SUBSTANCE ABUSE
| SCREENING FOR SUBSTANCE ABUSE —S. Pirzada Sattar, MD, Robert Wood Johnson Fellow, Assistant Professor
of Psychiatry, and Director, Addiction Fellowship Training, Creighton University School of Medicine, and Medical Director,
Substance Abuse Treatment Center, Omaha Veterans Affairs Medical Center, Omaha, NE
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| Abuse vs dependence: abuse defined as maladaptive pattern of use, manifested by recurrent and significant adverse consequences
occurring within same 12-mo period, related to repeated use of substances; dependence defined as maladaptive
pattern of substance use that leads to clinically significant impairment or distress, as manifested by meeting ≥3 of 7 criteria
and occurring within same 12-mo period; dependence considered more severe than abuse; tolerance (using increasing
amounts of substance to get same high over any period) and withdrawal not required to meet criteria for dependence
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| Examples of how control lost: smoker switches to brand of cigarettes with less tar and nicotine, but then smokes increased
number of cigarettes; similarly, drinker switches from liquor with higher alcohol content to beer, thinking he
or she will drink less; in “geographic cure,” substance-dependent person moves to another city, state, or country,
thinking that he or she will “leave their problems behind,” but after period of abstinence, “tests” self by using “just a
little bit”; after gaining confidence, individual slowly increases amount of substance and becomes dependent again
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| Willpower: “of no benefit; alcohol and drug use disorders are a medical condition and they need to be treated as
such”
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| Psychologic theories for why people use alcohol and drugs: thrill-seeking behavior and memory of relief of unpleasant
feelings, or of high, overpowers self-control and fear of consequences; speaker suggests “creativity” in educating patients
about use; eg, patient unconcerned about loss of liver and brain cells might be very concerned about loss of testicular
cells
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| Why health care providers do not address alcohol and drug use disorders: 1) they do not identify it, according to
studies; data suggest that approximately one-half of US population knows someone at close hand who has problems
with alcohol and drug use; this creates bias in health care providers that affects how they diagnose patients with alcohol
and drug problems; in recent survey, 2000 people asked whether they think alcohol and drug use significant problem
in United States; more lay people than family physicians said “yes”; if physicians think problem not significant
enough, they will not identify it, and if they do not identify it, they cannot treat it; 2) they do not have enough time to
identify alcohol and drug problems; patients may have significant other medical problems that must be addressed in
brief visit; 3) physicians often believe that available treatments do not work and therefore do not refer patients to treatment
programs; however, data from National Institute on Drug Abuse show treatment does work; 4) question not
framed correctly, and all too often judgmental; health care provider may ask, “you don’t have a problem with alcohol
or drugs, do you?” or “are you an alcoholic?” when question should be, “how much alcohol do you drink?” or “do you
ever use drugs?” 5) health care provider does not seek collateral information; 6) health care provider does not obtain
appropriate blood and urine tests; best marker for acute alcohol intoxication is γ-glutamyl transpeptidase (GGTP),
which picks up increased alcohol use within 1 wk; carbohydrate-deficient transferrin (CDT) picks up increased alcohol
use within 1 to 2 days, but not generally available; best marker for long-term alcohol use mean corpuscular volume
(MCV)
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| Other theories for why people use alcohol and drugs: genetics; social theory—the earlier the onset of exposure to alcohol
and drugs, the more likely individual will use; earliest psychologic theory—user did not receive adequate nurturing
during childhood; psychoanalytic theory—individual uses alcohol and drugs to assuage inner guilt or criticism;
cognitive behavioral theory—no matter the stimulus, individual responds by using alcohol or drugs; with therapy, individual
can learn to break connection between stimulus and response; self-medication theory—when patients in
studies asked why they used, ≈75% said to help deal with stress, to relax, to help with sleep, or to help forget problems;
15% said to get high
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| Prochaska’s Stages of Change Model: can be used to provide counseling appropriate to patient’s stage;
precontemplation—patient in denial, and is not even contemplating quitting; motivational enhancement therapy (confrontational
way of identifying contradictions in patient’s life) effective; contemplation and preparation—patient
thinking about problem and about how to quit using; best help is to educate patient about problems with alcohol and
drug use and about processes involved in rehabilitation; action—patient undergoes detoxification; maintenance—
ideally lasts for patient’s entire lifetime; relapse—important for health care provider not to get upset or angry with
