1

Alcohol and Drug Use Disorders

Brian Fuehrlein MD PhD

Director Psychiatric Emergency Room VA

Connecticut and Assistant Professor of

Psychiatry Yale University

2

Brian Fuehrlein Disclosures

I have no financial relationships to disclose

The contents of this activity may include discussion of off label or investigative drug uses The

faculty is aware that is their responsibility to disclose this information

3

Planning Committee Disclosures

AAAP aims to provide educational information that is balanced independent objective and free of bias

and based on evidence In order to resolve any identified Conflicts of Interest disclosure information from

all planners faculty and anyone in the position to control content is provided during the planning process

to ensure resolution of any identified conflicts This disclosure information is listed below

The following developers and planning committee members have reported that they have no

commercial relationships relevant to the content of this module to disclose PCSS-MAT lead

contributors Frances Levin MD and Adam Bisaga MD AAAP CMECPD Committee Members Dean

Krahn MD Kevin Sevarino MD PhD Tim Fong MD Tom Kosten MD Joji Suzuki MD and AAAP

Staff Kathryn Cates-Wessel Miriam Giles Carol Johnson and Justina Pereira

All faculty have been advised that any recommendations involving clinical medicine must be based on

evidence that is accepted within the profession of medicine as adequate justification for their indications

and contraindications in the care of patients All scientific research referred to reported or used in the

presentation must conform to the generally accepted standards of experimental design data collection

and analysis The content of this CME activity has been reviewed and the committee determined the

presentation is balanced independent and free of any commercial bias Speakers will inform the learners

if their presentation will include discussion of unlabeledinvestigational use of commercial products

4

Target Audience

The overarching goal of PCSS-MAT is to make

available the most effective medication-assisted

treatments to serve patients in a variety of settings

including primary care psychiatric care and pain

management settings

5

Educational Objectives

At the conclusion of this activity participants should be able to

Describe alcohol use disorder definitions and epidemiology

Recognize the symptoms time course and treatment for alcohol withdrawal

Describe key concepts in other drug use disorders

Define basic information on urine drug testing

6

Alcohol Use Disorder

Centers for Disease Control and Prevention (CDC) Alcohol-Related Disease Impact (ARDI)

Atlanta GA CDC

Epidemiology of DSM-5 Alcohol Use Disorder Results From the National Epidemiologic Survey

on Alcohol and Related Conditions III Grant BF1 Goldstein RB1 Saha TD1 Chou SP1 Jung J1

Zhang H1 Pickering RP1 Ruan WJ1 Smith SM1 Huang B1 Hasin DS2

Alcohol use disorder is highly prevalent highly comorbid disabling and often goes untreated

12-month and lifetime prevalence of AUD is 139 and 291 respectively

Only 198 of those with an AUD were ever treated

AUD is significantly associated with MDD bipolar 1 ASPD and borderline PD and also with panic disorder and generalized anxiety disorder

Alcohol leads to approximately 88000 deaths and 25 million years of potential life lost each year in the US

2

Brian Fuehrlein Disclosures

I have no financial relationships to disclose

The contents of this activity may include discussion of off label or investigative drug uses The

faculty is aware that is their responsibility to disclose this information

3

Planning Committee Disclosures

AAAP aims to provide educational information that is balanced independent objective and free of bias

and based on evidence In order to resolve any identified Conflicts of Interest disclosure information from

all planners faculty and anyone in the position to control content is provided during the planning process

to ensure resolution of any identified conflicts This disclosure information is listed below

The following developers and planning committee members have reported that they have no

commercial relationships relevant to the content of this module to disclose PCSS-MAT lead

contributors Frances Levin MD and Adam Bisaga MD AAAP CMECPD Committee Members Dean

Krahn MD Kevin Sevarino MD PhD Tim Fong MD Tom Kosten MD Joji Suzuki MD and AAAP

Staff Kathryn Cates-Wessel Miriam Giles Carol Johnson and Justina Pereira

All faculty have been advised that any recommendations involving clinical medicine must be based on

evidence that is accepted within the profession of medicine as adequate justification for their indications

and contraindications in the care of patients All scientific research referred to reported or used in the

presentation must conform to the generally accepted standards of experimental design data collection

and analysis The content of this CME activity has been reviewed and the committee determined the

presentation is balanced independent and free of any commercial bias Speakers will inform the learners

if their presentation will include discussion of unlabeledinvestigational use of commercial products

4

Target Audience

The overarching goal of PCSS-MAT is to make

available the most effective medication-assisted

treatments to serve patients in a variety of settings

including primary care psychiatric care and pain

management settings

5

Educational Objectives

At the conclusion of this activity participants should be able to

Describe alcohol use disorder definitions and epidemiology

Recognize the symptoms time course and treatment for alcohol withdrawal

Describe key concepts in other drug use disorders

Define basic information on urine drug testing

6

Alcohol Use Disorder

Centers for Disease Control and Prevention (CDC) Alcohol-Related Disease Impact (ARDI)

Atlanta GA CDC

Epidemiology of DSM-5 Alcohol Use Disorder Results From the National Epidemiologic Survey

on Alcohol and Related Conditions III Grant BF1 Goldstein RB1 Saha TD1 Chou SP1 Jung J1

Zhang H1 Pickering RP1 Ruan WJ1 Smith SM1 Huang B1 Hasin DS2

Alcohol use disorder is highly prevalent highly comorbid disabling and often goes untreated

12-month and lifetime prevalence of AUD is 139 and 291 respectively

Only 198 of those with an AUD were ever treated

AUD is significantly associated with MDD bipolar 1 ASPD and borderline PD and also with panic disorder and generalized anxiety disorder

Alcohol leads to approximately 88000 deaths and 25 million years of potential life lost each year in the US

3

Planning Committee Disclosures

AAAP aims to provide educational information that is balanced independent objective and free of bias

and based on evidence In order to resolve any identified Conflicts of Interest disclosure information from

all planners faculty and anyone in the position to control content is provided during the planning process

to ensure resolution of any identified conflicts This disclosure information is listed below

The following developers and planning committee members have reported that they have no

commercial relationships relevant to the content of this module to disclose PCSS-MAT lead

contributors Frances Levin MD and Adam Bisaga MD AAAP CMECPD Committee Members Dean

Krahn MD Kevin Sevarino MD PhD Tim Fong MD Tom Kosten MD Joji Suzuki MD and AAAP

Staff Kathryn Cates-Wessel Miriam Giles Carol Johnson and Justina Pereira

All faculty have been advised that any recommendations involving clinical medicine must be based on

evidence that is accepted within the profession of medicine as adequate justification for their indications

and contraindications in the care of patients All scientific research referred to reported or used in the

presentation must conform to the generally accepted standards of experimental design data collection

and analysis The content of this CME activity has been reviewed and the committee determined the

presentation is balanced independent and free of any commercial bias Speakers will inform the learners

if their presentation will include discussion of unlabeledinvestigational use of commercial products

4

Target Audience

The overarching goal of PCSS-MAT is to make

available the most effective medication-assisted

treatments to serve patients in a variety of settings

including primary care psychiatric care and pain

management settings

5

Educational Objectives

At the conclusion of this activity participants should be able to

Describe alcohol use disorder definitions and epidemiology

Recognize the symptoms time course and treatment for alcohol withdrawal

Describe key concepts in other drug use disorders

Define basic information on urine drug testing

6

Alcohol Use Disorder

Centers for Disease Control and Prevention (CDC) Alcohol-Related Disease Impact (ARDI)

Atlanta GA CDC

Epidemiology of DSM-5 Alcohol Use Disorder Results From the National Epidemiologic Survey

on Alcohol and Related Conditions III Grant BF1 Goldstein RB1 Saha TD1 Chou SP1 Jung J1

Zhang H1 Pickering RP1 Ruan WJ1 Smith SM1 Huang B1 Hasin DS2

Alcohol use disorder is highly prevalent highly comorbid disabling and often goes untreated

12-month and lifetime prevalence of AUD is 139 and 291 respectively

Only 198 of those with an AUD were ever treated

AUD is significantly associated with MDD bipolar 1 ASPD and borderline PD and also with panic disorder and generalized anxiety disorder

Alcohol leads to approximately 88000 deaths and 25 million years of potential life lost each year in the US

4

Target Audience

The overarching goal of PCSS-MAT is to make

available the most effective medication-assisted

treatments to serve patients in a variety of settings

including primary care psychiatric care and pain

management settings

5

Educational Objectives

At the conclusion of this activity participants should be able to

Describe alcohol use disorder definitions and epidemiology

Recognize the symptoms time course and treatment for alcohol withdrawal

Describe key concepts in other drug use disorders

Define basic information on urine drug testing

6

Alcohol Use Disorder

Centers for Disease Control and Prevention (CDC) Alcohol-Related Disease Impact (ARDI)

Atlanta GA CDC

Epidemiology of DSM-5 Alcohol Use Disorder Results From the National Epidemiologic Survey

on Alcohol and Related Conditions III Grant BF1 Goldstein RB1 Saha TD1 Chou SP1 Jung J1

Zhang H1 Pickering RP1 Ruan WJ1 Smith SM1 Huang B1 Hasin DS2

Alcohol use disorder is highly prevalent highly comorbid disabling and often goes untreated

12-month and lifetime prevalence of AUD is 139 and 291 respectively

Only 198 of those with an AUD were ever treated

AUD is significantly associated with MDD bipolar 1 ASPD and borderline PD and also with panic disorder and generalized anxiety disorder

Alcohol leads to approximately 88000 deaths and 25 million years of potential life lost each year in the US

5

Educational Objectives

At the conclusion of this activity participants should be able to

Describe alcohol use disorder definitions and epidemiology

Recognize the symptoms time course and treatment for alcohol withdrawal

Describe key concepts in other drug use disorders

Define basic information on urine drug testing

6

Alcohol Use Disorder

Centers for Disease Control and Prevention (CDC) Alcohol-Related Disease Impact (ARDI)

Atlanta GA CDC

Epidemiology of DSM-5 Alcohol Use Disorder Results From the National Epidemiologic Survey

on Alcohol and Related Conditions III Grant BF1 Goldstein RB1 Saha TD1 Chou SP1 Jung J1

Zhang H1 Pickering RP1 Ruan WJ1 Smith SM1 Huang B1 Hasin DS2

Alcohol use disorder is highly prevalent highly comorbid disabling and often goes untreated

12-month and lifetime prevalence of AUD is 139 and 291 respectively

Only 198 of those with an AUD were ever treated

AUD is significantly associated with MDD bipolar 1 ASPD and borderline PD and also with panic disorder and generalized anxiety disorder

Alcohol leads to approximately 88000 deaths and 25 million years of potential life lost each year in the US

6

Alcohol Use Disorder

Centers for Disease Control and Prevention (CDC) Alcohol-Related Disease Impact (ARDI)

Atlanta GA CDC

Epidemiology of DSM-5 Alcohol Use Disorder Results From the National Epidemiologic Survey

on Alcohol and Related Conditions III Grant BF1 Goldstein RB1 Saha TD1 Chou SP1 Jung J1

Zhang H1 Pickering RP1 Ruan WJ1 Smith SM1 Huang B1 Hasin DS2

Alcohol use disorder is highly prevalent highly comorbid disabling and often goes untreated

12-month and lifetime prevalence of AUD is 139 and 291 respectively

Only 198 of those with an AUD were ever treated

AUD is significantly associated with MDD bipolar 1 ASPD and borderline PD and also with panic disorder and generalized anxiety disorder

Alcohol leads to approximately 88000 deaths and 25 million years of potential life lost each year in the US

