Training Module One
Goal - The goal of this module is to enable the physician to identify the incidence, prevalence, and associated health issues of substance abuse.
- Identify the incidence and prevalence of substance abuse in Utah and nation wide.
- Understand the Use-Abuse continuum from universal prevention to after care.
- Distinguish the various health issues associated with drug abuse.
- Understand the changing face of substance abuse and the methods for screening, referring, and treating drug-abusing patients.
- Recognize the ways in which stigma and bias impede the drug-abuse recovery process.
- Substance Abuse Nation Wide
- Substance Abuse in Utah
- Use-Abuse Continuum
- Tools for the Physician
Module Time Frame - 25 minutes
Abuse of drugs (including alcohol and tobacco) is the number one cause of preventable illness and death in the United States. Each year, more than 500,000 deaths - or over one in four - in the United States is attributable to abuse of alcohol, tobacco or other drugs. Alcohol is the most commonly used psychoactive substance; in a 2005 survey, 28 percent of persons aged 12 to 20 and 55 percent of persons aged 21 and over had consumed alcohol in the past month. Approximately 25 percent of the total population has smoked tobacco in the past month and 8 percent have used illicit drugs in the past month (see Table 1 below).
TABLE 1: Estimated Percentage of Illicit Drug Usage in the United States Population According to Gender, Age and Race
|Ever Used||Used Past Year||Used Past Month|
Source: National Household Survey on Drug Abuse: Population Estimates 2005
Although addictive disorders are widespread in the general population, their manifestations and the opportunities provided for specific interventions may vary widely among certain demographic groups. An understanding of these specifics is helpful for ensuring appropriate diagnosis and treatment.
Adolescents and Young Adults
Persons between 18 and 25 years of age are the most likely to use illicit drugs. The age at which an adolescent begins using alcohol and illicit drugs is a powerful predictor of later alcohol and drug problems, especially if use begins before age 15.
According to the National Household Survey on Drug Abuse, teenagers use alcohol and tobacco more than any other drug. The incidence of binge drinking - defined as having five or more drinks on the same occasion on at least 1 day in the past 30 days- is 9% for persons 12 to 17 and 42% for persons 18 to 25. The incidence of heavy alcohol use - defined as drinking five or more drinks on the same occasion on each of 5 or more days in the past 30 days - is 2.4% for persons 12 to 17 and 15% for persons 18 to 25. All heavy drinkers are binge drinkers.
In 2005, 20% of 15 year olds and 40% of 18 year olds reported that they have used marijuana. Typically, the adolescent whose drug involvement progresses to substance abuse begins with commercially available drugs such and alcohol and tobacco, then progresses to using marijuana and goes on to using other drug or combinations of drugs. For this reason, cigarettes, alcohol, marijuana are sometimes called "gateway" drugs.
During pregnancy, at least 25% of women use nicotine, and 5% to 8% are at risk for alcohol-related problems; the prevalence of illicit drug use in pregnant women is unclear, but it appears to be lower than that of nicotine and alcohol use. Women who use drugs during pregnancy have increased rates of meconium staining, fetal-monitor abnormalities, precipitous delivery, abruptio placentae and premature delivery. Infants born to addicts are more likely to have birth defects, because most addicted mothers also abuse alcohol, a known teratogen. Even occasional use of alcohol, tobacco, or illicit drugs should be identified and discouraged in pregnant women.
With age comes a higher incidence of chronic painful physical disorders that may be treated with substances that have the potential for abuse. Vulnerability to addiction may be increased by feelings of anger, depression, and anxiety about the aging process. Alcoholism in the elderly remains an underreported and often hidden disorder. In addition, the elderly consume a disproportionate amount of prescription drugs and commonly use several prescriptions and over-the-counter medications concomitantly.
Substance Abuse does not occur in a vacuum
According to the Salt Lake County Division of Substance Abuse, alcohol and drugs are associated with 45% of rapes, 51% of assaults, 70% of teen suicides, 50% of traffic fatalities, 52% of murders, 68% of manslaughter charges, 55% of burglaries, 51% of thefts, and 80% of child abuse (see Table 2).
