Brief Interventions: Targeting Substance Use and Abuse

From University of Wisconsin’s 2008 Primary Care Conference

Educational Objectives

The goal of this program is to reduce rates of risky substance use and smoking. After hearing and assimilating this program, the clinician will be better able to:

Explain the effect of substance use on the reward center of the brain and its clinical implications.

Screen all patients for substance use and identify patients who may benefit from brief interventions.

Appropriately prescribe pharmacotherapeutic agents to aid patients in stopping use of alcohol or opioids.

Discuss the importance of targeted personal advice, specific quit plans, and follow-up for patients attempting to quit smoking.

Compare mechanism of action and outcome of approved pharmacotherapies for smoking cessation.

Faculty Disclosure

In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the planning committee to disclose relevant financial relationships within the past 12 months that might create any per­sonal conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business or commercial interest. For this program, the following has been disclosed: Dr. Jorenby has received research support from the National Institute on Drug Abuse, Pfizer, and Nabi Pharmaceuticals. Dr. Brown and the planning committee reported nothing to disclose.

Acknowledgments

Drs. Brown and Jorenby were recorded at 2008 Primary Care Conference, jointly sponsored by University of Wis­consin School of Medicine and Public Health and University of Wisconsin, Madison, Continuing Education in Nurs­ing, and held November 13-14, 2008, in Madison, WI. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.

Alcohol Abuse: You Can Make a Difference

Richard L. Brown, MD, MPH, Associate Professor, Department of Family Medicine, University of Wisconsin School of Medicine and Public Health, Madison

Drinking and drug use: abstinence  —  no use of drugs or alcohol; drink equivalents  —  12 oz beer; 5 oz wine; 1.5 oz 80-proof liquor; low-risk use  —  no use of illicit drugs; appropriate use of prescription drugs; modest intake of alco­hol (£14 drinks/week and £4 drinks per sitting for men <65 yr of age; fewer drinks/week for women <65 yr of age [women generally weigh less; absorb and metabolize alcohol more completely than men]); individuals ³65 yr of age should have no more than one drink per sitting (increased risk for falling and confusion); at-risk use  —  drinking larger amounts of alcohol per week; using illicit drugs or inappropriately using prescription drugs; individual does not suffer significant negative consequences; abuse  —  individual suffers repeated negative consequences as result of substance use; biomedical consequences tend to develop later than personal and social consequences; addiction  —  in addition to serious negative consequences, individual has physical dependence (ie, suffers with­drawal symptoms; however, physical dependence can occur without addiction); true addiction involves compulsive use (ie, patient unsuccessful at limiting use) and preoccupation with obtaining and using substance

Physiology of addiction: down-regulation of reward center  —brain center involved with pleasure and rewards nor­mally stimulated by activities related to survival (eg, eating, sex); addiction “hijacks” reward center, so it responds primarily (or only) to drugs or alcohol; when not using substances, difficult for individual to experience pleasure; patients report needing to drink or use drugs in order “to feel normal”; with long-term use, reward center down-reg­ulates further, so drinking or using drugs no longer sufficiently stimulates; return to normal function  —  generally occurs after »2 yr of abstinence

Prevalence of substance use problems: screening patients at primary care clinics found 78% of patients abstinent or low-risk and 5% dependent; 17% engage in “at-risk” drinking but not alcoholics (good opportunity for interven­tion); if drugs considered, »25% of patients in primary care settings may benefit from brief interventions targeted at substance use; populations of special concern include pregnant women and minors; morbidity and mortality  —  substance use common cause of hospitalization and death; alcohol consumption contributes to cardiovascular dis­ease (increases blood pressure [BP] and cholesterol); association with employment status  —  prevalence of heavy drinking (³60 drinks/month) slightly higher among full-time workers than in general population; drug use some­what more common among unemployed (vs general population)

Impact: health care utilization  —  increased number of hospital admissions and visits to emergency department (ED) and primary care physicians; economic impact  —  leading cause of disability among men; many workplace issues (eg, absenteeism, decreased productivity) related to substance use