7

Clinical Presentation

Steve presents to clinic for a

routine exam

Steve reports doing well with no

complaints

Steve reports drinking ldquo1-2 drinksrdquo

before bed a few nights each week

Steversquos wife reports that he actually drinks

a fifth of vodka nearly every night

8

12 oz regular beer (5 alcohol)

bull Light beer contains slightly less alcohol (42)

bull Malt beverages contain approximately 7 alcohol

5 oz of table wine (12 alcohol)

15 oz of 80 proof spirits (40 alcohol)

Remember 60 as an easy way to figure out drink size and percent

Standard Drinks

9

Letrsquos Review Measures

1 cup = 8 oz = 53 drinks

1 pint = 2 cups = 16 oz = 106 drinks

1 quart = 2 pints = 32 oz = 213 drinks

1 gallon = 4 quarts = 128 oz = 853 drinks

The above assumes 80 proof spirits

10

Nip = common airplane bottle = 50 ml = 17 oz =

slightly more than 1 standard drink

Fifth = fifth of a gallon = 750 ml = 254 oz = 17

standard drinks

Handle = approximately half gallon = 175 L = 59 oz

= 393 standard drinks

Some Other Terms

11

Binge drinking = 4 drinks in one sitting for women or 5 for men on at least 1 day in the past month

Heavy alcohol use = binge drinking 5 or more days in the past month

Low risk drinking

bull Women no more than 3 drinks in one sitting or 7 in a week

bull Men no more than 4 drinks on a single day or 14 in a week

More Definitions

Definitions from National Institute on Alcohol Abuse and Alcoholism

12

Screening for Alcohol Use Disorder

Screen for risky drinking (gt3 drinks in one sitting or gt7

drinks in one week for women and gt4 drinks in one sitting or

gt14 drinks in one week for men) [criteria previous slide]

CAGE (Cut down Annoyed Guilty Eye opener)

AUDIT-C (Alcohol Use Disorders Identification Test)

bull How often did you have a drink containing alcohol in the

past year

bull How often did you have six or more drinks on one occasion

in the past year

13

Legal Intoxication vs Clinical Intoxication

Impact on BAL

14

On average one standard drink is metabolized per hour (002)

Hence a BAL of 030 will take approximately 15 hours to metabolize to zero

People with tolerance start to develop withdrawal approximately 6 hours from last drink hence the E in CAGE

Withdrawal will develop long before the BAL reaches 0

Alcohol Metabolism

15

16

Alcohol withdrawal

bull For most it is not

complicated

bull For some it is deadly

bull We must stratify risk

and triage appropriately

Risk Stratification

17

Risk Stratification

18

Detox is not treatment

Alcohol withdrawal is an

acute complication of a

chronic medical condition

Treating the acute

complication does not treat

the underlying condition

Most Importantly

19

Be aware of standard drink sizes and common terms

Understand the impact on BAL and clinical vs legal

intoxication

Routinely screen all patients for alcohol use disorders

Be able to identify alcohol withdrawal symptoms and

basic treatment strategies

Remember that Detox is not treatment

Alcohol Summary

20

Tom is a 61 year old man with an alcohol

use disorder

He was sober and in recovery from

36 ndash 60 years of age

At 60 he was prescribed Xanax for

anxiety

ldquoI did not even know what they gave me As soon as I took it I had a powerful urge to drink alcohol It was as if I had never stopped drinkingrdquo

He relapsed on alcohol and over the past year has struggled

He is now presenting for treatment of alcohol use disorder

Clinical Presentation

21

Alprazolam (Xanax) diazepam (Valium)

lorazepam (Ativan) clonazepam

(Klonopin) chlordiazepoxide (Librium)

and temazepam (Restoril) are the most

common

Indicated and useful for anxiety and

insomnia if properly monitored though

not considered first line for either

Pharmacologic overlap with alcohol

Benzodiazepines

22

Benzodiazepines (continued)

Do not fly the plane unless you know how to land

ldquoBarsrdquo = Xanax 2 mg

Can cause overdose death when mixed with opioids or alcohol

Often mixed with alcohol to magnify the high

Withdrawal can be protracted and dangerous

Common cause of falls and delirium in elderly

23

ldquoWhen I start to run out I begin crawling

around on the carpet looking for any

little bit I can find

Then I look around and think every car

car outside is the police and they

are after me

Then I look in the mirror my eyes are bloodshot and my heart is racing I feel awful and paranoid

Then I say to myself that I will NEVER do this again

Then I do it again the next dayrdquo

Clinical Presentation

24

Dopamine reuptake inhibitor

Leads to supraphysiologic dopamine release

Crack is mixed with a base smoked and is

highly addictive

Was widely used recreationally prior to 1914

including mixed with alcohol (Vin Mariani)

Snorting 146 minutes to peak

Injecting 31 minutes to peak

Smoking 14 minutes to peak

Cocaine

25

ldquoWoe to you my princess when I come I will

kiss you quite red and feed you til you are

plump And if you are forward you shall

see who is the stronger a gentle little girl

who doesnrsquot eat enough or a big wild man

who has cocaine in his body In my last

depression I took coca again and a small

dose lifted me to the heights in a wonderful

fashion I am just now busy collecting

literature for a song of praise to this magical

substancerdquo

Cocaine

26

Acute

bull Pleasure alertness energy sexuality tachycardia hallucinations paranoia hypertension

Crash

bull Peaks 2-4 days but up to a week of prolonged dysthymia hypersomnolence irritability suicidality cravings

Chronic

bull Profound anhedonia and other long term consequences dependent on route of admin

Cocaine

27

Chris is a 40-year old male who presents

to clinic seeking help with anxiety He reports

chronic anxiety with worry and ruminations

He also reports occasional panic attacks

He has tried SSRIs in the past with minimal

improvement He is currently smoking

marijuana daily and states that it is the only

thing that helps

He is willing to try a new medication but unwilling to stop smoking marijuana

Clinical Presentation

28

ldquoMarijuanardquo is the term for the plant Cannabis

THC = Tetrahydrocannabinol = psychoactive

CBD = Cannabidiol = sedating not psychoactive

Sativa and Indica differ in THCCBD ratio

Marijuana the herb is generally dried flowers

Hashish is a resin with higher THC levels and generally heated in a pipe or eaten

Hash oil is the most potent and can be smoked ingested or used topically

Marijuana

29

Joint marijuana rolled in paper

Fatty larger amount of marijuana

Doobie rolled with king size paper

Blunt Rolled with cigar wrapper and contains tobacco

Pipes (also known as bowls) are usually glass and rarely have a filter

Bongs contain water filter

Marijuana

30

Marijuana Legal Status

31

Marijuana Effects

Acute Intoxication

bull Improved mood increased well-being calmness relaxation

and sociability

bull Increased self-confidence magical thinking distorted

perception of time and space increased sensory perception

bull Tachycardia palpitations vasodilation conjunctival

irritation dry mouth increased appetite

bull Anxiety panic confusion hallucinations paranoia

psychosis

Withdrawal

bull Anxiety depression mood changes GI distress decreased

appetite insomnia irritability

32

First Illicit Drug Used

Figure from SAMHSA

33

Marijuana

34

ldquoIt bothers me that people are so stupid as to use

this stuffrdquo ndash John W Huffman developer

Sprayed on dried plant material or inhaled in

vaporizer

Marketed as ldquonot for human consumptionrdquo and were

sold legally under hundreds of brands most notably

K2 and Spice

Synthetic Cannabinoids

35

False belief that these are ldquonaturalrdquo and thus harmless

They are also not detected in routine drug screens

Acute effects are very unpredictable and generally

less pleasant than natural cannabis

Psychotic symptoms include extreme anxiety

confusion paranoia and hallucinations

Synthetic Cannabinoids

36

Mike is a 23 year old who presents

to the ER with paranoia

He reports holding a loaded gun

and pointing it at people outside of his

window thinking they were all trying

to kill him

He previously used meth heavily but has recently cut down

His last use was 3 days ago

Clinical Presentation

37

Janice is a 36 year old female who presented to the ER seeking

help with methamphetamine addiction

She appears older than stated age and is very thin

She has several missing teeth and otherwise poor

dentition

Her skin has multiple lesions

ldquoWhen I first starting smoking ice it felt so good Now it no longer feels like that

I do not even get much pleasure out of it any more I do not get pleasure out

of anything anymore I have no desire to see family or friends or do the things

I used to love I wish I could have fun like I used tordquo

Clinical Presentation

38

Crystal Ice Glass

Leads to an acute increase in synaptic dopamine concentration through various mechanisms

Can be prescribed as Desoxyn for

ADHD

Prominent in the western region of US and made famous by Breaking Bad

television series

Many accidents and fires are associated

with ldquobackyardrdquo meth labs

Methamphetamine

39

Mental illness and co-morbid or co-occurring substance use disorder is common

Approximately 13 of all people with mental illness and 12 with severe mental illness also have a substance use disorder

Self medication hypothesis vs substance

induced disorder

Multi-modal parallel or integrated treatment approach is most effective

Dual Diagnosis

Data from SAMHSA

40

Toxicology Screening

Urine most common method given cost and ease of collection Problem adulteration and substitution

bull On-site rapid testing

bull Immunoassay (initial lab screen)

bull GCMS

Blood better for quantitative analysis detection of acute intoxication Problem invasive detection for shorter periods than urine

Saliva Non-invasive lower potential for adulteration than urine Problem higher detection threshold and greater cost

Sweat Can identify substances over longer period of time Problem difficult to collect and quantify

Hair Easy to collect less likelihood of adulteration provides qualitative account of history of ingestion Problem poor at detecting acute intoxication more labor-intensive to process

41

Screening for drugs in healthy individuals

with no prior suspicion

bull Workplace or athletic testing

Testing for drugs in ill persons with a prior suspicion of use

Monitoring for drugs as part of a pain management or treatment program

While reliable on-site urine drug testing offers preliminary results When making treatment altering decisions urine should always be sent for confirmatory testing

Urine Testing

42

Urine Detection Limits

Alcohol 6 - 12 hours

EtG (ethylglucuronide) 4 days

Amphetaminesmeth 2 - 3 days

Benzos (short-acting) 3 days

Cocaine 3 - 4 days

Morphine 2 days

Marijuana (THC) 3 - 30+ days

Methadone 2 - 4 days

Buprenorphine 2 - 4 days

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

Adapted from Helander et al 2009 Moeller et al 2008

NIDA Neurobio of Addiction (2016 In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

43

Urine Drug Testing Stimulants

Amphetamine Methamphetamine

bull False positives pseudoephedrine bupropion labetolol ranitidine trazodone TCAs

bull Low sensitivity for detection of MDMA

bull 2 methamphetamine isomers d (CNS) and l (peripheral)

Cocaine

bull Primary metabolite benzoyleconine

bull False positives rare (coca leaf tea adulterated natural products)

Opiates

bull Tests for morphine-based substances

bull Unreliable for synthetic opioids like oxycodone

44

Summary

Alcohol use disorder is a common and deadly illness

with significant comorbidities

Alcohol withdrawal management does not treat AUD

It is important to understand key concepts in other

drug use disorders

Urine drug testing is an important piece to clinical

decision making

45

References

Disease ImCenters for Disease Control and Prevention (CDC) Alcohol-Related pact (ARDI) Atlanta GA CDC

Epidemiology of DSM-5 Alcohol Use Disorder Results From the National Epidemiologic Survey on Alcohol and Related Conditions III Grant BF1 Goldstein RB1 Saha TD1 Chou SP1 Jung J1 Zhang H1 Pickering RP1 Ruan WJ1 Smith SM1 Huang B1 Hasin DS2

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment Levounis Zerbo and Aggarwal Eds

Stahre M Roeber J Kanny D Brewer RD Zhang X Contribution of excessive alcohol consumption to deaths and years of potential life lost in the United States Prev Chronic Dis 201411130293

