Upload
thomasine-strickland
View
215
Download
0
Tags:
Embed Size (px)
Citation preview
MEDICAL MEDICAL COMORBIDITIES OF COMORBIDITIES OF
SUBSTANCE USE SUBSTANCE USE DISORDERSDISORDERS
Oregon Psychiatric AssociationOregon Psychiatric AssociationMarch 4, 2006March 4, 2006
ObjectivesObjectives
Review epidemiology of alcohol/substance Review epidemiology of alcohol/substance use disordersuse disorders
Review importance of these disorders in Review importance of these disorders in medicinemedicine
General overview of medical complications General overview of medical complications of alcohol/substance use disordersof alcohol/substance use disorders
Discuss specific complicationsDiscuss specific complications MethamphetaminesMethamphetamines AlcoholAlcohol OthersOthers
EpidemiologyEpidemiology
2/3 ever consumed alcohol2/3 ever consumed alcohol ~40% ever used illicit drugs~40% ever used illicit drugs 20% use tobacco20% use tobacco Lifetime prevalenceLifetime prevalence
Alcohol use disordersAlcohol use disorders Men - 15-20%Men - 15-20% Women - 8%Women - 8%
Drug use disordersDrug use disorders Men – 8%Men – 8% Women – 5%Women – 5%
ImportanceImportance
20-40% of general hospital admissions20-40% of general hospital admissions 20% of primary care visits20% of primary care visits One million ER visits per yearOne million ER visits per year
Drug use primary problemDrug use primary problem 50-75% of trauma visits50-75% of trauma visits Up to 200,000 deaths per yearUp to 200,000 deaths per year Alcohol decreases life expectancy by Alcohol decreases life expectancy by
15 yrs15 yrs ~40% of suicides involve drugs/alcohol~40% of suicides involve drugs/alcohol
Societal Costs – Alcohol Use Societal Costs – Alcohol Use DisordersDisorders
Total: ~$185 BillionTotal: ~$185 Billion
Source: Harwood, H. Report prepared by the Lewin Group for the National Institute on Alcohol Abuse and Alcoholism; 2000. National Institutes of Health, NIH Publication No. 98-4327. Rockville, MD.
http://www.niaaa.nih.gov
†FAS = fetal alcohol syndrome.
47%
20%
2%
9%
4%13%
5%
1%
Specialty Alcohol Services*
Medical Consequences (except FAS†)
Medical Consequences of FAS
Lost Future Earnings Due toPremature Deaths
Lost Earnings Due toAlcohol-Related Illness
Lost Earnings Due to FAS
Lost Earnings Due to Crime/Victims
Crashes, Fires, Criminal Justice, etc
Medical ConsequencesMedical Consequences
Direct EffectsDirect Effects Toxicity of substance of abuseToxicity of substance of abuse Toxicity of contaminantsToxicity of contaminants
Indirect EffectsIndirect Effects Infectious diseasesInfectious diseases TraumaTrauma Nutritional deficienciesNutritional deficiencies Consequences of intoxication/withdrawal Consequences of intoxication/withdrawal
statesstates
Case #1Case #1
43 yo woman c/o dyspepsia, epigastric 43 yo woman c/o dyspepsia, epigastric burning and anxietyburning and anxiety
PMH – hypertensionPMH – hypertension Meds: Atenolol 25mg qdMeds: Atenolol 25mg qd HPI, ROS – unremarkableHPI, ROS – unremarkable Labs in past year – all WNLLabs in past year – all WNL
Case #1Case #1