Screening: first step in evidence-based strategies (screening, brief intervention, referral, and treatment [SBIRT]); brief screening for all patients in primary care setting; goal  —identify patients who engage in risky substance use (not just dependence); screening questions  —  last time patient had >5 drinks (for men) or >4 drinks (for women); considered positive when incident occurred within 3 mo of visit; question often used as single-item screening tool; other screening questions address issues of control and desire to reduce use; speaker recommends 6-question CRAFFT test for screening adolescents; assessment  —  for patients with positive results on initial screening; Alco­hol, Smoking, and Substance Involvement Screening Test (ASSIST), developed by World Health Organization (WHO), addresses use of 10 categories of substances

Brief intervention: low-risk use  —  reinforce healthy behaviors; at-risk use or abuse  —  perform brief initial interven­tion (typically lasts 5-15 min); ³1 follow-up session recommended; goal to change behavior, not to have patient admit problem; educate patient about risks and negative consequences; individualize advice (eg, relative to age, health, and family history); encourage abstinence (or reduced intake, if patient unwilling to abstain) for patients with family history of alcoholism; help patient set specific concrete goals; follow up

Evidence: meta-analysis of >50 randomized controlled trials (RCTs) showed benefit even among controls (ie, ask­ing screening questions with no intervention resulted in decreased use), but intervention associated with signifi­cantly greater improvement in self-reported drinking and objective measures; several studies showed screening and appropriate interventions (in primary care or trauma setting) resulted in substantial cost savings (within first year of implementation) and fewer hospitalizations and ED visits

Treating alcohol-dependent patients: alcoholism chronic disease, requiring ongoing management; management of substance abuse as effective as management of other chronic diseases (eg, diabetes, hypertension, asthma); relapses common; management strategy may require changes over time; disulfiram (Antabuse)  —  no long-term benefit dem­onstrated; short-term use beneficial for some patients; naltrexone and acamprosate  —  decrease cravings; effective, but underprescribed; associated with few adverse effects; off-label medications  —  some studies show benefit of topiramate (Topamax) and possibly ondansetron (Zofran) in reducing cravings for alcohol

Treating opioid-dependent patients: methadone  —  most effective treatment, but highly regulated; buprenorphine  — effective; better safety profile than methadone; prescription requires 8-hr training (Web-based training acceptable); partial opioid agonist, so ceiling effect prevents abuse and decreases street value; agent also acts as partial antago­nist (can induce withdrawal symptoms if taken at high doses); sublingual administration (high first-pass metabo­lism precludes oral administration); one formulation (Suboxone) also contains naloxone, which further reduces risk for misuse (induces withdrawal if injected); in pregnant women, safety of naloxone unknown, so use buprenorphine monotherapy (bid); after training completed, government-supported telephone mentoring program available for questions about use

Combining medications and behavioral interventions (Project COMBINE): 9-arm RCT, sponsored by National Institute on Alcohol Abuse and Alcoholism; results  —  all treatment groups substantially reduced drinking; acam­prosate less effective (previous studies showed benefit with severe alcoholism; Project COMBINE focused on mild-to-moderate alcoholism); naltrexone, cognitive-behavioral therapy (CBT), and combination therapy (naltrex­one plus CBT) similarly effective ; continued management and follow-up important for reducing risk for relapse

Smoking Cessation: 2008 Guidelines Update

Douglas E. Jorenby, PhD, Professor of Medicine, and Director of Clinical Services, Center for Tobacco Re­search and Intervention, University of Wisconsin School of Medicine and Public Health, Madison

Clinical practice guidelines: United States Public Health Service updated clinical practice guideline (Treating To­bacco Use and Dependence) in May 2008; 5-A approach  —  ask about tobacco use; advise to quit; assess willing­ness to make quit attempt; assist in quit attempt; arrange for follow-up

Ask: every patient at every visit; helpful to have system that adds screening question to vital signs (eg, stamp on med­ical chart or question embedded in electronic medical records); studies show benefit associated with single screen­ing question about smoking; identifies  —  never smokers (congratulate), former smokers (congratulate and encourage), and current smokers (advise to quit)