8

12 oz regular beer (5 alcohol)

bull Light beer contains slightly less alcohol (42)

bull Malt beverages contain approximately 7 alcohol

5 oz of table wine (12 alcohol)

15 oz of 80 proof spirits (40 alcohol)

Remember 60 as an easy way to figure out drink size and percent

Standard Drinks

9

Letrsquos Review Measures

1 cup = 8 oz = 53 drinks

1 pint = 2 cups = 16 oz = 106 drinks

1 quart = 2 pints = 32 oz = 213 drinks

1 gallon = 4 quarts = 128 oz = 853 drinks

The above assumes 80 proof spirits

10

Nip = common airplane bottle = 50 ml = 17 oz =

slightly more than 1 standard drink

Fifth = fifth of a gallon = 750 ml = 254 oz = 17

standard drinks

Handle = approximately half gallon = 175 L = 59 oz

= 393 standard drinks

Some Other Terms

11

Binge drinking = 4 drinks in one sitting for women or 5 for men on at least 1 day in the past month

Heavy alcohol use = binge drinking 5 or more days in the past month

Low risk drinking

bull Women no more than 3 drinks in one sitting or 7 in a week

bull Men no more than 4 drinks on a single day or 14 in a week

More Definitions

Definitions from National Institute on Alcohol Abuse and Alcoholism

12

Screening for Alcohol Use Disorder

Screen for risky drinking (gt3 drinks in one sitting or gt7

drinks in one week for women and gt4 drinks in one sitting or

gt14 drinks in one week for men) [criteria previous slide]

CAGE (Cut down Annoyed Guilty Eye opener)

AUDIT-C (Alcohol Use Disorders Identification Test)

bull How often did you have a drink containing alcohol in the

past year

bull How often did you have six or more drinks on one occasion

in the past year

13

Legal Intoxication vs Clinical Intoxication

Impact on BAL

14

On average one standard drink is metabolized per hour (002)

Hence a BAL of 030 will take approximately 15 hours to metabolize to zero

People with tolerance start to develop withdrawal approximately 6 hours from last drink hence the E in CAGE

Withdrawal will develop long before the BAL reaches 0

Alcohol Metabolism

15

16

Alcohol withdrawal

bull For most it is not

complicated

bull For some it is deadly

bull We must stratify risk

and triage appropriately

Risk Stratification

17

Risk Stratification

18

Detox is not treatment

Alcohol withdrawal is an

acute complication of a

chronic medical condition

Treating the acute

complication does not treat

the underlying condition

Most Importantly

19

Be aware of standard drink sizes and common terms

Understand the impact on BAL and clinical vs legal

intoxication

Routinely screen all patients for alcohol use disorders

Be able to identify alcohol withdrawal symptoms and

basic treatment strategies

Remember that Detox is not treatment

Alcohol Summary

20

Tom is a 61 year old man with an alcohol

use disorder

He was sober and in recovery from

36 ndash 60 years of age

At 60 he was prescribed Xanax for

anxiety

ldquoI did not even know what they gave me As soon as I took it I had a powerful urge to drink alcohol It was as if I had never stopped drinkingrdquo

He relapsed on alcohol and over the past year has struggled

He is now presenting for treatment of alcohol use disorder

Clinical Presentation

21

Alprazolam (Xanax) diazepam (Valium)

lorazepam (Ativan) clonazepam

(Klonopin) chlordiazepoxide (Librium)

and temazepam (Restoril) are the most

common

Indicated and useful for anxiety and

insomnia if properly monitored though

not considered first line for either

Pharmacologic overlap with alcohol

Benzodiazepines

22

Benzodiazepines (continued)

Do not fly the plane unless you know how to land

ldquoBarsrdquo = Xanax 2 mg

Can cause overdose death when mixed with opioids or alcohol

Often mixed with alcohol to magnify the high

Withdrawal can be protracted and dangerous

Common cause of falls and delirium in elderly

23

ldquoWhen I start to run out I begin crawling

around on the carpet looking for any

little bit I can find

Then I look around and think every car

car outside is the police and they

are after me

Then I look in the mirror my eyes are bloodshot and my heart is racing I feel awful and paranoid

Then I say to myself that I will NEVER do this again

Then I do it again the next dayrdquo

Clinical Presentation

24

Dopamine reuptake inhibitor

Leads to supraphysiologic dopamine release

Crack is mixed with a base smoked and is

highly addictive

Was widely used recreationally prior to 1914

including mixed with alcohol (Vin Mariani)

Snorting 146 minutes to peak

Injecting 31 minutes to peak

Smoking 14 minutes to peak

Cocaine

25

ldquoWoe to you my princess when I come I will

kiss you quite red and feed you til you are

plump And if you are forward you shall

see who is the stronger a gentle little girl

who doesnrsquot eat enough or a big wild man

who has cocaine in his body In my last

depression I took coca again and a small

dose lifted me to the heights in a wonderful

fashion I am just now busy collecting

literature for a song of praise to this magical

substancerdquo

Cocaine

26

Acute

bull Pleasure alertness energy sexuality tachycardia hallucinations paranoia hypertension

Crash

bull Peaks 2-4 days but up to a week of prolonged dysthymia hypersomnolence irritability suicidality cravings

Chronic

bull Profound anhedonia and other long term consequences dependent on route of admin

Cocaine

27

Chris is a 40-year old male who presents

to clinic seeking help with anxiety He reports

chronic anxiety with worry and ruminations

He also reports occasional panic attacks

He has tried SSRIs in the past with minimal

improvement He is currently smoking

marijuana daily and states that it is the only

thing that helps

He is willing to try a new medication but unwilling to stop smoking marijuana

Clinical Presentation

28

ldquoMarijuanardquo is the term for the plant Cannabis

THC = Tetrahydrocannabinol = psychoactive

CBD = Cannabidiol = sedating not psychoactive

Sativa and Indica differ in THCCBD ratio

Marijuana the herb is generally dried flowers

Hashish is a resin with higher THC levels and generally heated in a pipe or eaten

Hash oil is the most potent and can be smoked ingested or used topically

Marijuana

29

Joint marijuana rolled in paper

Fatty larger amount of marijuana

Doobie rolled with king size paper

Blunt Rolled with cigar wrapper and contains tobacco

Pipes (also known as bowls) are usually glass and rarely have a filter

Bongs contain water filter

Marijuana

30

Marijuana Legal Status

31

Marijuana Effects

Acute Intoxication

bull Improved mood increased well-being calmness relaxation

and sociability

bull Increased self-confidence magical thinking distorted

perception of time and space increased sensory perception

bull Tachycardia palpitations vasodilation conjunctival

irritation dry mouth increased appetite

bull Anxiety panic confusion hallucinations paranoia

psychosis

Withdrawal

bull Anxiety depression mood changes GI distress decreased

appetite insomnia irritability

32

First Illicit Drug Used

Figure from SAMHSA

33

Marijuana

34

ldquoIt bothers me that people are so stupid as to use

this stuffrdquo ndash John W Huffman developer

Sprayed on dried plant material or inhaled in

vaporizer

Marketed as ldquonot for human consumptionrdquo and were

sold legally under hundreds of brands most notably

K2 and Spice

Synthetic Cannabinoids

35

False belief that these are ldquonaturalrdquo and thus harmless

They are also not detected in routine drug screens

Acute effects are very unpredictable and generally

less pleasant than natural cannabis

Psychotic symptoms include extreme anxiety

confusion paranoia and hallucinations

Synthetic Cannabinoids

36

Mike is a 23 year old who presents

to the ER with paranoia

He reports holding a loaded gun

and pointing it at people outside of his

window thinking they were all trying

to kill him

He previously used meth heavily but has recently cut down

His last use was 3 days ago

Clinical Presentation

37

Janice is a 36 year old female who presented to the ER seeking

help with methamphetamine addiction

She appears older than stated age and is very thin

She has several missing teeth and otherwise poor

dentition

Her skin has multiple lesions

ldquoWhen I first starting smoking ice it felt so good Now it no longer feels like that

I do not even get much pleasure out of it any more I do not get pleasure out

of anything anymore I have no desire to see family or friends or do the things

I used to love I wish I could have fun like I used tordquo

Clinical Presentation

38

Crystal Ice Glass

Leads to an acute increase in synaptic dopamine concentration through various mechanisms

Can be prescribed as Desoxyn for

ADHD

Prominent in the western region of US and made famous by Breaking Bad

television series

Many accidents and fires are associated

with ldquobackyardrdquo meth labs

Methamphetamine

39

Mental illness and co-morbid or co-occurring substance use disorder is common

Approximately 13 of all people with mental illness and 12 with severe mental illness also have a substance use disorder

Self medication hypothesis vs substance

induced disorder

Multi-modal parallel or integrated treatment approach is most effective

Dual Diagnosis

Data from SAMHSA

40

Toxicology Screening

Urine most common method given cost and ease of collection Problem adulteration and substitution

bull On-site rapid testing

bull Immunoassay (initial lab screen)

bull GCMS

Blood better for quantitative analysis detection of acute intoxication Problem invasive detection for shorter periods than urine

Saliva Non-invasive lower potential for adulteration than urine Problem higher detection threshold and greater cost

Sweat Can identify substances over longer period of time Problem difficult to collect and quantify

Hair Easy to collect less likelihood of adulteration provides qualitative account of history of ingestion Problem poor at detecting acute intoxication more labor-intensive to process

41

Screening for drugs in healthy individuals

with no prior suspicion

bull Workplace or athletic testing

Testing for drugs in ill persons with a prior suspicion of use

Monitoring for drugs as part of a pain management or treatment program

While reliable on-site urine drug testing offers preliminary results When making treatment altering decisions urine should always be sent for confirmatory testing

Urine Testing

42

Urine Detection Limits

Alcohol 6 - 12 hours

EtG (ethylglucuronide) 4 days

Amphetaminesmeth 2 - 3 days

Benzos (short-acting) 3 days

Cocaine 3 - 4 days

Morphine 2 days

Marijuana (THC) 3 - 30+ days

Methadone 2 - 4 days

Buprenorphine 2 - 4 days

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

Adapted from Helander et al 2009 Moeller et al 2008

NIDA Neurobio of Addiction (2016 In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

43

Urine Drug Testing Stimulants

Amphetamine Methamphetamine

bull False positives pseudoephedrine bupropion labetolol ranitidine trazodone TCAs

bull Low sensitivity for detection of MDMA

bull 2 methamphetamine isomers d (CNS) and l (peripheral)

Cocaine

bull Primary metabolite benzoyleconine

bull False positives rare (coca leaf tea adulterated natural products)

Opiates

bull Tests for morphine-based substances

bull Unreliable for synthetic opioids like oxycodone

44

Summary

Alcohol use disorder is a common and deadly illness

with significant comorbidities

Alcohol withdrawal management does not treat AUD

It is important to understand key concepts in other

drug use disorders

Urine drug testing is an important piece to clinical

decision making

45

References

Disease ImCenters for Disease Control and Prevention (CDC) Alcohol-Related pact (ARDI) Atlanta GA CDC

Epidemiology of DSM-5 Alcohol Use Disorder Results From the National Epidemiologic Survey on Alcohol and Related Conditions III Grant BF1 Goldstein RB1 Saha TD1 Chou SP1 Jung J1 Zhang H1 Pickering RP1 Ruan WJ1 Smith SM1 Huang B1 Hasin DS2

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment Levounis Zerbo and Aggarwal Eds

Stahre M Roeber J Kanny D Brewer RD Zhang X Contribution of excessive alcohol consumption to deaths and years of potential life lost in the United States Prev Chronic Dis 201411130293

