Reading Assignment: Introduction to Substance Use Disorders

Substance Use Disorders: Introduction

Substance use disorders and their related problems are among society’s most pervasive health and social concerns and they have been on the rise since the 1980s. Each year, one in four deaths in the United States is related to alcohol, illicit drug, or tobacco consumption.1 Annually, in 2016, over 64,000 deaths are from overdoses alone, up from about 25,000 in 2007.²  

In 2016, the economic cost of alcohol and drug abuse was $740 billion annually, up from $276 billion in 1995.³

This amounts to more than $2300 per year for every man, woman, and child in the United States when we account for the costs of health care, motor vehicle crashes, crime, lost productivity, and other adverse outcomes of alcohol and drug abuse.³

The purpose of this module is to introduce learners to the topic of substance abuse and its relationship to vulnerable populations.

After completing this module students should be able to:

• define the socio economic, racial, and political factors that modify risk for substance abuse
• find data on evidence-based prevention strategies
• apply  screening tools to identify patients at risk for substance abuse

Additionally the module will introduce the following:

1. What are the policies and politics that impact health disparities among substance using populations?
2. What are the goals to eliminate health disparities among substance using populations (from Healthy People 2020)?
3. Are there promising strategies? What can health providers do to address substance use in clinical care? What about a surgeon considering an elective procedure for a patient?
4. What is the physician’s role in screening and addressing substance abuse?
5. What are available supports and resources?

Terminology: Assignment: Treatment Of Substance Use/Abuse

The current Diagnostic and Statistical Manual for Mental Disorders, the DSM-5, removes the term “substance abuse” and replaces it with “substance use disorders.”  This allows for clarity in terminology; “a diagnosis of substance use disorder is based on evidence of impaired control, social impairment, risky use, and pharmacological criteria.”  Definitions for various subtypes have been clarified as well.⁴

Contextual Determinants of Substance Use

The “War on Drugs” was “declared” by Richard Nixon in 1971 and evolved from a treatment-based approach to a law enforcement strategy.  Policy and research have been driven by an emphasis on the role of individual factors in substance use prevention and treatment. Specifically, how do we identify an at risk person, prevent abuse, and intervene to treat that person? With the “war on drugs”, this resulted in often criminalizing the person with a substance use disorder. Much less emphasis has been given to understanding the determinants of substance use. Although individual characteristics are partly responsible for morbidity due to substance use, they do not explain all the interpersonal variability in behaviors. Contextual factors associated with substance use behavior may include:

• Structural factors (e.g., How is the person treated when the disorder is identified? What is the availability of services?),
• Social norms and attitudes (e.g., social trust (does the person trust the provider), illness vs personal failing),
• Issues of advantage and opportunity or lack thereof (e.g., neighborhood socioeconomic status and opportunities),
• Features of the physical environment (e.g., housing quality),
• Racism and discrimination, and
• Incarceration policies ⁵

What is the health burden and what are the goals to eliminate health disparities caused by substance use?

As of 2015, about 26 million Americans struggled with substance abuse, many with two or more substances and many with underlying psychiatric disease. Most are unaware that they have a problem and many have difficulty obtaining treatment.⁴

Alcohol and drug dependent persons without primary medical care have a substantial burden of medical illness compared to age- and gender- matched U.S. population controls. While the optimal measure of medical illness burden in this population is unclear, a variety of health measures document this medical illness burden in addicted persons.⁶

Although archived, Healthy People 2010 report is still available and documents health burdens.⁷

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Cardiovascular disease, stroke, cancer, HIV/AIDS, hepatitis, renal disease, and lung disease are all disproportionately present in those with substance use disorders and rates for the following are higher in populations affected by substance use disorders:

• Teenage pregnancy
• Other sexually transmitted infections (STIs)
• Domestic violence
• Child abuse
• Motor vehicle crashes
• Physical fights
• Crime
• Homicide
• Suicide
• Adverse Childhood Experiences

Public health agencies continue to look at ways to reduce substance use disorders and the negative health consequences due to substance use and to expand access to effective treatment. The goal for 2020 for substance use is the same as it was for Healthy People 2010:⁸

“Reduce substance abuse to protect the health, safety, and quality of life for all, especially children.”

What are the policies and politics that impact health disparities for those with substance use disorders?

The War on Drugs

Watch the JayZ video and read the accompanying short document. ⁹

Given the increasing rates of substance use disorders and the incarceration policies in the USA, there are few health policy and public health experts who claim the War on Drugs worked.

Questions to ask yourself: Is it time to have a differently informed policy?  How does the current criminalization policy contribute to institutional racism? Consider reading The New Jim Crow:  Mass Incarceration in the Age of Colorblindness by Michelle Alexander for even more context than the fact sheet above. What happens when drug offenses are felonies and African Americans are 5 times more likely to be incarcerated for a drug offense? What has happened to our criminal justice system and what it does to people of color in particular?

Assignment: Treatment Of Substance Use/Abuse

The Opioid Overdose Crisis

A quote from the National Institute on Drug Abuse (NIDA)on this subject:

• Roughly 21 to 29 percent of patients prescribed opioids for chronic pain misuse them.
• Between 8 and 12 percent develop an opioid use disorder.
• An estimated 4 to 6 percent who misuse prescription opioids transition to .
• About 80 percent of people who use heroin first misused prescription opioids. ¹⁰

What should be clear from the above numbers is that this epidemic started with physicians prescribing opiates to their patients without careful monitoring and often when other medications and modalities would have worked just as well.  Physicians are largely responsible for this epidemic. This is clearly an area where physicians can get more training in managing our patients’ pain, working with patients who need short-term courses of opioids, and intervening with patients who have developed additions.

