Mario San Bartolomé, MD, MBA, MRO, FASAM SUBSTANCE USE DISORDERS and the GASTROINTESTINAL TRACT Mario San Bartolome, MD, MBA, MRO, FASAM Medical Director Substance Use Disorders Molina Healthcare, Inc. Diplomate, American Board of Addiction Medicine Diplomate, American Board of Family Medicine Certified, Medical Review Officer FINANCIAL DISCLOSURES LEARNING OBJECTIVES NONE Understand the disease model of addiction Understand the neurobiological association between behaviors in addiction and the brain s reward center. Understand the in the impact that drugs of abuse have on the GI system. DISEASE Simple Road to Understanding Addiction a disease is a cluster of symptoms and /or signs with a more or less predictable course. Symptoms are what the patients tell you. Signs are what you see. The cluster may be associated with physical abnormality or may not. [Page x, Psychiatric Diagnosis, 1 st Ed, 1994, Woodruff, Goodwin, Guze] 1
DEFINITIONS Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors. Volkow ND, Kim SW, Wang GJ, et al. Acute alcohol intoxication decreases glucose metabolism but increases acetate uptake in the brain. Neuroimage 2013;64:277-283 DEFINITIONS Quick Stats about Addiction Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death. COST OF ADDICTION Over $700 Billion 2
THE GREAT HIGHJACKING Levels of dopamine increase in the reward center when animals do those behaviors which ensure survival Food / Water Eating/Drinking =DOPAMINE RELEASE DON T MESS WITH MAMMA 3
BUT WHAT ABOUT GI STUFF? Addiction is a complex but treatable disease that affects brain function and behavior ESOPHAGUS GERD Dysfunction in lower esophageal sphincter Dysfunction in esophageal peristalsis Abnormal gastric acid secretion Direct damage to esophageal and gastric mucosa Possible effects from acetaldehyde generated from ethanol degradation (known toxin and carcinogen) ETHANOL METABOLISM MALLORY-WEIS SYNDROME Massive bleeding cased by tears in the mucosa at the cardioesophageal junction after vomiting. 5-15% of all cases of upper GI bleeding In alcoholism, related to increased gastric pressure from repeated retching and vomiting following excessive acute alcohol consumption The Effect of Inflammatory Cytokines in Alcoholic Liver Disease - Scientific Figure on ResearchGate. Available from: https://www.researchgate.net/259567098_fig3_the-pathway-of-ethanol-metabolism-ethanol-is-metabolized-into-acetaldehyde-by-alcohol 4
STOMACH ALCOHOLIC GASTRITIS ALCOHOLIC GASTRITIS Exposure of gastric mucosa to 20% alcohol induces gastric mucosal injury Gastritis in alcohol dependent people highly related to H. pylori infection Available evidence not conclusive on whether alcoholic beverage consumption causes chronic chemical gastropathy Other causes confound gastritis-like symptoms PANCREATITIS SMALL INTESTINE Diarrhea Altered motility Permeability Nutritional disorders Figure 76-1. Intracellular events giving rise to alcoholic pancreatitis. Adapted from ASAM Principles of Addiction Medicine, by RK Reis et al, 2014, 5 th Edition, p. 1147. Copyright 2014 ASAM 5
COLON OPIATES & OPIOIDS Portal HTN related Hemorrhoids & Colonic varices Chemical colitis (alcohol enemas) Reduced incidence of ulcerative colitis Cancer Opioid induced Bowel Dysfunction (OBD) Blockade of propulsive peristalsis Inhibition of the secretion of intestinal fluids Increased intestinal fluid absorption Prolonged GI transit time Exacerbation by concurrent use of often constipating medications, dehydration, advancing age, metabolic abnormalities, and chemotherapy. Can result in fecal impaction and stercoral perforation OBD vs NARCOTIC BOWEL SYNDROME Opioid bowel dysfunction (OBD) -Constipation, nausea, vomiting, bloating, ileus, and sometimes pain. Narcotic Bowel Syndrome (NBS) Abdominal pain is the predominant symptom Progressive and paradoxical increase in pain despite continued or escalating dosages of narcotics prescribed to relieve the pain Laxative Misuse No euphoria associated with laxative use May be associated with bulimia nervosa Can be a form of Munchausen syndrome 6
ANTICHOLINERGIC MEDICATIONS TOBACCO SMOKING Amitriptyline Clonidine Doxepin Antihistamines Medications for Overactive Bladder and Parkinson s Disease Dizziness, dry mouth, delirium and abdominal pain Linked to cancers of the upper aerodigestive tract and pancreas Increases risk of Crohn s disease and decreases Ulcerative Colitis Combination of Alcohol with Tobacco smoking is additive HEY, WHAT ABOUT THE LIVER? LIVER Cirrhosis of the liver is the 12 th most common cause of death in America (38,170 in 2014) 1.5% of total deaths Alcohol-related Liver Disease (ALD) 2 nd most common indication for liver transplantation Happy Liver Sad Liver Alcohol induced and Viral Hepatitis associated. SIGNALING MECHANISM 7
METHAMPHETAMINE Bowel Ischemia possibly by splanchnic vasoconstriction or necrotizing angiitis Paralytic ileus Viral Hepatitis / HIV from IV use The disparity between the typical cirrhosis of chronic viral hepatitis (small liver, big nodules) and alcoholic liver diseases (big liver, small nodules) is particularly evident here. Ironically, these patients were both autopsied the same day (photograph courtesy of T.H.Kent, M.D.) CANNABIS Body Packing Cannabinoid receptors widely expressed in upper and lower GI tract Antiemetic effects related to the expression of CB1 receptors in the dorsal vagal nucleus. Inhibit gastric emptying and gastric acid secretion May also paradoxically cause hyperemesis in some people and has been related to cyclic vomiting illness. Not well understood. Case courtesy of A.Prof Frank Gaillard, Radiopaedia.org, rid: 19527 THANK YOU Join me in the fight against: It sort of makes you stop and think, doesn t it? 8