9

Letrsquos Review Measures

1 cup = 8 oz = 53 drinks

1 pint = 2 cups = 16 oz = 106 drinks

1 quart = 2 pints = 32 oz = 213 drinks

1 gallon = 4 quarts = 128 oz = 853 drinks

The above assumes 80 proof spirits

10

Nip = common airplane bottle = 50 ml = 17 oz =

slightly more than 1 standard drink

Fifth = fifth of a gallon = 750 ml = 254 oz = 17

standard drinks

Handle = approximately half gallon = 175 L = 59 oz

= 393 standard drinks

Some Other Terms

11

Binge drinking = 4 drinks in one sitting for women or 5 for men on at least 1 day in the past month

Heavy alcohol use = binge drinking 5 or more days in the past month

Low risk drinking

bull Women no more than 3 drinks in one sitting or 7 in a week

bull Men no more than 4 drinks on a single day or 14 in a week

More Definitions

Definitions from National Institute on Alcohol Abuse and Alcoholism

12

Screening for Alcohol Use Disorder

Screen for risky drinking (gt3 drinks in one sitting or gt7

drinks in one week for women and gt4 drinks in one sitting or

gt14 drinks in one week for men) [criteria previous slide]

CAGE (Cut down Annoyed Guilty Eye opener)

AUDIT-C (Alcohol Use Disorders Identification Test)

bull How often did you have a drink containing alcohol in the

past year

bull How often did you have six or more drinks on one occasion

in the past year

13

Legal Intoxication vs Clinical Intoxication

Impact on BAL

14

On average one standard drink is metabolized per hour (002)

Hence a BAL of 030 will take approximately 15 hours to metabolize to zero

People with tolerance start to develop withdrawal approximately 6 hours from last drink hence the E in CAGE

Withdrawal will develop long before the BAL reaches 0

Alcohol Metabolism

15

16

Alcohol withdrawal

bull For most it is not

complicated

bull For some it is deadly

bull We must stratify risk

and triage appropriately

Risk Stratification

17

Risk Stratification

18

Detox is not treatment

Alcohol withdrawal is an

acute complication of a

chronic medical condition

Treating the acute

complication does not treat

the underlying condition

Most Importantly

19

Be aware of standard drink sizes and common terms

Understand the impact on BAL and clinical vs legal

intoxication

Routinely screen all patients for alcohol use disorders

Be able to identify alcohol withdrawal symptoms and

basic treatment strategies

Remember that Detox is not treatment

Alcohol Summary

20

Tom is a 61 year old man with an alcohol

use disorder

He was sober and in recovery from

36 ndash 60 years of age

At 60 he was prescribed Xanax for

anxiety

ldquoI did not even know what they gave me As soon as I took it I had a powerful urge to drink alcohol It was as if I had never stopped drinkingrdquo

He relapsed on alcohol and over the past year has struggled

He is now presenting for treatment of alcohol use disorder

Clinical Presentation

21

Alprazolam (Xanax) diazepam (Valium)

lorazepam (Ativan) clonazepam

(Klonopin) chlordiazepoxide (Librium)

and temazepam (Restoril) are the most

common

Indicated and useful for anxiety and

insomnia if properly monitored though

not considered first line for either

Pharmacologic overlap with alcohol

Benzodiazepines

22

Benzodiazepines (continued)

Do not fly the plane unless you know how to land

ldquoBarsrdquo = Xanax 2 mg

Can cause overdose death when mixed with opioids or alcohol

Often mixed with alcohol to magnify the high

Withdrawal can be protracted and dangerous

Common cause of falls and delirium in elderly

23

ldquoWhen I start to run out I begin crawling

around on the carpet looking for any

little bit I can find

Then I look around and think every car

car outside is the police and they

are after me

Then I look in the mirror my eyes are bloodshot and my heart is racing I feel awful and paranoid

Then I say to myself that I will NEVER do this again

Then I do it again the next dayrdquo

Clinical Presentation

24

Dopamine reuptake inhibitor

Leads to supraphysiologic dopamine release

Crack is mixed with a base smoked and is

highly addictive

Was widely used recreationally prior to 1914

including mixed with alcohol (Vin Mariani)

Snorting 146 minutes to peak

Injecting 31 minutes to peak

Smoking 14 minutes to peak

Cocaine

25

ldquoWoe to you my princess when I come I will

kiss you quite red and feed you til you are

plump And if you are forward you shall

see who is the stronger a gentle little girl

who doesnrsquot eat enough or a big wild man

who has cocaine in his body In my last

depression I took coca again and a small

dose lifted me to the heights in a wonderful

fashion I am just now busy collecting

literature for a song of praise to this magical

substancerdquo

Cocaine

26

Acute

bull Pleasure alertness energy sexuality tachycardia hallucinations paranoia hypertension

Crash

bull Peaks 2-4 days but up to a week of prolonged dysthymia hypersomnolence irritability suicidality cravings

Chronic

bull Profound anhedonia and other long term consequences dependent on route of admin

Cocaine

27

Chris is a 40-year old male who presents

to clinic seeking help with anxiety He reports

chronic anxiety with worry and ruminations

He also reports occasional panic attacks

He has tried SSRIs in the past with minimal

improvement He is currently smoking

marijuana daily and states that it is the only

thing that helps

He is willing to try a new medication but unwilling to stop smoking marijuana

Clinical Presentation

28

ldquoMarijuanardquo is the term for the plant Cannabis

THC = Tetrahydrocannabinol = psychoactive

CBD = Cannabidiol = sedating not psychoactive

Sativa and Indica differ in THCCBD ratio

Marijuana the herb is generally dried flowers

Hashish is a resin with higher THC levels and generally heated in a pipe or eaten

Hash oil is the most potent and can be smoked ingested or used topically

Marijuana

29

Joint marijuana rolled in paper

Fatty larger amount of marijuana

Doobie rolled with king size paper

Blunt Rolled with cigar wrapper and contains tobacco

Pipes (also known as bowls) are usually glass and rarely have a filter

Bongs contain water filter

Marijuana

30

Marijuana Legal Status

31

Marijuana Effects

Acute Intoxication

bull Improved mood increased well-being calmness relaxation

and sociability

bull Increased self-confidence magical thinking distorted

perception of time and space increased sensory perception

bull Tachycardia palpitations vasodilation conjunctival

irritation dry mouth increased appetite

bull Anxiety panic confusion hallucinations paranoia

psychosis

Withdrawal

bull Anxiety depression mood changes GI distress decreased

appetite insomnia irritability

32

First Illicit Drug Used

Figure from SAMHSA

33

Marijuana

34

ldquoIt bothers me that people are so stupid as to use

this stuffrdquo ndash John W Huffman developer

Sprayed on dried plant material or inhaled in

vaporizer

Marketed as ldquonot for human consumptionrdquo and were

sold legally under hundreds of brands most notably

K2 and Spice

Synthetic Cannabinoids

35

False belief that these are ldquonaturalrdquo and thus harmless

They are also not detected in routine drug screens

Acute effects are very unpredictable and generally

less pleasant than natural cannabis

Psychotic symptoms include extreme anxiety

confusion paranoia and hallucinations

Synthetic Cannabinoids

36

Mike is a 23 year old who presents

to the ER with paranoia

He reports holding a loaded gun

and pointing it at people outside of his

window thinking they were all trying

to kill him

He previously used meth heavily but has recently cut down

His last use was 3 days ago

Clinical Presentation

37

Janice is a 36 year old female who presented to the ER seeking

help with methamphetamine addiction

She appears older than stated age and is very thin

She has several missing teeth and otherwise poor

dentition

Her skin has multiple lesions

ldquoWhen I first starting smoking ice it felt so good Now it no longer feels like that

I do not even get much pleasure out of it any more I do not get pleasure out

of anything anymore I have no desire to see family or friends or do the things

I used to love I wish I could have fun like I used tordquo

Clinical Presentation

38

Crystal Ice Glass

Leads to an acute increase in synaptic dopamine concentration through various mechanisms

Can be prescribed as Desoxyn for

ADHD

Prominent in the western region of US and made famous by Breaking Bad

television series

Many accidents and fires are associated

with ldquobackyardrdquo meth labs

Methamphetamine

39

Mental illness and co-morbid or co-occurring substance use disorder is common

Approximately 13 of all people with mental illness and 12 with severe mental illness also have a substance use disorder

Self medication hypothesis vs substance

induced disorder

Multi-modal parallel or integrated treatment approach is most effective

Dual Diagnosis

Data from SAMHSA

40

Toxicology Screening

Urine most common method given cost and ease of collection Problem adulteration and substitution

bull On-site rapid testing

bull Immunoassay (initial lab screen)

bull GCMS

Blood better for quantitative analysis detection of acute intoxication Problem invasive detection for shorter periods than urine

Saliva Non-invasive lower potential for adulteration than urine Problem higher detection threshold and greater cost

Sweat Can identify substances over longer period of time Problem difficult to collect and quantify

Hair Easy to collect less likelihood of adulteration provides qualitative account of history of ingestion Problem poor at detecting acute intoxication more labor-intensive to process

41

Screening for drugs in healthy individuals

with no prior suspicion

bull Workplace or athletic testing

Testing for drugs in ill persons with a prior suspicion of use

Monitoring for drugs as part of a pain management or treatment program

While reliable on-site urine drug testing offers preliminary results When making treatment altering decisions urine should always be sent for confirmatory testing

Urine Testing

42

Urine Detection Limits

Alcohol 6 - 12 hours

EtG (ethylglucuronide) 4 days

Amphetaminesmeth 2 - 3 days

Benzos (short-acting) 3 days

Cocaine 3 - 4 days

Morphine 2 days

Marijuana (THC) 3 - 30+ days

Methadone 2 - 4 days

Buprenorphine 2 - 4 days

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

Adapted from Helander et al 2009 Moeller et al 2008

NIDA Neurobio of Addiction (2016 In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

43

Urine Drug Testing Stimulants

Amphetamine Methamphetamine

bull False positives pseudoephedrine bupropion labetolol ranitidine trazodone TCAs

bull Low sensitivity for detection of MDMA

bull 2 methamphetamine isomers d (CNS) and l (peripheral)

Cocaine

bull Primary metabolite benzoyleconine

bull False positives rare (coca leaf tea adulterated natural products)

Opiates

bull Tests for morphine-based substances

bull Unreliable for synthetic opioids like oxycodone

44

Summary

Alcohol use disorder is a common and deadly illness

with significant comorbidities

Alcohol withdrawal management does not treat AUD

It is important to understand key concepts in other

drug use disorders

Urine drug testing is an important piece to clinical

decision making

45

References

Disease ImCenters for Disease Control and Prevention (CDC) Alcohol-Related pact (ARDI) Atlanta GA CDC

Epidemiology of DSM-5 Alcohol Use Disorder Results From the National Epidemiologic Survey on Alcohol and Related Conditions III Grant BF1 Goldstein RB1 Saha TD1 Chou SP1 Jung J1 Zhang H1 Pickering RP1 Ruan WJ1 Smith SM1 Huang B1 Hasin DS2

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment Levounis Zerbo and Aggarwal Eds

Stahre M Roeber J Kanny D Brewer RD Zhang X Contribution of excessive alcohol consumption to deaths and years of potential life lost in the United States Prev Chronic Dis 201411130293

10

Nip = common airplane bottle = 50 ml = 17 oz =

slightly more than 1 standard drink

Fifth = fifth of a gallon = 750 ml = 254 oz = 17

standard drinks

Handle = approximately half gallon = 175 L = 59 oz

= 393 standard drinks

Some Other Terms

11

Binge drinking = 4 drinks in one sitting for women or 5 for men on at least 1 day in the past month