Equally devastating is the morbidity caused by the use of illegal and legal drugs. In terms of demands on health care resources and loss of productivity, the cost of substance abuse is tremendous, whether attributable to cancer and cardiopulmonary disease from tobacco, falls and oversedation from misuse of prescription drugs, or bacterial and viral infections (including human immunodeficiency virus) associated with injection of illicit drugs.
According to the State Division of Substance Abuse annual report, in 2003, 33.5% of Utah 12th graders said they had used alcohol, tobacco, or another drug at least once during their lifetimes (see Table 3).
|Grade 6||Grade 7||Grade 8||Grade 9||Grade 10||Grade 11||Grade 12||Middle
In 2000, 4.9% of adults in Utah were classified as dependent on either alcohol or drugs and in need of treatment services. In 2005, 6.4% of Utah youth ages 12 - 17 were classified as dependent on drugs and alcohol (See Table 4).
|District||Adults (18 Years +)||Youth (12 - 17 years)|
|% Need Treatment||# Need Treatment||Current Capacity||% Need Treatment||# Need Treatment||Current Capacity|
|Salt Lake County||5.7%||38,769||6,955||8.7%||7,574||1,448|
|San Juan County||4.2%||399||74||8.3%||157||29|
|Weber Human Services||5.0%||7,709||1,779||7.4%||1,517||254|
*Taken from the 2000 State of Utah Telephone Household Survey Treatment Needs Assessment Project
** Taken from the 2005 State of Utah Prevention Needs Assessment Survey
Universal prevention strategies address the entire population (national, local community, school, neighborhood), with messages and programs aimed at preventing or delaying the abuse of alcohol, tobacco, and other drugs. For example, it would include the general population and subgroups such as pregnant women, children, adolescents, and the elderly. The mission of universal prevention is to deter the onset of substance abuse by providing all individuals the information and skills necessary to prevent the problem. All members of the population share the same general risk for substance abuse, although the risk may vary greatly among individuals. Universal prevention programs are delivered to large groups without any prior screening for substance abuse risk. The entire population is assessed as at-risk for substance abuse and capable of benefiting from prevention programs.
Selective prevention strategies target subsets of the total population that are deemed to be at risk for substance abuse by virtue of their membership in a particular population segment--for example, children of adult alcoholics, dropouts, or students who are failing academically. Risk groups may be identified on the basis of biological, psychological, social, or environmental risk factors known to be associated with substance abuse (IOM 1994), and targeted subgroups may be defined by age, gender, family history, place of residence such as high drug-use or low-income neighborhoods, and victimization by physical and/or sexual abuse. Selective prevention targets the entire subgroup regardless of the degree of risk of any individual within the group. One individual in the subgroup may not be at personal risk for substance abuse, while another person in the same subgroup may be abusing substances. The selective prevention program is presented to the entire subgroup because the subgroup as a whole is at higher risk for substance abuse than the general population. An individual's personal risk is not specifically assessed or identified and is based solely on a presumption given his or her membership in the at-risk subgroup.
Indicated prevention strategies are designed to prevent the onset of substance abuse in individuals who do not meet DSM-IV criteria for addiction, but who are showing early danger signs, such as falling grades and consumption of alcohol and other gateway drugs. The mission of indicated prevention is to identify individuals who are exhibiting early signs of substance abuse and other problem behaviors associated with substance abuse and to target them with special programs. The individuals are exhibiting substance abuse-like behavior, but at a subclinical level (IOM 1994). Indicated prevention approaches are used for individuals who may or may not be abusing substances, but exhibit risk factors that increase their chances of developing a drug abuse problem. Indicated prevention programs address risk factors associated with the individual, such as conduct disorders, and alienation from parents, school, and positive peer groups. Less emphasis is placed on assessing or addressing environmental influences, such as community values. The aim of indicated prevention programs is not only the reduction in first-time substance abuse, but also reduction in the length of time the signs continue, delay of onset of substance abuse, and/or reduction in the severity of substance use. Individuals can be referred to indicated prevention programs by parents, teachers, school counselors, school nurses, youth workers, friends, or the courts. Young people may volunteer to participate in indicated prevention programs.
