treatment are ideal. However, the starting point is first understanding that more than one illness is affecting your patient. Only then can you work toward developing an effective treatment plan. 14

15 Let s move ahead now and talk about substance related health effects. As we briefly reviewed in our introductory SBIRT program, substance use can have an impact on many parts of our bodies. For individuals with pre existing health problems, and particularly for those with complex medical problems that are treated with a variety of different medications, substance use can really complicate the person s health AND treatment of their medical problems. Reference: Beyond Hangovers understanding alcohol s impact on your health 15

16 In the earlier training module, SBIRT for the Special Needs of Older Adults, we briefly reviewed some of the common health challenges older adults face, and how drinking in particular can complicate the course and outcome of treatment. Today we ll take a little deeper look at some of those problems. 16

17 Most of what is known today about health risks relates to excessive alcohol use. However, there is also a growing body of evidence about both illicit drugs and misuse of opioids. As listed on the slide, there are some great educational materials available at no cost, which can help with educating peers in health care settings and clients alike. We encourage you to take time to review these to supplement the content provided in this module. 17

18 While it s beyond the scope of this module to review common physical findings, lab values, or other data that may relate to substance use, we urge you to think carefully about healthrelated complications of alcohol and drug use as antecedents to discussion. The SBIRT annual screen is just one way that health care providers may detect substance use. 18

19 Alcohol related disruptions to neurotransmitters can trigger mood and behavioral changes, including depression, agitation, memory loss, and even seizures. With long term and heavy use, alterations in neurons lead to brain mass and structure changes that may affect a wide range of abilities. And as we reviewed in the program for youth, there are special risks associated with substance use early in life, from pregnancy through adolescence. References: Beyond Hangovers understanding alcohol s impact on your health The Affects of Long Term Drug Use On The Brain ( affects of long term drug use on the brain/) The Effects of Drugs and Alcohol on the Adolescent Brain ( effects of drugs and alcohol on the adolescentbrain.html) 19

20 While researchers now understand that drinking moderate amounts of alcohol can protect some individuals from the risks of coronary artery disease, they also know that excessive or long term drinking and drug use cause a wide variety of cardiovascular risks. Evidence also indicates that drug use has considerable implications for cardiac health from risks of myocardial infarction to arrhythmias. References: Beyond Hangovers understanding alcohol s impact on your health Addiction, Heart Disease, and Stroke ( health issues/addiction heart disease stroke/) 20

21 The more a person drinks, the higher the risk for a variety of cancers. The National Cancer Institute identifies alcohol as a risk factor for mouth, esophagus, pharynx, larynx, liver, and breast cancers. Heavy drinking can also increase the risk of developing other types of cancer, such as colon or rectal cancer. References: Beyond Hangovers understanding alcohol s impact on your health Medical Consequences of Drug Abuse Cancer ( consequences drug abuse/cancer) 21

22 Drinking too much alcohol can weaken the immune system, which makes it easier for diseases to overtake the body. It can suppress both the innate and acquired immune systems, creating vulnerability to illness and disease that the person would otherwise resist. References: Beyond Hangovers understanding alcohol s impact on your health 22

23 Heavy drinking causes fat to build up in the liver, which can lead to dangerous inflammations and also development of scar tissue. Excessive scar tissue can lead to cirrhosis of the liver. Complications of cirrhosis may include jaundice, insulin resistance and type 2 diabetes, and liver cancer. Chronic use of some drugs such as heroin, inhalants, and steroids can also lead to significant liver damage. References: Beyond Hangovers understanding alcohol s impact on your health Liver Damage ( consequences drugabuse/liver damage) 23

24 Long time excessive alcohol consumption can lead to pancreatitis. Damage can also be caused by heroin, cocaine, and non medical use of prescription drugs. Pancreatitis is a risk factor for the development of pancreatic cancer. References: Beyond Hangovers understanding alcohol s impact on your health The Effects of Drug Abuse on Your Pancreas ( effects ofdrug abuse on your pancreas/) 24

25 Certain drugs and the excessive use of alcohol can cause kidney damage or lead to kidney failure. References: Alcohol and Your Kidneys ( Medical Consequences of Drug Abuse Kidney Damage ( consequences drug abuse/kidneydamage) 25

26 Another important consideration is the relationship between tobacco use and substance use. As outlined on the slide, there s a strong relationship between smoking and both alcohol and drug use. In turn, we urge thoughtful consideration of possible substance use among clients who may smoke, particularly youth. References: Smoking and Adolescence ( adolescence) Alcohol and Tobacco ( Substance Use and Tobacco ( usetobacco.asp) The association between cigarette smoking and drug abuse in the United States ( 26

27 This is just a brief list of medical conditions that may become more complex when substance use is involved. Alcohol and drug use can make the medical condition worsen, or more difficult to manage. For those who use multiple drugs to treat their health conditions, alcohol use can interact with those medications and cause problems, particularly in older adults who have multiple medical conditions. In short, this is another important subpopulation to carefully monitor for substance use! References: Psychotropic drug use and alcohol consumption among older adults in Germany ( comments.pdf) Alcohol, drugs and much more in later life ( ) 27

28 While you are not expected to use detoxification methods with your clients, it s important to understand warning signs that a client may be using alcohol or drugs at a level that they need help to safely stop. Being prepared is really the main issue. 28

29 The signs and symptoms of withdrawal from alcohol and drug use cover a wide range of both emotional and physical symptoms. Of equal importance, withdrawal symptoms vary from person to person. References: Withdrawal ( 29

30 The most dangerous physical withdrawal symptoms come from suddenly stopping the use of alcohol and tranquilizers. Reference: Withdrawal ( 30

31 Some individuals may present to you asking for help with detoxification from alcohol or drugs. Decisions about next steps should be guided by thorough evaluation, AND also what options are readily available. For example, you may attempt to refer the patient for specialty treatment, but the service is already full and wait listed. Having a working relationship with specialty services ahead of time will help in the decision making process needed to keep the person safe. As discussed in SBIRT, a warm handoff that supports the person as they get to treatment is essential. Individuals with strong support systems are more likely to succeed. In some cases, emergency services may be indicated, and clearly any dangerous symptoms of withdrawal will require immediate emergency care. Reference: Detox: Summary & Key Issues to Remember ( key issues to remember/) 31

32 While every individual s experience with detox will be different, there are guidelines to assist in clinical decision making. The one provided by the American Addiction Centers is a good example, but there are others that may provide better guidance based on your clinical setting and the primary population that you serve. As before, collaborating with substance use specialty care providers in advance of a crisis can ease the tension of knowing what is best for individual clients in your practice. Reference: Alcohol Withdrawal Treatment, Symptoms, and Timeline ( timelines treatments/alcohol/) 32

33 In summary, concurrent mental, medical, and substance use disorders demand thoughtful assessment and treatment. Using standardized scales and physical findings based on assessments help clinicians better gauge therapeutic next steps for care and treatment. While treatment can be challenging for those with dual diagnoses or co occurring conditions, understanding the complexity of issues is an important first step in the provisions of comprehensive, competent care and treatment. 33