Heavy alcohol use = binge drinking 5 or more days in the past month

Low risk drinking

bull Women no more than 3 drinks in one sitting or 7 in a week

bull Men no more than 4 drinks on a single day or 14 in a week

More Definitions

Definitions from National Institute on Alcohol Abuse and Alcoholism

12

Screening for Alcohol Use Disorder

Screen for risky drinking (gt3 drinks in one sitting or gt7

drinks in one week for women and gt4 drinks in one sitting or

gt14 drinks in one week for men) [criteria previous slide]

CAGE (Cut down Annoyed Guilty Eye opener)

AUDIT-C (Alcohol Use Disorders Identification Test)

bull How often did you have a drink containing alcohol in the

past year

bull How often did you have six or more drinks on one occasion

in the past year

13

Legal Intoxication vs Clinical Intoxication

Impact on BAL

14

On average one standard drink is metabolized per hour (002)

Hence a BAL of 030 will take approximately 15 hours to metabolize to zero

People with tolerance start to develop withdrawal approximately 6 hours from last drink hence the E in CAGE

Withdrawal will develop long before the BAL reaches 0

Alcohol Metabolism

15

16

Alcohol withdrawal

bull For most it is not

complicated

bull For some it is deadly

bull We must stratify risk

and triage appropriately

Risk Stratification

17

Risk Stratification

18

Detox is not treatment

Alcohol withdrawal is an

acute complication of a

chronic medical condition

Treating the acute

complication does not treat

the underlying condition

Most Importantly

19

Be aware of standard drink sizes and common terms

Understand the impact on BAL and clinical vs legal

intoxication

Routinely screen all patients for alcohol use disorders

Be able to identify alcohol withdrawal symptoms and

basic treatment strategies

Remember that Detox is not treatment

Alcohol Summary

20

Tom is a 61 year old man with an alcohol

use disorder

He was sober and in recovery from

36 ndash 60 years of age

At 60 he was prescribed Xanax for

anxiety

ldquoI did not even know what they gave me As soon as I took it I had a powerful urge to drink alcohol It was as if I had never stopped drinkingrdquo

He relapsed on alcohol and over the past year has struggled

He is now presenting for treatment of alcohol use disorder

Clinical Presentation

21

Alprazolam (Xanax) diazepam (Valium)

lorazepam (Ativan) clonazepam

(Klonopin) chlordiazepoxide (Librium)

and temazepam (Restoril) are the most

common

Indicated and useful for anxiety and

insomnia if properly monitored though

not considered first line for either

Pharmacologic overlap with alcohol

Benzodiazepines

22

Benzodiazepines (continued)

Do not fly the plane unless you know how to land

ldquoBarsrdquo = Xanax 2 mg

Can cause overdose death when mixed with opioids or alcohol

Often mixed with alcohol to magnify the high

Withdrawal can be protracted and dangerous

Common cause of falls and delirium in elderly

23

ldquoWhen I start to run out I begin crawling

around on the carpet looking for any

little bit I can find

Then I look around and think every car

car outside is the police and they

are after me

Then I look in the mirror my eyes are bloodshot and my heart is racing I feel awful and paranoid

Then I say to myself that I will NEVER do this again

Then I do it again the next dayrdquo

Clinical Presentation

24

Dopamine reuptake inhibitor

Leads to supraphysiologic dopamine release

Crack is mixed with a base smoked and is

highly addictive

Was widely used recreationally prior to 1914

including mixed with alcohol (Vin Mariani)

Snorting 146 minutes to peak

Injecting 31 minutes to peak

Smoking 14 minutes to peak

Cocaine

25

ldquoWoe to you my princess when I come I will

kiss you quite red and feed you til you are

plump And if you are forward you shall

see who is the stronger a gentle little girl

who doesnrsquot eat enough or a big wild man

who has cocaine in his body In my last

depression I took coca again and a small

dose lifted me to the heights in a wonderful

fashion I am just now busy collecting

literature for a song of praise to this magical

substancerdquo

Cocaine

26

Acute

bull Pleasure alertness energy sexuality tachycardia hallucinations paranoia hypertension

Crash

bull Peaks 2-4 days but up to a week of prolonged dysthymia hypersomnolence irritability suicidality cravings

Chronic

bull Profound anhedonia and other long term consequences dependent on route of admin

Cocaine

27

Chris is a 40-year old male who presents

to clinic seeking help with anxiety He reports

chronic anxiety with worry and ruminations

He also reports occasional panic attacks

He has tried SSRIs in the past with minimal

improvement He is currently smoking

marijuana daily and states that it is the only

thing that helps

He is willing to try a new medication but unwilling to stop smoking marijuana

Clinical Presentation

28

ldquoMarijuanardquo is the term for the plant Cannabis

THC = Tetrahydrocannabinol = psychoactive

CBD = Cannabidiol = sedating not psychoactive

Sativa and Indica differ in THCCBD ratio

Marijuana the herb is generally dried flowers

Hashish is a resin with higher THC levels and generally heated in a pipe or eaten

Hash oil is the most potent and can be smoked ingested or used topically

Marijuana

29

Joint marijuana rolled in paper

Fatty larger amount of marijuana

Doobie rolled with king size paper

Blunt Rolled with cigar wrapper and contains tobacco

Pipes (also known as bowls) are usually glass and rarely have a filter

Bongs contain water filter

Marijuana

30

Marijuana Legal Status

31

Marijuana Effects

Acute Intoxication

bull Improved mood increased well-being calmness relaxation

and sociability

bull Increased self-confidence magical thinking distorted

perception of time and space increased sensory perception

bull Tachycardia palpitations vasodilation conjunctival

irritation dry mouth increased appetite

bull Anxiety panic confusion hallucinations paranoia

psychosis

Withdrawal

bull Anxiety depression mood changes GI distress decreased

appetite insomnia irritability

32

First Illicit Drug Used

Figure from SAMHSA

33

Marijuana

34

ldquoIt bothers me that people are so stupid as to use

this stuffrdquo ndash John W Huffman developer

Sprayed on dried plant material or inhaled in

vaporizer

Marketed as ldquonot for human consumptionrdquo and were

sold legally under hundreds of brands most notably

K2 and Spice

Synthetic Cannabinoids

35

False belief that these are ldquonaturalrdquo and thus harmless

They are also not detected in routine drug screens

Acute effects are very unpredictable and generally

less pleasant than natural cannabis

Psychotic symptoms include extreme anxiety

confusion paranoia and hallucinations

Synthetic Cannabinoids

36

Mike is a 23 year old who presents

to the ER with paranoia

He reports holding a loaded gun

and pointing it at people outside of his

window thinking they were all trying

to kill him

He previously used meth heavily but has recently cut down

His last use was 3 days ago

Clinical Presentation

37

Janice is a 36 year old female who presented to the ER seeking

help with methamphetamine addiction

She appears older than stated age and is very thin

She has several missing teeth and otherwise poor

dentition

Her skin has multiple lesions

ldquoWhen I first starting smoking ice it felt so good Now it no longer feels like that

I do not even get much pleasure out of it any more I do not get pleasure out

of anything anymore I have no desire to see family or friends or do the things

I used to love I wish I could have fun like I used tordquo

Clinical Presentation

38

Crystal Ice Glass

Leads to an acute increase in synaptic dopamine concentration through various mechanisms

Can be prescribed as Desoxyn for

ADHD

Prominent in the western region of US and made famous by Breaking Bad

television series

Many accidents and fires are associated

with ldquobackyardrdquo meth labs

Methamphetamine

39

Mental illness and co-morbid or co-occurring substance use disorder is common

Approximately 13 of all people with mental illness and 12 with severe mental illness also have a substance use disorder

Self medication hypothesis vs substance

induced disorder

Multi-modal parallel or integrated treatment approach is most effective

Dual Diagnosis

Data from SAMHSA

40

Toxicology Screening

Urine most common method given cost and ease of collection Problem adulteration and substitution

bull On-site rapid testing

bull Immunoassay (initial lab screen)

bull GCMS

Blood better for quantitative analysis detection of acute intoxication Problem invasive detection for shorter periods than urine

Saliva Non-invasive lower potential for adulteration than urine Problem higher detection threshold and greater cost

Sweat Can identify substances over longer period of time Problem difficult to collect and quantify

Hair Easy to collect less likelihood of adulteration provides qualitative account of history of ingestion Problem poor at detecting acute intoxication more labor-intensive to process

41

Screening for drugs in healthy individuals

with no prior suspicion

bull Workplace or athletic testing

Testing for drugs in ill persons with a prior suspicion of use

Monitoring for drugs as part of a pain management or treatment program

While reliable on-site urine drug testing offers preliminary results When making treatment altering decisions urine should always be sent for confirmatory testing

Urine Testing

42

Urine Detection Limits

Alcohol 6 - 12 hours

EtG (ethylglucuronide) 4 days

Amphetaminesmeth 2 - 3 days

Benzos (short-acting) 3 days

Cocaine 3 - 4 days

Morphine 2 days

Marijuana (THC) 3 - 30+ days

Methadone 2 - 4 days

Buprenorphine 2 - 4 days

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

Adapted from Helander et al 2009 Moeller et al 2008

NIDA Neurobio of Addiction (2016 In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

43

Urine Drug Testing Stimulants

Amphetamine Methamphetamine

bull False positives pseudoephedrine bupropion labetolol ranitidine trazodone TCAs

bull Low sensitivity for detection of MDMA

bull 2 methamphetamine isomers d (CNS) and l (peripheral)

Cocaine

bull Primary metabolite benzoyleconine

bull False positives rare (coca leaf tea adulterated natural products)

Opiates

bull Tests for morphine-based substances

bull Unreliable for synthetic opioids like oxycodone

44

Summary

Alcohol use disorder is a common and deadly illness

with significant comorbidities

Alcohol withdrawal management does not treat AUD

It is important to understand key concepts in other

drug use disorders

Urine drug testing is an important piece to clinical

decision making

45

References

Disease ImCenters for Disease Control and Prevention (CDC) Alcohol-Related pact (ARDI) Atlanta GA CDC

Epidemiology of DSM-5 Alcohol Use Disorder Results From the National Epidemiologic Survey on Alcohol and Related Conditions III Grant BF1 Goldstein RB1 Saha TD1 Chou SP1 Jung J1 Zhang H1 Pickering RP1 Ruan WJ1 Smith SM1 Huang B1 Hasin DS2

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment Levounis Zerbo and Aggarwal Eds

Stahre M Roeber J Kanny D Brewer RD Zhang X Contribution of excessive alcohol consumption to deaths and years of potential life lost in the United States Prev Chronic Dis 201411130293

11

Binge drinking = 4 drinks in one sitting for women or 5 for men on at least 1 day in the past month

Heavy alcohol use = binge drinking 5 or more days in the past month

Low risk drinking

bull Women no more than 3 drinks in one sitting or 7 in a week

bull Men no more than 4 drinks on a single day or 14 in a week

More Definitions

Definitions from National Institute on Alcohol Abuse and Alcoholism

12

Screening for Alcohol Use Disorder

Screen for risky drinking (gt3 drinks in one sitting or gt7

drinks in one week for women and gt4 drinks in one sitting or

gt14 drinks in one week for men) [criteria previous slide]

CAGE (Cut down Annoyed Guilty Eye opener)

AUDIT-C (Alcohol Use Disorders Identification Test)

bull How often did you have a drink containing alcohol in the

past year

bull How often did you have six or more drinks on one occasion

in the past year

13

Legal Intoxication vs Clinical Intoxication

Impact on BAL

14

On average one standard drink is metabolized per hour (002)

Hence a BAL of 030 will take approximately 15 hours to metabolize to zero

People with tolerance start to develop withdrawal approximately 6 hours from last drink hence the E in CAGE