Drug addiction is a complex, but treatable brain disease. It is characterized by compulsive drug craving, seeking, and use that persist even in the face of severe adverse consequences. For many people, drug addiction becomes chronic, with relapses possible even after long periods of abstinence. In fact, relapse to drug abuse occurs at rates similar to those for other well-characterized, chronic medical illnesses such as diabetes, hypertension, and asthma. As a chronic, recurring illness, addiction may require repeated treatments to increase the intervals between relapses and diminish their intensity, until abstinence is achieved. Through treatment tailored to individual needs, people with drug addiction can recover and lead productive lives.
The ultimate goal of drug addiction treatment is to enable an individual to achieve lasting abstinence, but the immediate goals are to reduce drug abuse, improve the individual's ability to function, and minimize the medical and social complications of drug abuse and addiction. Like people with diabetes or heart disease, people in treatment for drug addiction will need to change behavior to adopt a more healthful lifestyle.
Scientific research since the mid-1970s shows that treatment can help many people change destructive behaviors, avoid relapse, and successfully remove themselves from a life of substance abuse and addiction. Recovery from drug addiction is a long-term process and frequently requires multiple episodes of treatment. Based on this research, key principles have been identified that should form the basis of any effective treatment program:
- No single treatment is appropriate for all individuals.
- Treatment needs to be readily available.
- Effective treatment attends to multiple needs of the individual, not just his or her drug addiction.
- An individual's treatment and services plan must be assessed often and modified to meet the person's changing needs.
- Remaining in treatment for an adequate period of time is critical for treatment effectiveness.
- Counseling and other behavioral therapies are critical components of virtually all effective treatments for addiction.
- For certain types of disorders, medications are an important element of treatment, especially when combined with counseling and other behavioral therapies.
- Addicted or drug-abusing individuals with coexisting mental disorders should have both disorders treated in an integrated way.
- Medical management of withdrawal syndrome is only the first stage of addiction treatment and by itself does little to change long-term drug use.
- Treatment does not need to be voluntary to be effective.
- Possible drug use during treatment must be monitored continuously.
- Treatment programs should provide assessment for HIV/AIDS, hepatitis B and C, tuberculosis, and other infectious diseases, and should provide counseling to help patients modify or change behaviors that place themselves or others at risk of infection.
- As is the case with other chronic, relapsing diseases, recovery from drug addiction can be a long-term process and typically requires multiple.
In chemical dependency, relapse is the act of taking that first drink or drug after being deliberately clean and sober for a time. It helps though to view relapse as a process that begins well in advance of that act. People who have relapsed can usually point back to certain things that they thought and did long before they actually drank or used that eventually caused the relapse. They may have become complacent in their program of recovery in some way or refused to ask for help when they needed it. Each persons relapse factors are unique to them, their diagnosis, and personal plan of recovery.
Relapse is usually caused by a combinations of factors. Some possible factors and warning signs might be:
- Stopping medications on one's own or against the advice of medical professionals
- Hanging around old drinking haunts and drug using friends
- Isolating - not attending meetings - not using the telephone for support
- Feeling overconfident - that you no longer need support
- Relationship difficulties - ongoing serious conflicts - a spouse who still uses
- Setting unrealistic goals - perfectionism - being too hard on ourselves
- Feeling overwhelmed - confused - useless - stressed out
- Constant boredom - irritability - lack of routine and structure in life
- Avoidance - refusing to deal with personal issues and other problems of daily living
- Major life changes - loss - grief - trauma - painful emotions - winning the lottery
- Ignoring relapse warning signs and triggers
Almost everyone in recovery has times when compelling thoughts of drinking or using drugs resurface. In early recovery, drinking or drugging dreams are not uncommon. Recovery takes time, but by becoming familiar with triggers and warning signs, utilizing the various recovery tools, and having a practical plan of action, individuals greatly minimize the tendency to lapse back into their addictions.