Naloxone/Narcan

Availability of Nalaxone/Narcan, a drug that reverses opioid overdoses, is shown to reduce overdose deaths. Watch this TED talk by Baltimore Health Commissioner Dr. Leana Wen, who talks about how her city is training citizens to save lives:

The following article has an algorithm for administration by non EMS persons. 46 states now sell it over the counter (as of 10/2017) and Wyoming was the only WWAMI state where this was not the case. The following article has an algorithm for administration of naloxone by lay persons.¹¹

In Seattle, Overdose Prevention Training and naloxone (Narcan) prescriptions are available FREE at the Downtown Needle Exchange at the Robert Clewis Center in Belltown (2124 4th Ave, Seattle). You can walk-in Monday-Friday 1:00-5:00pm and ask for naloxone training. You will be trained on how to recognize an overdose and how to administer naloxone. Then you’ll have a quick visit with the on-site pharmacist, who will give you your naloxone kit. ¹²

Promising Strategies – What can health providers do?

Health providers must adequately screen (and preferably universally screen to avoid explicit and implicit bias) and provide brief effective counseling for substance use during routine clinical care. To eliminate health disparities providers must improve recognition of risk, detection of substance use, and assure proper treatment. Providers must ensure that more people in their practices receive care that includes:

• Exercising caution in prescribing habit forming medications in clinical practice
• Employing effective prevention interventions
• Screening for chemical dependency
• Providing information about naloxone for family members of those with substance use disorders
• Providing brief in-clinic treatment
• Referrals to appropriate treatment
• Encouraging harm reduction strategies

Healthy People 2020 takes a three pronged evidence based approach:  clinical efforts, community programs, and Consumer Education.  They base recommendations on the US Preventive Services Task Force and CDC data.⁸ You may look at some of these for the case below.

Clinical Strategies

• Among the most evidenced based clinical strategies is SBIRT–the screening, brief intervention and referral to treatment strategy. A website explaining it is:
• Should you want to get training in SBIRT, see the follow
• Remember to think about whom you are screening.  Here is the CRAFT tool for screening adolescents

Community strategies can include outreach, education, and continued work for more opportunities for at risk youth and adults.

Harm reduction strategies are also considered by a number of communities.

• Read or listen to this short piece on NPR about Portugal

• Needle Exchange programs provide clean needles in exchange for used ones. This map, the most recently available, shows locations throughout the country. These services reduce spread of HIV and Hepatitis C, provide education on risk reduction and on preventing overdose deaths.

• Safe injection sites are another harm reduction strategy. There are sites in Australia and Canada and their evaluations suggest fewer overdoses and perhaps lower rates of infection, because of supervision with clean needles. In the USA there are those working to establish laws to allow sites. The Vancouver program, Insite, is discussed here:

As clinicians, having support available by phone is important:

For assistance and information call:

• The National Drug & Alcohol Treatment Referral Routing Service: 1-800-662-HELP
• The National Clearinghouse for Alcohol & Drug Information in The Federal Substance Abuse and Mental Health Services Administration (SAMHSA): 1-800-729-6686
• Covenant House Nineline (crisis intervention for homeless and at-risk youth): 1-800-999-9999
• Girls & Boys Town National Hotline: 1-800-448-3000

On the next page, complete the Substance Use Disorder Case Study reflections (posting only available to Underserved Pathway Students).

Please work through the case study and complete reflections for the three different sections. You may combine all your responses in one post, by hitting Reply on the next screen.

Recommended Readings & Web Resources

• Links to some demographic/trend Information
• Review article about substance abuse in the LGBT communities
• Substance Abuse and Mental Health Services Administration
• The National Institute on Drug Abuse
• Alcoholics Anonymous
• Alateen
• Al-Anon
• Narcotics Anonymous
• The National Council on Alcoholism & Drug Dependence
• The National Institute on Alcohol Abuse & Alcoholism

References:

1. Medical Consequences of Drug Abuse-Mortality (2012)

2. NIDA, Advancing Addiction Science. Overdose Death Rates. September, 2017
3. NIDA, Advancing Addiction Science. Trends and Statistics. April, 2017

4. Cornerstone Recovery Center. Redefining addiction: Substance use disorders vs substance abuse and dependence. December 2016.
5. Galea S, Ahern J, Vlahov D. Contextual determinants of drug use risk behavior: a theoretic framework. J Urban Health. 2003 Dec;80 (4 Suppl 3):iii50-8.
6. De Alba, I., Samet, J.H. and Saitz, R. Burden of Medical Illness in Drug and Alcohol Dependent Persons without Primary Care. American Journal of Addiction, 13, pp. 33-45, 2004.
7. Healthy People 2010

8. Healthy People 2020

9. We are the Drug Policy Alliance. JAYZ and A Brief History of the Drug War.
10. NIDA, Advancing Addiction Science. Opioid Overdose Crisis. February 2018.
11. Drennan IR and Orkin AM. Prehospital Naloxone Administration for Opioid-Related Emergencies. Journal of Emergency Medical Services, Mar 2, 2016
12. 12. Public Health, Seattle-King County. King County Needle Exchange.

13. World Health Organization. WHO/AUDIT: The Alcohol Use Disorders Identification Test.