Withdrawal will develop long before the BAL reaches 0

Alcohol Metabolism

15

16

Alcohol withdrawal

bull For most it is not

complicated

bull For some it is deadly

bull We must stratify risk

and triage appropriately

Risk Stratification

17

Risk Stratification

18

Detox is not treatment

Alcohol withdrawal is an

acute complication of a

chronic medical condition

Treating the acute

complication does not treat

the underlying condition

Most Importantly

19

Be aware of standard drink sizes and common terms

Understand the impact on BAL and clinical vs legal

intoxication

Routinely screen all patients for alcohol use disorders

Be able to identify alcohol withdrawal symptoms and

basic treatment strategies

Remember that Detox is not treatment

Alcohol Summary

20

Tom is a 61 year old man with an alcohol

use disorder

He was sober and in recovery from

36 ndash 60 years of age

At 60 he was prescribed Xanax for

anxiety

ldquoI did not even know what they gave me As soon as I took it I had a powerful urge to drink alcohol It was as if I had never stopped drinkingrdquo

He relapsed on alcohol and over the past year has struggled

He is now presenting for treatment of alcohol use disorder

Clinical Presentation

21

Alprazolam (Xanax) diazepam (Valium)

lorazepam (Ativan) clonazepam

(Klonopin) chlordiazepoxide (Librium)

and temazepam (Restoril) are the most

common

Indicated and useful for anxiety and

insomnia if properly monitored though

not considered first line for either

Pharmacologic overlap with alcohol

Benzodiazepines

22

Benzodiazepines (continued)

Do not fly the plane unless you know how to land

ldquoBarsrdquo = Xanax 2 mg

Can cause overdose death when mixed with opioids or alcohol

Often mixed with alcohol to magnify the high

Withdrawal can be protracted and dangerous

Common cause of falls and delirium in elderly

23

ldquoWhen I start to run out I begin crawling

around on the carpet looking for any

little bit I can find

Then I look around and think every car

car outside is the police and they

are after me

Then I look in the mirror my eyes are bloodshot and my heart is racing I feel awful and paranoid

Then I say to myself that I will NEVER do this again

Then I do it again the next dayrdquo

Clinical Presentation

24

Dopamine reuptake inhibitor

Leads to supraphysiologic dopamine release

Crack is mixed with a base smoked and is

highly addictive

Was widely used recreationally prior to 1914

including mixed with alcohol (Vin Mariani)

Snorting 146 minutes to peak

Injecting 31 minutes to peak

Smoking 14 minutes to peak

Cocaine

25

ldquoWoe to you my princess when I come I will

kiss you quite red and feed you til you are

plump And if you are forward you shall

see who is the stronger a gentle little girl

who doesnrsquot eat enough or a big wild man

who has cocaine in his body In my last

depression I took coca again and a small

dose lifted me to the heights in a wonderful

fashion I am just now busy collecting

literature for a song of praise to this magical

substancerdquo

Cocaine

26

Acute

bull Pleasure alertness energy sexuality tachycardia hallucinations paranoia hypertension

Crash

bull Peaks 2-4 days but up to a week of prolonged dysthymia hypersomnolence irritability suicidality cravings

Chronic

bull Profound anhedonia and other long term consequences dependent on route of admin

Cocaine

27

Chris is a 40-year old male who presents

to clinic seeking help with anxiety He reports

chronic anxiety with worry and ruminations

He also reports occasional panic attacks

He has tried SSRIs in the past with minimal

improvement He is currently smoking

marijuana daily and states that it is the only

thing that helps

He is willing to try a new medication but unwilling to stop smoking marijuana

Clinical Presentation

28

ldquoMarijuanardquo is the term for the plant Cannabis

THC = Tetrahydrocannabinol = psychoactive

CBD = Cannabidiol = sedating not psychoactive

Sativa and Indica differ in THCCBD ratio

Marijuana the herb is generally dried flowers

Hashish is a resin with higher THC levels and generally heated in a pipe or eaten

Hash oil is the most potent and can be smoked ingested or used topically

Marijuana

29

Joint marijuana rolled in paper

Fatty larger amount of marijuana

Doobie rolled with king size paper

Blunt Rolled with cigar wrapper and contains tobacco

Pipes (also known as bowls) are usually glass and rarely have a filter

Bongs contain water filter

Marijuana

30

Marijuana Legal Status

31

Marijuana Effects

Acute Intoxication

bull Improved mood increased well-being calmness relaxation

and sociability

bull Increased self-confidence magical thinking distorted

perception of time and space increased sensory perception

bull Tachycardia palpitations vasodilation conjunctival

irritation dry mouth increased appetite

bull Anxiety panic confusion hallucinations paranoia

psychosis

Withdrawal

bull Anxiety depression mood changes GI distress decreased

appetite insomnia irritability

32

First Illicit Drug Used

Figure from SAMHSA

33

Marijuana

34

ldquoIt bothers me that people are so stupid as to use

this stuffrdquo ndash John W Huffman developer

Sprayed on dried plant material or inhaled in

vaporizer

Marketed as ldquonot for human consumptionrdquo and were

sold legally under hundreds of brands most notably

K2 and Spice

Synthetic Cannabinoids

35

False belief that these are ldquonaturalrdquo and thus harmless

They are also not detected in routine drug screens

Acute effects are very unpredictable and generally

less pleasant than natural cannabis

Psychotic symptoms include extreme anxiety

confusion paranoia and hallucinations

Synthetic Cannabinoids

36

Mike is a 23 year old who presents

to the ER with paranoia

He reports holding a loaded gun

and pointing it at people outside of his

window thinking they were all trying

to kill him

He previously used meth heavily but has recently cut down

His last use was 3 days ago

Clinical Presentation

37

Janice is a 36 year old female who presented to the ER seeking

help with methamphetamine addiction

She appears older than stated age and is very thin

She has several missing teeth and otherwise poor

dentition

Her skin has multiple lesions

ldquoWhen I first starting smoking ice it felt so good Now it no longer feels like that

I do not even get much pleasure out of it any more I do not get pleasure out

of anything anymore I have no desire to see family or friends or do the things

I used to love I wish I could have fun like I used tordquo

Clinical Presentation

38

Crystal Ice Glass

Leads to an acute increase in synaptic dopamine concentration through various mechanisms

Can be prescribed as Desoxyn for

ADHD

Prominent in the western region of US and made famous by Breaking Bad

television series

Many accidents and fires are associated

with ldquobackyardrdquo meth labs

Methamphetamine

39

Mental illness and co-morbid or co-occurring substance use disorder is common

Approximately 13 of all people with mental illness and 12 with severe mental illness also have a substance use disorder

Self medication hypothesis vs substance

induced disorder

Multi-modal parallel or integrated treatment approach is most effective

Dual Diagnosis

Data from SAMHSA

40

Toxicology Screening

Urine most common method given cost and ease of collection Problem adulteration and substitution

bull On-site rapid testing

bull Immunoassay (initial lab screen)

bull GCMS

Blood better for quantitative analysis detection of acute intoxication Problem invasive detection for shorter periods than urine

Saliva Non-invasive lower potential for adulteration than urine Problem higher detection threshold and greater cost

Sweat Can identify substances over longer period of time Problem difficult to collect and quantify

Hair Easy to collect less likelihood of adulteration provides qualitative account of history of ingestion Problem poor at detecting acute intoxication more labor-intensive to process

41

Screening for drugs in healthy individuals

with no prior suspicion

bull Workplace or athletic testing

Testing for drugs in ill persons with a prior suspicion of use

Monitoring for drugs as part of a pain management or treatment program

While reliable on-site urine drug testing offers preliminary results When making treatment altering decisions urine should always be sent for confirmatory testing

Urine Testing

42

Urine Detection Limits

Alcohol 6 - 12 hours

EtG (ethylglucuronide) 4 days

Amphetaminesmeth 2 - 3 days

Benzos (short-acting) 3 days

Cocaine 3 - 4 days

Morphine 2 days

Marijuana (THC) 3 - 30+ days

Methadone 2 - 4 days

Buprenorphine 2 - 4 days

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

Adapted from Helander et al 2009 Moeller et al 2008

NIDA Neurobio of Addiction (2016 In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

43

Urine Drug Testing Stimulants

Amphetamine Methamphetamine

bull False positives pseudoephedrine bupropion labetolol ranitidine trazodone TCAs

bull Low sensitivity for detection of MDMA

bull 2 methamphetamine isomers d (CNS) and l (peripheral)

Cocaine

bull Primary metabolite benzoyleconine

bull False positives rare (coca leaf tea adulterated natural products)

Opiates

bull Tests for morphine-based substances

bull Unreliable for synthetic opioids like oxycodone

44

Summary

Alcohol use disorder is a common and deadly illness

with significant comorbidities

Alcohol withdrawal management does not treat AUD

It is important to understand key concepts in other

drug use disorders

Urine drug testing is an important piece to clinical

decision making

45

References

Disease ImCenters for Disease Control and Prevention (CDC) Alcohol-Related pact (ARDI) Atlanta GA CDC

Epidemiology of DSM-5 Alcohol Use Disorder Results From the National Epidemiologic Survey on Alcohol and Related Conditions III Grant BF1 Goldstein RB1 Saha TD1 Chou SP1 Jung J1 Zhang H1 Pickering RP1 Ruan WJ1 Smith SM1 Huang B1 Hasin DS2

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment Levounis Zerbo and Aggarwal Eds

Stahre M Roeber J Kanny D Brewer RD Zhang X Contribution of excessive alcohol consumption to deaths and years of potential life lost in the United States Prev Chronic Dis 201411130293

12

Screening for Alcohol Use Disorder

Screen for risky drinking (gt3 drinks in one sitting or gt7

drinks in one week for women and gt4 drinks in one sitting or

gt14 drinks in one week for men) [criteria previous slide]

CAGE (Cut down Annoyed Guilty Eye opener)

AUDIT-C (Alcohol Use Disorders Identification Test)

bull How often did you have a drink containing alcohol in the

past year

bull How often did you have six or more drinks on one occasion

in the past year

13

Legal Intoxication vs Clinical Intoxication

Impact on BAL

14

On average one standard drink is metabolized per hour (002)

Hence a BAL of 030 will take approximately 15 hours to metabolize to zero

People with tolerance start to develop withdrawal approximately 6 hours from last drink hence the E in CAGE

Withdrawal will develop long before the BAL reaches 0

Alcohol Metabolism

15

16

Alcohol withdrawal

bull For most it is not

complicated

bull For some it is deadly

bull We must stratify risk

and triage appropriately

Risk Stratification

17

Risk Stratification

18

Detox is not treatment

Alcohol withdrawal is an

acute complication of a

chronic medical condition

Treating the acute

complication does not treat

the underlying condition

Most Importantly

19

Be aware of standard drink sizes and common terms

Understand the impact on BAL and clinical vs legal

intoxication

Routinely screen all patients for alcohol use disorders

Be able to identify alcohol withdrawal symptoms and

basic treatment strategies

Remember that Detox is not treatment

Alcohol Summary

20

Tom is a 61 year old man with an alcohol

use disorder

He was sober and in recovery from

36 ndash 60 years of age

At 60 he was prescribed Xanax for

anxiety

ldquoI did not even know what they gave me As soon as I took it I had a powerful urge to drink alcohol It was as if I had never stopped drinkingrdquo

He relapsed on alcohol and over the past year has struggled

He is now presenting for treatment of alcohol use disorder

Clinical Presentation

21

Alprazolam (Xanax) diazepam (Valium)

lorazepam (Ativan) clonazepam

(Klonopin) chlordiazepoxide (Librium)

and temazepam (Restoril) are the most

common

Indicated and useful for anxiety and

insomnia if properly monitored though

not considered first line for either

Pharmacologic overlap with alcohol

Benzodiazepines

22

Benzodiazepines (continued)