Advise: for all patients using tobacco; even brief (<3 min) advice improves rates of smoking cessation; consistent im­plementation would have large cumulative impact; advice should be clear, strong, and personalized; patients report importance of clinician advice in decision to quit smoking; personalizing risk (eg, relative to medical and family history) important; assess  —  important to assess patient’s readiness to quit smoking now; assist those ready to quit

Assist: help patient develop quit plan; provide practical counseling and social support; recommend pharmacotherapy to most patients; recommendations on pharmacotherapy  —  guidelines strongly support use; evidence insufficient for use in adolescents, pregnant women, and those who smoke <10 cigarettes per day; avoid use if contraindications to specific medicines present

Arrange: important to follow up with patients soon after quit date; increasing contact and support decreases likeli­hood of relapse; options include telephone contact and use of quit-lines; most relapses occur within 2 wk of quit­ting; first few days especially important

Patients not ready to quit: counseling may improve chances of quitting in future; relevance  —  personalized ap­proach; risks and rewards  —  motivation for quitting (what patient considers important); roadblocks  —  time-limited events that make quitting unlikely; repetition  —  cannot force patients to quit, but ask at each visit and be prepared to support decision

Elements of effective treatment: meta-analysis showed brief problem-solving counseling increased likelihood of quitting by »50% (ie, odds ratio [OR] »1.5); social support associated with similar increase; pharmacotherapy asso­ciated with OR of 1.5 to 3; smoking-cessation counseling  —  multiple RCTs show that interventions lasting <3 min increase quit rates, but dose-response evident (ie, likelihood of quitting increases with increasing number and/or duration of counseling sessions); combination therapy  —  meta-analysis showed benefit of adding counseling to pharmacotherapy (increased OR by almost 50%)

Quit plan: set quit date  —  important; useful to have »1 wk to prepare, but avoid setting date too far in future; some medications have 1-wk lead-in period; use meaningful life events (eg, birthday, new job, new home) as motivating factors and goals; review past quit attempts  —  smokers who have relapsed often view past quit attempt as failure; validating successes important; anticipate challenges  —  ask patient about timing of smoking cravings and triggers; help patient anticipate and prepare for cravings (eg, have distractors ready); quit-lines  —  free telephone-based sup­port for individuals quitting smoking (eg, 1-800-QUIT NOW); calls automatically directed to state programs, where available; some programs offer free short-term supplies (eg, transdermal system [patch], gum) for nicotine replacement; meta-analysis found telephone counseling as effective as in-person (individual or group) counseling

Bupropion: first non-nicotine medication approved for smoking cessation; antidepressant agent has greater effect on dopamine levels than other classes of antidepressants (eg, selective serotonin reuptake inhibitors); importance of dopamine  —  part of mesolimbic reward system; nicotine powerfully stimulates reward system; upon quitting, smokers often report feelings of depression or absence of pleasure (hypoactive reward system); effect of therapy  —  quit rates double (compared to placebo); good option for patients with comorbid depression

Nicotine replacement therapy (NRT): effects of nicotine  —addictive substance in tobacco; in most patients, does not cause adverse health effects (exceptions include pregnant women and patients with recent cardiac events); goal of NRT  —  reduce cravings and withdrawal symptoms without adverse health effects associated with other components of tobacco