patient and not to drop him or her from treatment program; rather, focus on getting patient back into action phase
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| Maintenance therapy: includes individual therapy, group therapy, self-help groups, and structured living; when patient
under treatment for other medical or psychiatric problems, helpful if physician takes opportunity to provide brief intervention
for alcohol and drug problems as well
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| IS THERE A ROLE FOR MEDICATIONS IN TREATING ADDICTION DISORDERS? Marc A. Schuckit, MD,
Distinguished Professor of Psychiatry, University of California, San Diego, School of Medicine, and Director, Alcohol
Research Center and Alcohol and Drug Treatment Program, Veterans Affairs San Diego Healthcare System, La
Jolla, CA
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| Introduction: similar to hypertension and adult-onset diabetes, alcohol and drug dependence chronic relapsing disorders
and must be treated as such; patients must be motivated to change and to comply long-term with treatment; cognitive
behavioral, interpersonal, and psychologic aspects key to care; medications may be helpful as adjuncts to psychotherapy
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| Statistics: in United States, alcohol problems cost $300 billion and cause 22,000 deaths per year; every socioeconomic
and educational group affected
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| Observations: all medical and psychiatric interventions have costs and risks; not enough to say “that a particular medication
makes sense”; rather, assets of particular treatment must outweigh liabilities; spontaneous remission rate for alcohol
and drug dependence 20% to 30%; some people change in response to brief intervention by physician; speaker
recommends conservative approach to chronic relapsing disorders and keeping abreast of new psychologic and pharmacologic
treatments that have data to support their efficacy
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| Detoxification: no treatment available or needed for cannabinols, hallucinogens, or inhalants; in general, only classes of
substances that require detoxification are depressants (eg, alcohol, benzodiazepines) and opioids; stimulants produce
withdrawal symptoms, but no treatment available except for general support; goal after detoxification is to get patients
motivated and stay motivated to change
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| Rehabilitation training: little provided in medical school or other postgraduate courses; moreover, training often provided
by clinicians who are contemptuous and/or disparaging of people with alcohol and drug problems; however,
data show that people in alcohol and drug treatment programs do well, especially those with “a lot to lose” (eg, career),
“a lot of assets,” and social support system; studies show that among people who complete private treatment
programs, 1-yr abstinence rate ≈70%, “and 1-yr abstinence rate predicts ≈70% 5-yr abstinence rate”; however, even in
treatment programs for the “have-nots,” 1-yr abstinence rate 52%
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| Core of treatment: cognitive and behavioral; motivate patient with education about “what’s likely to happen to them
and how they can avoid it”; help patient to identify clean and sober peer support group; help patient recognize how to
be engaged with family and job in way that does not involve using substances; teach patient how to recognize triggers
for relapse and what to do if he or she does relapse
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| 12-step groups: use cognitive and behavioral techniques to help patient get, and stay, clean and sober; help patients recognize
that they cannot control substance, that they need help, and that they must reach out to others; can be useful tools to augment
clinical treatment
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| Motivational interviewing: requires empathy and understanding on part of interviewer; trust built between clinician and
patient by emphasizing that patient in control of his or her change; clinician helps patient uncover why he or she is resistant
to change and provides guidance on dealing with ambivalence; several 15-min sessions with follow-up call effective
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| Medications for alcohol rehabilitation: adjuncts to cognitive behavioral therapy; speaker requires double-blind controlled
trials to inform risk-benefit ratio
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 | Disulfiram (Antabuse): oldest drug for alcohol rehabilitation; average dose 250 mg/day, although not very effective at
that dose because of side-effect profile; makes drinker avoid alcohol due to fear of vomiting, blood pressure instability,
and diarrhea (“it’s pretty embarrassing; and you feel awful”); disulfiram stops breakdown of alcohol at first
byproduct, acetaldehyde, which “really makes you sick”; does not change craving; in large study, outcome with disulfiram
same as with placebo; good news—disulfiram inexpensive; bad news—potential side effects include rash,
halitosis, depression, psychosis, and hepatitis (“that’s just the drug; that’s not the alcohol-drug interaction”);
“mother rule”—“if my mother were alcohol dependent, would I put her on Antabuse? probably not,” but speaker