Do not fly the plane unless you know how to land

ldquoBarsrdquo = Xanax 2 mg

Can cause overdose death when mixed with opioids or alcohol

Often mixed with alcohol to magnify the high

Withdrawal can be protracted and dangerous

Common cause of falls and delirium in elderly

23

ldquoWhen I start to run out I begin crawling

around on the carpet looking for any

little bit I can find

Then I look around and think every car

car outside is the police and they

are after me

Then I look in the mirror my eyes are bloodshot and my heart is racing I feel awful and paranoid

Then I say to myself that I will NEVER do this again

Then I do it again the next dayrdquo

Clinical Presentation

24

Dopamine reuptake inhibitor

Leads to supraphysiologic dopamine release

Crack is mixed with a base smoked and is

highly addictive

Was widely used recreationally prior to 1914

including mixed with alcohol (Vin Mariani)

Snorting 146 minutes to peak

Injecting 31 minutes to peak

Smoking 14 minutes to peak

Cocaine

25

ldquoWoe to you my princess when I come I will

kiss you quite red and feed you til you are

plump And if you are forward you shall

see who is the stronger a gentle little girl

who doesnrsquot eat enough or a big wild man

who has cocaine in his body In my last

depression I took coca again and a small

dose lifted me to the heights in a wonderful

fashion I am just now busy collecting

literature for a song of praise to this magical

substancerdquo

Cocaine

26

Acute

bull Pleasure alertness energy sexuality tachycardia hallucinations paranoia hypertension

Crash

bull Peaks 2-4 days but up to a week of prolonged dysthymia hypersomnolence irritability suicidality cravings

Chronic

bull Profound anhedonia and other long term consequences dependent on route of admin

Cocaine

27

Chris is a 40-year old male who presents

to clinic seeking help with anxiety He reports

chronic anxiety with worry and ruminations

He also reports occasional panic attacks

He has tried SSRIs in the past with minimal

improvement He is currently smoking

marijuana daily and states that it is the only

thing that helps

He is willing to try a new medication but unwilling to stop smoking marijuana

Clinical Presentation

28

ldquoMarijuanardquo is the term for the plant Cannabis

THC = Tetrahydrocannabinol = psychoactive

CBD = Cannabidiol = sedating not psychoactive

Sativa and Indica differ in THCCBD ratio

Marijuana the herb is generally dried flowers

Hashish is a resin with higher THC levels and generally heated in a pipe or eaten

Hash oil is the most potent and can be smoked ingested or used topically

Marijuana

29

Joint marijuana rolled in paper

Fatty larger amount of marijuana

Doobie rolled with king size paper

Blunt Rolled with cigar wrapper and contains tobacco

Pipes (also known as bowls) are usually glass and rarely have a filter

Bongs contain water filter

Marijuana

30

Marijuana Legal Status

31

Marijuana Effects

Acute Intoxication

bull Improved mood increased well-being calmness relaxation

and sociability

bull Increased self-confidence magical thinking distorted

perception of time and space increased sensory perception

bull Tachycardia palpitations vasodilation conjunctival

irritation dry mouth increased appetite

bull Anxiety panic confusion hallucinations paranoia

psychosis

Withdrawal

bull Anxiety depression mood changes GI distress decreased

appetite insomnia irritability

32

First Illicit Drug Used

Figure from SAMHSA

33

Marijuana

34

ldquoIt bothers me that people are so stupid as to use

this stuffrdquo ndash John W Huffman developer

Sprayed on dried plant material or inhaled in

vaporizer

Marketed as ldquonot for human consumptionrdquo and were

sold legally under hundreds of brands most notably

K2 and Spice

Synthetic Cannabinoids

35

False belief that these are ldquonaturalrdquo and thus harmless

They are also not detected in routine drug screens

Acute effects are very unpredictable and generally

less pleasant than natural cannabis

Psychotic symptoms include extreme anxiety

confusion paranoia and hallucinations

Synthetic Cannabinoids

36

Mike is a 23 year old who presents

to the ER with paranoia

He reports holding a loaded gun

and pointing it at people outside of his

window thinking they were all trying

to kill him

He previously used meth heavily but has recently cut down

His last use was 3 days ago

Clinical Presentation

37

Janice is a 36 year old female who presented to the ER seeking

help with methamphetamine addiction

She appears older than stated age and is very thin

She has several missing teeth and otherwise poor

dentition

Her skin has multiple lesions

ldquoWhen I first starting smoking ice it felt so good Now it no longer feels like that

I do not even get much pleasure out of it any more I do not get pleasure out

of anything anymore I have no desire to see family or friends or do the things

I used to love I wish I could have fun like I used tordquo

Clinical Presentation

38

Crystal Ice Glass

Leads to an acute increase in synaptic dopamine concentration through various mechanisms

Can be prescribed as Desoxyn for

ADHD

Prominent in the western region of US and made famous by Breaking Bad

television series

Many accidents and fires are associated

with ldquobackyardrdquo meth labs

Methamphetamine

39

Mental illness and co-morbid or co-occurring substance use disorder is common

Approximately 13 of all people with mental illness and 12 with severe mental illness also have a substance use disorder

Self medication hypothesis vs substance

induced disorder

Multi-modal parallel or integrated treatment approach is most effective

Dual Diagnosis

Data from SAMHSA

40

Toxicology Screening

Urine most common method given cost and ease of collection Problem adulteration and substitution

bull On-site rapid testing

bull Immunoassay (initial lab screen)

bull GCMS

Blood better for quantitative analysis detection of acute intoxication Problem invasive detection for shorter periods than urine

Saliva Non-invasive lower potential for adulteration than urine Problem higher detection threshold and greater cost

Sweat Can identify substances over longer period of time Problem difficult to collect and quantify

Hair Easy to collect less likelihood of adulteration provides qualitative account of history of ingestion Problem poor at detecting acute intoxication more labor-intensive to process

41

Screening for drugs in healthy individuals

with no prior suspicion

bull Workplace or athletic testing

Testing for drugs in ill persons with a prior suspicion of use

Monitoring for drugs as part of a pain management or treatment program

While reliable on-site urine drug testing offers preliminary results When making treatment altering decisions urine should always be sent for confirmatory testing

Urine Testing

42

Urine Detection Limits

Alcohol 6 - 12 hours

EtG (ethylglucuronide) 4 days

Amphetaminesmeth 2 - 3 days

Benzos (short-acting) 3 days

Cocaine 3 - 4 days

Morphine 2 days

Marijuana (THC) 3 - 30+ days

Methadone 2 - 4 days

Buprenorphine 2 - 4 days

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

Adapted from Helander et al 2009 Moeller et al 2008

NIDA Neurobio of Addiction (2016 In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

43

Urine Drug Testing Stimulants

Amphetamine Methamphetamine

bull False positives pseudoephedrine bupropion labetolol ranitidine trazodone TCAs

bull Low sensitivity for detection of MDMA

bull 2 methamphetamine isomers d (CNS) and l (peripheral)

Cocaine

bull Primary metabolite benzoyleconine

bull False positives rare (coca leaf tea adulterated natural products)

Opiates

bull Tests for morphine-based substances

bull Unreliable for synthetic opioids like oxycodone

44

Summary

Alcohol use disorder is a common and deadly illness

with significant comorbidities

Alcohol withdrawal management does not treat AUD

It is important to understand key concepts in other

drug use disorders

Urine drug testing is an important piece to clinical

decision making

45

References

Disease ImCenters for Disease Control and Prevention (CDC) Alcohol-Related pact (ARDI) Atlanta GA CDC

Epidemiology of DSM-5 Alcohol Use Disorder Results From the National Epidemiologic Survey on Alcohol and Related Conditions III Grant BF1 Goldstein RB1 Saha TD1 Chou SP1 Jung J1 Zhang H1 Pickering RP1 Ruan WJ1 Smith SM1 Huang B1 Hasin DS2

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment Levounis Zerbo and Aggarwal Eds

Stahre M Roeber J Kanny D Brewer RD Zhang X Contribution of excessive alcohol consumption to deaths and years of potential life lost in the United States Prev Chronic Dis 201411130293

13

Legal Intoxication vs Clinical Intoxication

Impact on BAL

14

On average one standard drink is metabolized per hour (002)

Hence a BAL of 030 will take approximately 15 hours to metabolize to zero

People with tolerance start to develop withdrawal approximately 6 hours from last drink hence the E in CAGE

Withdrawal will develop long before the BAL reaches 0

Alcohol Metabolism

15

16

Alcohol withdrawal

bull For most it is not

complicated

bull For some it is deadly

bull We must stratify risk

and triage appropriately

Risk Stratification

17

Risk Stratification

18

Detox is not treatment

Alcohol withdrawal is an

acute complication of a

chronic medical condition

Treating the acute

complication does not treat

the underlying condition

Most Importantly

19

Be aware of standard drink sizes and common terms

Understand the impact on BAL and clinical vs legal

intoxication

Routinely screen all patients for alcohol use disorders

Be able to identify alcohol withdrawal symptoms and

basic treatment strategies

Remember that Detox is not treatment

Alcohol Summary

20

Tom is a 61 year old man with an alcohol

use disorder

He was sober and in recovery from

36 ndash 60 years of age

At 60 he was prescribed Xanax for

anxiety

ldquoI did not even know what they gave me As soon as I took it I had a powerful urge to drink alcohol It was as if I had never stopped drinkingrdquo

He relapsed on alcohol and over the past year has struggled

He is now presenting for treatment of alcohol use disorder

Clinical Presentation

21

Alprazolam (Xanax) diazepam (Valium)

lorazepam (Ativan) clonazepam

(Klonopin) chlordiazepoxide (Librium)

and temazepam (Restoril) are the most

common

Indicated and useful for anxiety and

insomnia if properly monitored though

not considered first line for either

Pharmacologic overlap with alcohol

Benzodiazepines

22

Benzodiazepines (continued)

Do not fly the plane unless you know how to land

ldquoBarsrdquo = Xanax 2 mg

Can cause overdose death when mixed with opioids or alcohol

Often mixed with alcohol to magnify the high

Withdrawal can be protracted and dangerous

Common cause of falls and delirium in elderly

23

ldquoWhen I start to run out I begin crawling

around on the carpet looking for any

little bit I can find

Then I look around and think every car

car outside is the police and they

are after me

Then I look in the mirror my eyes are bloodshot and my heart is racing I feel awful and paranoid

Then I say to myself that I will NEVER do this again

Then I do it again the next dayrdquo

Clinical Presentation

24

Dopamine reuptake inhibitor

Leads to supraphysiologic dopamine release

Crack is mixed with a base smoked and is

highly addictive

Was widely used recreationally prior to 1914

including mixed with alcohol (Vin Mariani)

Snorting 146 minutes to peak

Injecting 31 minutes to peak

Smoking 14 minutes to peak

Cocaine

25

ldquoWoe to you my princess when I come I will

kiss you quite red and feed you til you are

plump And if you are forward you shall

see who is the stronger a gentle little girl

who doesnrsquot eat enough or a big wild man

who has cocaine in his body In my last

depression I took coca again and a small

dose lifted me to the heights in a wonderful

fashion I am just now busy collecting

literature for a song of praise to this magical

substancerdquo

Cocaine

26

Acute

bull Pleasure alertness energy sexuality tachycardia hallucinations paranoia hypertension

Crash

bull Peaks 2-4 days but up to a week of prolonged dysthymia hypersomnolence irritability suicidality cravings

Chronic

bull Profound anhedonia and other long term consequences dependent on route of admin

Cocaine

27

Chris is a 40-year old male who presents

to clinic seeking help with anxiety He reports

chronic anxiety with worry and ruminations

He also reports occasional panic attacks

He has tried SSRIs in the past with minimal

improvement He is currently smoking

marijuana daily and states that it is the only

thing that helps

He is willing to try a new medication but unwilling to stop smoking marijuana

Clinical Presentation

28

ldquoMarijuanardquo is the term for the plant Cannabis

THC = Tetrahydrocannabinol = psychoactive

CBD = Cannabidiol = sedating not psychoactive

Sativa and Indica differ in THCCBD ratio

Marijuana the herb is generally dried flowers

Hashish is a resin with higher THC levels and generally heated in a pipe or eaten