PE:PE: Looks anxiousLooks anxious Hands are cold,clammy, slightly shakyHands are cold,clammy, slightly shaky Wearing strong perfumeWearing strong perfume P: 102 regularP: 102 regular BP: 155/101BP: 155/101 Temp, respirations – normalTemp, respirations – normal Remainder of PE only remarkable for mild Remainder of PE only remarkable for mild
tachycardiatachycardia
What’s Your Diagnosis?What’s Your Diagnosis?Differential – substance use disordersDifferential – substance use disorders
Mild intoxication – stimulantsMild intoxication – stimulantsWithdrawal – alcohol, opioids, Withdrawal – alcohol, opioids, sedative/hypnoticssedative/hypnotics
Clues Clues GI symptoms – gastritisGI symptoms – gastritisHypertensionHypertensionSymptoms of alcohol withdrawalSymptoms of alcohol withdrawalUse of perfume, aftershave, mouthwash to cover Use of perfume, aftershave, mouthwash to cover smell of alcoholsmell of alcohol
Defining the “Standard Drink”Defining the “Standard Drink” 10-15g ethanol 10-15g ethanol
12 oz of regular beer or cooler (5% alcohol)12 oz of regular beer or cooler (5% alcohol)
5 oz of table wine (12% alcohol)5 oz of table wine (12% alcohol)
1.5 oz of hard liquor (40% alcohol, 80 proof)1.5 oz of hard liquor (40% alcohol, 80 proof)
The average person metabolizes about 1 standard drink per The average person metabolizes about 1 standard drink per hourhour
12 oz12 oz 8.5 oz8.5 oz 5 oz5 oz 3.5 oz3.5 oz 2.5 oz2.5 oz 1.5 oz1.5 oz 1.5 oz1.5 oz
12 oz12 ozbeer beer
ororcoolercooler
8-9 oz8-9 ozmalt liquormalt liquor
5 oz5 ozwinewine
3-4 oz3-4 ozfortified winefortified wine
2-3 oz2-3 ozcordial,cordial,liqueur,liqueur,
or or aperitifaperitif
1.5 oz1.5 ozbrandybrandy
1.5 oz1.5 ozhard hard
liquorliquor
Source: National Institute on Alcohol Abuse and Alcoholism. Bethesda, Md: NIAAA; 2004. NIH Publication No. 04-3769.
Chronic Alcohol UseChronic Alcohol Use
Liver DiseaseLiver DiseaseCirrhosisCirrhosis
Coronary Artery DiseaseCoronary Artery DiseaseCardiomyopathyCardiomyopathyArrhythmiasArrhythmiasHypertension Hypertension StrokeStroke
Duodenal ulcersDuodenal ulcers
Cognitive disordersCognitive disordersCVACVAPsychosisPsychosis
PancreatitisPancreatitisDiabetesDiabetes
Head, Neck, GI cancersHead, Neck, GI cancers
Stomach ulcersStomach ulcersGastritisGastritis
Adapted from: Schuckit MA. In: Harrison’s Principles of Internal Medicine. New York: McGraw-Hill; 2001:2561-2566. .
NeuropathiesNeuropathiesAnemias Anemias Nutritional DeficienciesNutritional Deficiencies
Diseases Associated with Diseases Associated with Chronic Alcohol UseChronic Alcohol Use
CardiomyopathyCardiomyopathy
Gastritis, other GI Gastritis, other GI complicationscomplications
Liver diseaseLiver disease
DementiaDementia
NeuropathyNeuropathy
PancreatitisPancreatitis
AnemiasAnemias
Head, Neck, GI Head, Neck, GI cancerscancers
DiabetesDiabetes
Coronary artery Coronary artery diseasedisease
CVACVA
Nutritional Nutritional deficienciesdeficiencies
HypertensionHypertension
Sources: Schuckit MA. In: Harrison’s Principles of Internal Medicine. New York: McGraw-Hill; 2001:2561-2566. American Psychiatric Association. DSM-IV-TR. American Psychiatric Association: Washington, DC; 2000.