does not object to other clinicians using disulfiram
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| Naltrexone (ReVia): opioid blocker; speaker posits that any other opioid blocker would produce similar results; if patient
taking pain medications, naltrexone may block some of their effects; ≈15% of patients discontinue naltrexone
due to side effects of headache and “just not feeling very well”; usual doses 50 to 150 mg/day; however, most trials
lasted only 3 to 4 mo, and naltrexone usually taken for 6 to 12 mo; most trials also involved relatively small samples;
overall, most trials indicate naltrexone better than placebo for time to first drink, amount of drinking, when one
drinks, and number of days during which one drinks; however, impact of naltrexone modest, increasing outcomes
by 15% to 20%; mother rule—“she’s getting naltrexone; it is worthwhile for patients who don’t find side effects
too bothersome, and that is most patients”
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| Acamprosate (Campral): blocks glutamate receptors; if glutamate system stimulated, muscle tension, insomnia, and
anxiety increased (if stimulated “way too much,” seizure occurs); during alcohol withdrawal, glutamate system
overactive and γ-aminobutyric acid (GABA) system underactive, producing discomfort that may last for months
(note, acute withdrawal better by day 5); acamprosate decreases glutamate-related activity; usual dose 2 g/day (usually
as 666 mg tid), effects and side effects modest; no good data, but speaker recommends using for 6 to 12 mo;
mother rule—“I’d use it for 6 to 12 mo”; improvement rate in trials 15% to 20%, although some trials show acamprosate
ineffective; one trial showed acamprosate increased suicidal ideation, but showed no increase in suicides; no
other trials have demonstrated this result
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| Combinations: naltrexone and acamprosate —3 trials, 2 positive and one negative; German study indicated combination
better than either drug alone; mother rule—“[combination is] what she’d be on if she needed medication”; disulfiram
and naltrexone—one study suggested combination better than either drug alone
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| On horizon: kudzu—herb used in Chinese medicine to decrease intoxication and overall use of alcohol; study showed
that normal subjects on kudzu less likely to drink and drank less than those on placebo; not yet tested in alcoholics;
baclofen (Kemstro)—GABA agonist; several open or very small controlled trials showed baclofen no better than
placebo in helping to maintain abstinence; side effects include memory impairment and confusion; baclofen currently
being tested for treatment of cocaine dependence; topiramate (Topamax)—“the trials are not convincing to
me”; at trial dose of 300 mg/day, caused “a lot of side effects”; speaker does not recommend its routine use; memantine
(Namenda)— blocks N-methyl-D -aspartate (NMDA) receptors; trials suggest it might be useful at 20 to 30 mg/
day, but trials early phase and results “not really very impressive”
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| Not effective: antipsychotics; drugs that affect dopamine receptors and transporters
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| Medications for opioid rehabilitation: naltrexone—anecdotally helpful; blocks opiate receptors and reduces impact (the
high) of opioid; methadone (Dolophine, Methadose)—dose usually >80 mg/day, but started at 10 mg/day and slowly increased
to 80 mg/day; can be given daily or 3 to 5 times per week; buprenorphine (Buprenex, Subutex)—dose usually 16
to 32 mg/day, sometimes in tablet that also contains naltrexone (to prevent patient from crushing tablet and administering
intravenously); can also be given daily or 3 to 5 times per week; no good data, but speaker recommends continuing methadone
or buprenorphine for 1 yr before trying to discontinue; in head-to-head comparison, methadone “a bit” more effective
than buprenorphine for clean urine and ensuring patient stays in treatment; methadone “tremendously” cheaper than buprenorphine,
but requires clinic with license (if no clinic available, use buprenorphine); mother rule—“if she’s opioid
dependent, she goes on methadone; but if, for whatever reason, she doesn’t want to go to that clinic or there’s not a clinic in
her area, buprenorphine is almost as good”
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| Core of treatment for any substance: “recognize the problem; get people into treatment by getting rid of stereotypes;
[use] good old cognitive behavioral approaches”
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Suggested Reading
Assanangkornchai S, Srisurapanont M: The treatment of alcohol dependence. Curr Opin Psychiatry 20:222, 2007;
Collins GB, McAllister MS: Buprenorphine maintenance: a new treatment for opioid dependence. Cleve Clin J Med
74:514, 2007; Comer SD et al: Sustained-release naltrexone: novel treatment for opioid dependence. Expert Opin Investig
Drugs 16:1285, 2007; Forman RF et al: Selection of a substance use disorder diagnostic instrument by the National
Drug Abuse Treatment Clinical Trials Network. J Subst Abuse Treat 27:1, 2004; Johnson BA et al: Topiramate for Alcoholism
Advisory Board; Topiramate for Alcoholism Study Group. Topiramate for treating alcohol dependence: a randomized
controlled trial. JAMA 98:1641, 2007; Johnson BA et al: Understanding and treating alcohol dependence.