Delivery systems: gum and lozenges  —  available in 2-mg and 4-mg doses; nicotine absorbed through buccal mu­cosa; patient must “chew and park” gum (otherwise patient will swallow most of nicotine); lowering pH of mouth (eg, by drinking acidic beverages) reduces absorption (wait 20 min or rinse mouth before using gum or lozenge); best if taken every 30 min to 1 hr (most patients do not take enough); transdermal system (patch)  —  new patch applied to skin (between waist and neck) each morning; prescription and over-the-counter versions available in 7-mg, 14-mg, and 21-mg doses; contact dermatitis may occur (reduced by rotating placement of patch); OR for smoking cessation almost doubles (compared to placebo); inhaler  —  plastic mouthpiece with at­tachable nicotine cartridges; patients “puff” on inhaler, but nicotine absorbed through buccal mucosa (not lungs), so pH issue still applies; »10% of smokers report importance of mimicking action of smoking; each puff delivers very small amount of nicotine, so heavy smokers unlikely to get enough nicotine to adequately relieve with­drawal symptoms; OR >2 (compared to placebo); nasal spray  —  dosed by squirting once in each nostril (delivers 1 mg nicotine); especially effective for heavy smokers; nicotine reaches brain faster than with other delivery methods (most closely approximates effect of smoking); adverse effects include irritation and nasal discharge (intolerable to many patients)

Varenicline: partial agonist of a₄b₂ nicotine subreceptor; when varenicline occupies receptor, it releases less dopa­mine (»30%) than when nicotine occupies receptor, but sufficient to decrease cravings; once receptors occupied by varenicline, nicotine cannot bind, so patients experience less pleasure from smoking

Comparison of pharmacotherapeutic approaches: using patch as reference standard, study compared efficacies of various pharmacotherapies; varenicline only monotherapy significantly more effective at increasing quit rates; ef­fective combination therapies  —  long-term use (>14 wk) of patch plus nicotine gum or nasal spray significantly im­proves quit rates over patch alone; patch plus bupropion (only approved combination therapy) has smaller effect

Questions and answers: nicotine toxicity  —  patch replaces 50% to 66% of nicotine for most smokers; safe to add gum or lozenges on as-needed basis; patients should reduce dose if nausea occurs; biofeedback  —  use of, eg, spi­rometry and/or carbon monoxide measurements useful for motivating and encouraging some patients; Food and Drug Administration (FDA) warning about varenicline  —  2 large trials found no increase in suicidality or depres­sion, even among patients with comorbid psychiatric disorders; consider using different agent in high-risk patients; FDA warning advises follow-up (good clinical practice in general); patients taking psychiatric medication  —  no studies have evaluated safety or efficacy of varenicline when combined with other psychiatric medications; meta­bolic pathways do not compete, but NRT recommended as conservative approach; because of metabolic changes that occur with smoking cessation, may need to decrease dose of psychiatric medication

Internet Resources

National Alliance of Advocates for Buprenorphine Treatment

www.naabt.org/ 

National Institute on Alcohol Abuse and Alcoholism

www.niaaa.nih.gov

World Health Organization ASSIST questionnaire

www.who.int/substance_abuse/activities/assist/en/

Suggested Reading

Barry DT et al: Integrating buprenorphine treatment into office-based practice: a qualitative study. J Gen Intern Med 24:218, 2009; Clinical Practice Guideline Treating Tobacco Use and Dependence 2008 Update Panel, Liaisons, and Staff: A clinical practice guideline for treating tobacco use and dependence: 2008 update. A US Public Health Service re­port. Am J Prev Med 35:158, 2008; Ernst DB et al: An intervention for treating alcohol dependence: relating elements of medical management to patient outcomes with implications for primary care. Ann Fam Med 6:435, 2008; Fiore MC, Jaen CR: A clinical blueprint to accelerate the elimination of tobacco use. JAMA 299:2083, 2008; Hajek P et al: Relapse pre­vention interventions for smoking cessation. Cochrane Database Syst Rev Jan 21;(1):CD003999, 2009; Hays JT, Ebbert JO: Varenicline for tobacco dependence. N Engl J Med 359:2018, 2008; Kaner EF et al: Effectiveness of brief alcohol in­terventions in primary care populations. Cochrane Database Syst Rev Apr 18;(2):CD004148, 2007; Madras BK et al: Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: comparison at intake and 6 months later. Drug Alcohol Depend 99:280, 2009; Olmsted CL, Kockler DR: Topiramate for alcohol dependence. Ann Pharmacother 42:1475, 2008; Salize HJ et al: Cost-effective primary care-based strategies to im­prove smoking cessation: more value for money. Arch Intern Med 169:230, 2009.