The profile of the substance abuse service client had changed substantially in the past 25 years. For example, the typical substance abuse service client in 1980 was white, male and 28 years old. Now service professionals treat individuals from a myriad of different backgrounds and demographics (See Table 6).
Table 6. Substance Abuse Service Clients 1980 vs. 2006
|Substance Abuse Service Client 1980:||Substance Abuse Service Clients 2006:|
|White, Male, 28 Years old||White, Male, Durgs Exposed Infants, Minorities, Female, Pregnant Women, Homeless Youth|
|Criminal Justice System||Criminal Justice System, Juvenile Justice System, Gangs, Drug Court, Parolees (CIAO), Workforce Services, Dually Diagnosed Clients|
|Primary Drug is Alcohol||Polydrug Use, Methamphetamines, Professional Denial, HIV, TB, Hepatitis C, Elderly Prescription Misuse|
|Age of First Use is 16 to 21 years||Age of First use is 12 years|
- Recognize potential substance abuse problem
- Conduct basic assessment
- Plant the seed for intervention/treatment
- Educate regarding the neurobiology of addiction
- Refer to professional treatment resources
Recognize potential substance abuse problem
Screening for alcohol and drug disorders can either be incorporated into routine history taking or can be done when a patient indicates specific problems associated with problematic use of drugs or alcohol. The patient is far more likely to respond to questions regarding drug use if the physician remains empathetic, respectful, and nonjudgmental.
Conduct basic assessment
When utilizing a direct approach to assessment, the physician should ask specifically about the amounts and frequency of alcohol use and other drug use in the past month, week and day. This line of questioning provides the physician with a quick means of learning the extent and consequences of the patient's drug and alcohol use. The disadvantage is that the physician may have difficulty estimating the true extent of the problem if the patient gives vague or dishonest responses.
If the physician is unable to get a sense of the patient's problems from these unstructured questions, an alternative approach is to ask the following "CAGE" questions:
"Have you felt that you ought to cut down on your drinking or drug use?"
"Have people annoyed you by criticizing your drinking or drug use?"
"Have you felt bad or guilty about your drinking or drug use?"
"Have you ever had a drink or used drugs first thing in the morning to steady your nerves, to get rid of a hangover or to get the day started?"
A positive answer to two or more of these questions suggests the need for additional assessment of drug or alcohol problems.
Plant the seed for intervention/treatment
The physician should provide the patient with information about the disorder and suggestions to help modify his or her behavior. The physician should stress the possible negative consequences of the patient's drug use, both currently and in the future. Giving the patient educational materials may reinforce these points.
Educate regarding the neurobiology of Addiction
Refer to professional treatment resources
For information on treatment facilities in your area call the Utah Behavioral Healthcare Network at 801-487-3943 or visit their website (www.ubhn.org).
According to the American Medical Association, one in ten physicians is likely to become dependent on one or more drugs. Anesthesiologists, Psychiatrists, Internests and Family Practioners are the most likely to develop a dependency on drugs (see Table 8). Substance abuse is more common in male physicians than it is in women physicians.
|Table 8. Relative Risk Comparison of Selected Specialities|
|Specialty||Relative Risk||% in PHP|
|Source: Mansky, PA (2003)|
Through the years, many people have come to view drug abuse and addiction as strictly a social problem. They tend to characterize people who take drugs as morally weak or as having criminal tendencies. They believe that drug abusers and addicts should be able to stop taking drugs but are unwilling to change their behavior. These myths have fueled the great stigma that drug abuse and addiction have historically carried. This stigma affects not only those afflicted with drug-related problems, but their families, their communities, and the health care professionals who work with them.
It is crucial to be aware of social stigma and bias regarding substance abuse. Keep in mind the following misperceptions and facts when working with substance abusing individuals:
|Substance Abuse is a criminal behavior||Substance abuse is a disease|
|Substance abuse is a result of moral weakness||Substance abuse is genetic|
|Substance abuse is a personal choice||Substance abuse is a result of the hijacked brain|
|Addiction is an acute condition||Addiction is a chronic, relapsing disease|