Alcohol Clin Exp Res 30:567, 2006; Johnson BA: Update on neuropharmacological treatments for alcoholism: Scientific
basis and clinical findings. Biochem Pharmacol 2007 Aug 9; [Epub ahead of print]; Johnson BA: Update on neuropharmacological
treatments for alcoholism: Scientific basis and clinical findings. Biochem Pharmacol 2007 Aug 9
[Epub ahead of print]; Lawrence AJ: Therapeutics for alcoholism: what’s the future? Drug and Alcohol Review 26:3,
2007; Lindberg M et al: Physicians-in-training attitudes toward caring for and working with patients with alcohol and
drug abuse diagnoses. South Med J 99:28, 2006; Lukas SE et al: An extract of the Chinese herbal root kudzu reduces alcohol
drinking by heavy drinkers in a naturalistic setting. Alcohol Clin Exp Res 29:756, 2005; Martin B, Beresford TP:
Disulfiram in context: structure and safety. J Clin Psychopharmacol. 27:415, 2007; Min X: A database for treating drug
addiction with traditional Chinese medicine. Addiction 102:282, 2007; Practice Guidelines for the Treatment of Patients
with Substance Use Disorders, Second Edition. Am J Psychiatry 164(4 suppl):1, 2007; Sattar SP et al: Addiction training
scale: pilot study of a self-report evaluation tool for psychiatry residents. Acad Psychiatry 28:204, 2004; Schuckit
MA et al: A comparison of factors associated with substance-induced versus independent depressions. J Stud Alcohol
Drugs 68:805, 2007; Schuckit MA et al: The ability of the Self-Rating of the Effects of Alcohol (SRE) Scale to predict
alcohol-related outcomes five years later. J Stud Alcohol Drugs 68:371, 2007; Schuckit MA, Saunders JB: The empirical
basis of substance use disorders diagnosis: research recommendations for the Diagnostic and Statistical Manual of
Mental Disorders, fifth edition (DSM-V). Addiction 101(Suppl 1):170, 2006; Schuckit MA: Comorbidity between substance
use disorders and psychiatric conditions. Addiction 101(Suppl 1):76, 2006; Seale JP et al: Effects of screening
and brief intervention training on resident and faculty alcohol intervention behaviours: a pre- post-intervention assessment.
BMC Fam Pract 6:46, 2005; Seppala MD: Dilemmas in diagnosing and treating co-occurring disorders: an addiction
professional’s perspective. Behav Healthc Tomorrow 13:42, 2004; Torrens M et al: Importance of clinical
diagnoses for comorbidity studies in substance use disorders. Neurotox Res 10:253, 2006.
Educational Objectives
| The goal of this program is to improve the rate of identifying substance use disorders and to assess the usefulness of
available medications. After hearing and assimilating this program, the clinician will be better able to:
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| 1. Differentiate between substance abuse and substance dependence.
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| 2. Explain why substance use disorders are underdiagnosed and undertreated.
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| 3. Discuss the role of Prochaska’s Stages of Change Model in treating substance abuse
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| 4. Elucidate the role of medications as adjunctive treatment for substance use disorders.
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| 5. List the medications that can be used in alcohol and opioid rehabilitation and describe their mechanisms of action.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members 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. Sattar has grant/research support
from AstraZeneca, Abbott, and BMS; is a consultant for Abbott; and is on the Speakers’ Bureaus of AstraZeneca, Abbott,
and BMS. Dr. Schuckit is on the Speakers’ Bureaus of Forest and Cephalon.
Acknowledgments
Dr. Sattar was recorded at the Third Annual: The Body and Its Brain—Clinical Perspectives, held March 31, 2007, in
Omaha, NE, and sponsored by Creighton University Medical Center. Dr. Schuckit was recorded at Advances in Psychopharmacology
Throughout the Life Span, held April 12-14, 2007, in San Diego, CA, and sponsored by the University
of California, San Diego, School of Medicine. The Audio-Digest Foundation thanks the speakers and the sponsors for
their cooperation in the production of this program.
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