Nutritional ConsequencesNutritional Consequences
Heavy drinkers – up to 50% of daily Heavy drinkers – up to 50% of daily caloric intakecaloric intake >25% - >25% - significant decrease in necessary significant decrease in necessary
nutrientsnutrients MalnutritionMalnutrition Vitamin deficienciesVitamin deficiencies Impairs activation and utilization of Impairs activation and utilization of
nutrientsnutrients Maldigestion (GI complications)Maldigestion (GI complications)
Specific DeficienciesSpecific Deficiencies ThiamineThiamine
Wernicke-Korsakoff’sWernicke-Korsakoff’s Neuropathies Neuropathies
FolateFolate Megaloblastic anemiaMegaloblastic anemia
Vitamin C – with high alcohol intakeVitamin C – with high alcohol intake Vitamin DVitamin D
Decreased intake, poor absorption, insufficient Decreased intake, poor absorption, insufficient sunlightsunlight
Decreased bone mass, densityDecreased bone mass, density Increased osteoporosis, bone fracturesIncreased osteoporosis, bone fractures
GI ComplicationsGI Complications
LiverLiver ETOH toxic to hepatocytesETOH toxic to hepatocytes AST>ALTAST>ALT Accelerates liver damage in hepatitis C Accelerates liver damage in hepatitis C
infectioninfection Increases risk of acetaminophen toxicityIncreases risk of acetaminophen toxicity Range of diseaseRange of disease
Fatty liverFatty liver Alcoholic hepatitisAlcoholic hepatitis FibrosisFibrosis CirrhosisCirrhosis
GI ComplicationsGI Complications
PancreatitisPancreatitis Generally after 10-15 years of heavy ETOHGenerally after 10-15 years of heavy ETOH
GI bleedingGI bleeding GastritisGastritis Peptic ulcer diseasePeptic ulcer disease Esophageal varicesEsophageal varices DuodenitisDuodenitis EsophagitisEsophagitis
Neurologic ComplicationsNeurologic Complications Wernicke’s encephalopathyWernicke’s encephalopathy
Delirium, ataxia, ophthalmoplegiaDelirium, ataxia, ophthalmoplegia Thiamine deficiencyThiamine deficiency Necrosis of mammillary bodies and Necrosis of mammillary bodies and
thalamusthalamus 50-85% 50-85% Korsakoff’s psychosis Korsakoff’s psychosis Few regain cognitive functionFew regain cognitive function
Korsakoff’s PsychosisKorsakoff’s Psychosis
Common pathology and etiology as Common pathology and etiology as Wernicke’sWernicke’s
Severe memory impairmentSevere memory impairment Recent and ongoing eventsRecent and ongoing events
Confabulation, lack of insightConfabulation, lack of insight Other intellectual functions may be Other intellectual functions may be
intactintact Treat with thiamineTreat with thiamine
Alcoholic DementiaAlcoholic Dementia
Prominent effects – frontal cortex, Prominent effects – frontal cortex, putamenputamen
Extreme variabilityExtreme variability EtiologyEtiology
NeurotoxicNeurotoxic Effects on neurotransmittersEffects on neurotransmitters Decreased cerebral blood flowDecreased cerebral blood flow Vitamin deficienciesVitamin deficiencies
Alcoholic DementiaAlcoholic Dementia
ImpairmentsImpairments Abstract thinkingAbstract thinking Problem solvingProblem solving Visual, spatial, motor abilitiesVisual, spatial, motor abilities New learningNew learning Remote memoryRemote memory Personal carePersonal care
Other Neurologic ComplicationsOther Neurologic Complications
““Blackouts” – transient anterograde amnesiaBlackouts” – transient anterograde amnesia ↑↑risk of CVArisk of CVA ↑↑risk of cerebral traumarisk of cerebral trauma Cerebellar degenerationCerebellar degeneration Metabolic encephalopathiesMetabolic encephalopathies Peripheral neuropathiesPeripheral neuropathies
Sensory, motor or autonomicSensory, motor or autonomic ““Stocking-glove” distributionStocking-glove” distribution
Other Organ SystemsOther Organ Systems HematologicHematologic
Anemias – Fe deficiency, folate deficiencyAnemias – Fe deficiency, folate deficiency Pancytopenia – alcohol toxic to bone marrowPancytopenia – alcohol toxic to bone marrow
MusculoskeletalMusculoskeletal RhabdomyolysisRhabdomyolysis Osteopenia/osteoporosis, fracturesOsteopenia/osteoporosis, fractures MyopathyMyopathy
CardiovascularCardiovascular CardiomyopathyCardiomyopathy HypertensionHypertension
DermatologicDermatologic Facial edema, rosacea, rhinophymaFacial edema, rosacea, rhinophyma
Metabolic/endocrineMetabolic/endocrine GoutGout Decreased testosteroneDecreased testosterone Menstrual abnormalitiesMenstrual abnormalities
MarijuanaMarijuana
Pulmonary toxicityPulmonary toxicity COPDCOPD
Head, neck cancersHead, neck cancers Cognitive deficitsCognitive deficits
Attention, short term Attention, short term memorymemory
Information processingInformation processing Motor impairmentMotor impairment
↓ ↓ Immune responseImmune response ↓ ↓ Testosterone levelsTestosterone levels Menstrual abnormalitiesMenstrual abnormalities
SummarySummary
Common disordersCommon disorders Many medical complicationsMany medical complications Patients frequently present to ERs, Patients frequently present to ERs,
general medical settingsgeneral medical settings Important to assess all patients for Important to assess all patients for
alcohol, tobacco, other substance usealcohol, tobacco, other substance use Complaints may caused/exacerbated by Complaints may caused/exacerbated by
substance use substance use