Hash oil is the most potent and can be smoked ingested or used topically

Marijuana

29

Joint marijuana rolled in paper

Fatty larger amount of marijuana

Doobie rolled with king size paper

Blunt Rolled with cigar wrapper and contains tobacco

Pipes (also known as bowls) are usually glass and rarely have a filter

Bongs contain water filter

Marijuana

30

Marijuana Legal Status

31

Marijuana Effects

Acute Intoxication

bull Improved mood increased well-being calmness relaxation

and sociability

bull Increased self-confidence magical thinking distorted

perception of time and space increased sensory perception

bull Tachycardia palpitations vasodilation conjunctival

irritation dry mouth increased appetite

bull Anxiety panic confusion hallucinations paranoia

psychosis

Withdrawal

bull Anxiety depression mood changes GI distress decreased

appetite insomnia irritability

32

First Illicit Drug Used

Figure from SAMHSA

33

Marijuana

34

ldquoIt bothers me that people are so stupid as to use

this stuffrdquo ndash John W Huffman developer

Sprayed on dried plant material or inhaled in

vaporizer

Marketed as ldquonot for human consumptionrdquo and were

sold legally under hundreds of brands most notably

K2 and Spice

Synthetic Cannabinoids

35

False belief that these are ldquonaturalrdquo and thus harmless

They are also not detected in routine drug screens

Acute effects are very unpredictable and generally

less pleasant than natural cannabis

Psychotic symptoms include extreme anxiety

confusion paranoia and hallucinations

Synthetic Cannabinoids

36

Mike is a 23 year old who presents

to the ER with paranoia

He reports holding a loaded gun

and pointing it at people outside of his

window thinking they were all trying

to kill him

He previously used meth heavily but has recently cut down

His last use was 3 days ago

Clinical Presentation

37

Janice is a 36 year old female who presented to the ER seeking

help with methamphetamine addiction

She appears older than stated age and is very thin

She has several missing teeth and otherwise poor

dentition

Her skin has multiple lesions

ldquoWhen I first starting smoking ice it felt so good Now it no longer feels like that

I do not even get much pleasure out of it any more I do not get pleasure out

of anything anymore I have no desire to see family or friends or do the things

I used to love I wish I could have fun like I used tordquo

Clinical Presentation

38

Crystal Ice Glass

Leads to an acute increase in synaptic dopamine concentration through various mechanisms

Can be prescribed as Desoxyn for

ADHD

Prominent in the western region of US and made famous by Breaking Bad

television series

Many accidents and fires are associated

with ldquobackyardrdquo meth labs

Methamphetamine

39

Mental illness and co-morbid or co-occurring substance use disorder is common

Approximately 13 of all people with mental illness and 12 with severe mental illness also have a substance use disorder

Self medication hypothesis vs substance

induced disorder

Multi-modal parallel or integrated treatment approach is most effective

Dual Diagnosis

Data from SAMHSA

40

Toxicology Screening

Urine most common method given cost and ease of collection Problem adulteration and substitution

bull On-site rapid testing

bull Immunoassay (initial lab screen)

bull GCMS

Blood better for quantitative analysis detection of acute intoxication Problem invasive detection for shorter periods than urine

Saliva Non-invasive lower potential for adulteration than urine Problem higher detection threshold and greater cost

Sweat Can identify substances over longer period of time Problem difficult to collect and quantify

Hair Easy to collect less likelihood of adulteration provides qualitative account of history of ingestion Problem poor at detecting acute intoxication more labor-intensive to process

41

Screening for drugs in healthy individuals

with no prior suspicion

bull Workplace or athletic testing

Testing for drugs in ill persons with a prior suspicion of use

Monitoring for drugs as part of a pain management or treatment program

While reliable on-site urine drug testing offers preliminary results When making treatment altering decisions urine should always be sent for confirmatory testing

Urine Testing

42

Urine Detection Limits

Alcohol 6 - 12 hours

EtG (ethylglucuronide) 4 days

Amphetaminesmeth 2 - 3 days

Benzos (short-acting) 3 days

Cocaine 3 - 4 days

Morphine 2 days

Marijuana (THC) 3 - 30+ days

Methadone 2 - 4 days

Buprenorphine 2 - 4 days

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

Adapted from Helander et al 2009 Moeller et al 2008

NIDA Neurobio of Addiction (2016 In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

43

Urine Drug Testing Stimulants

Amphetamine Methamphetamine

bull False positives pseudoephedrine bupropion labetolol ranitidine trazodone TCAs

bull Low sensitivity for detection of MDMA

bull 2 methamphetamine isomers d (CNS) and l (peripheral)

Cocaine

bull Primary metabolite benzoyleconine

bull False positives rare (coca leaf tea adulterated natural products)

Opiates

bull Tests for morphine-based substances

bull Unreliable for synthetic opioids like oxycodone

44

Summary

Alcohol use disorder is a common and deadly illness

with significant comorbidities

Alcohol withdrawal management does not treat AUD

It is important to understand key concepts in other

drug use disorders

Urine drug testing is an important piece to clinical

decision making

45

References

Disease ImCenters for Disease Control and Prevention (CDC) Alcohol-Related pact (ARDI) Atlanta GA CDC

Epidemiology of DSM-5 Alcohol Use Disorder Results From the National Epidemiologic Survey on Alcohol and Related Conditions III Grant BF1 Goldstein RB1 Saha TD1 Chou SP1 Jung J1 Zhang H1 Pickering RP1 Ruan WJ1 Smith SM1 Huang B1 Hasin DS2

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment Levounis Zerbo and Aggarwal Eds

Stahre M Roeber J Kanny D Brewer RD Zhang X Contribution of excessive alcohol consumption to deaths and years of potential life lost in the United States Prev Chronic Dis 201411130293

14

On average one standard drink is metabolized per hour (002)

Hence a BAL of 030 will take approximately 15 hours to metabolize to zero

People with tolerance start to develop withdrawal approximately 6 hours from last drink hence the E in CAGE

Withdrawal will develop long before the BAL reaches 0

Alcohol Metabolism

15

16

Alcohol withdrawal

bull For most it is not

complicated

bull For some it is deadly

bull We must stratify risk

and triage appropriately

Risk Stratification

17

Risk Stratification

18

Detox is not treatment

Alcohol withdrawal is an

acute complication of a

chronic medical condition

Treating the acute

complication does not treat

the underlying condition

Most Importantly

19

Be aware of standard drink sizes and common terms

Understand the impact on BAL and clinical vs legal

intoxication

Routinely screen all patients for alcohol use disorders

Be able to identify alcohol withdrawal symptoms and

basic treatment strategies

Remember that Detox is not treatment

Alcohol Summary

20

Tom is a 61 year old man with an alcohol

use disorder

He was sober and in recovery from

36 ndash 60 years of age

At 60 he was prescribed Xanax for

anxiety

ldquoI did not even know what they gave me As soon as I took it I had a powerful urge to drink alcohol It was as if I had never stopped drinkingrdquo

He relapsed on alcohol and over the past year has struggled

He is now presenting for treatment of alcohol use disorder

Clinical Presentation

21

Alprazolam (Xanax) diazepam (Valium)

lorazepam (Ativan) clonazepam

(Klonopin) chlordiazepoxide (Librium)

and temazepam (Restoril) are the most

common

Indicated and useful for anxiety and

insomnia if properly monitored though

not considered first line for either

Pharmacologic overlap with alcohol

Benzodiazepines

22

Benzodiazepines (continued)

Do not fly the plane unless you know how to land

ldquoBarsrdquo = Xanax 2 mg

Can cause overdose death when mixed with opioids or alcohol

Often mixed with alcohol to magnify the high

Withdrawal can be protracted and dangerous

Common cause of falls and delirium in elderly

23

ldquoWhen I start to run out I begin crawling

around on the carpet looking for any

little bit I can find

Then I look around and think every car

car outside is the police and they

are after me

Then I look in the mirror my eyes are bloodshot and my heart is racing I feel awful and paranoid

Then I say to myself that I will NEVER do this again

Then I do it again the next dayrdquo

Clinical Presentation

24

Dopamine reuptake inhibitor

Leads to supraphysiologic dopamine release

Crack is mixed with a base smoked and is

highly addictive

Was widely used recreationally prior to 1914

including mixed with alcohol (Vin Mariani)

Snorting 146 minutes to peak

Injecting 31 minutes to peak

Smoking 14 minutes to peak

Cocaine

25

ldquoWoe to you my princess when I come I will

kiss you quite red and feed you til you are

plump And if you are forward you shall

see who is the stronger a gentle little girl

who doesnrsquot eat enough or a big wild man

who has cocaine in his body In my last

depression I took coca again and a small

dose lifted me to the heights in a wonderful

fashion I am just now busy collecting

literature for a song of praise to this magical

substancerdquo

Cocaine

26

Acute

bull Pleasure alertness energy sexuality tachycardia hallucinations paranoia hypertension

Crash

bull Peaks 2-4 days but up to a week of prolonged dysthymia hypersomnolence irritability suicidality cravings

Chronic

bull Profound anhedonia and other long term consequences dependent on route of admin

Cocaine

27

Chris is a 40-year old male who presents

to clinic seeking help with anxiety He reports

chronic anxiety with worry and ruminations

He also reports occasional panic attacks

He has tried SSRIs in the past with minimal

improvement He is currently smoking

marijuana daily and states that it is the only

thing that helps

He is willing to try a new medication but unwilling to stop smoking marijuana

Clinical Presentation

28

ldquoMarijuanardquo is the term for the plant Cannabis

THC = Tetrahydrocannabinol = psychoactive

CBD = Cannabidiol = sedating not psychoactive

Sativa and Indica differ in THCCBD ratio

Marijuana the herb is generally dried flowers

Hashish is a resin with higher THC levels and generally heated in a pipe or eaten

Hash oil is the most potent and can be smoked ingested or used topically

Marijuana

29

Joint marijuana rolled in paper

Fatty larger amount of marijuana

Doobie rolled with king size paper

Blunt Rolled with cigar wrapper and contains tobacco

Pipes (also known as bowls) are usually glass and rarely have a filter

Bongs contain water filter

Marijuana

30

Marijuana Legal Status

31

Marijuana Effects

Acute Intoxication

bull Improved mood increased well-being calmness relaxation

and sociability

bull Increased self-confidence magical thinking distorted

perception of time and space increased sensory perception

bull Tachycardia palpitations vasodilation conjunctival

irritation dry mouth increased appetite

bull Anxiety panic confusion hallucinations paranoia

psychosis

Withdrawal

bull Anxiety depression mood changes GI distress decreased

appetite insomnia irritability

32

First Illicit Drug Used

Figure from SAMHSA

33

Marijuana

34

ldquoIt bothers me that people are so stupid as to use

this stuffrdquo ndash John W Huffman developer

Sprayed on dried plant material or inhaled in

vaporizer

Marketed as ldquonot for human consumptionrdquo and were

sold legally under hundreds of brands most notably

K2 and Spice

Synthetic Cannabinoids

35

False belief that these are ldquonaturalrdquo and thus harmless

They are also not detected in routine drug screens

Acute effects are very unpredictable and generally

less pleasant than natural cannabis

Psychotic symptoms include extreme anxiety

confusion paranoia and hallucinations

Synthetic Cannabinoids

36

Mike is a 23 year old who presents

to the ER with paranoia

He reports holding a loaded gun

and pointing it at people outside of his

window thinking they were all trying

to kill him

He previously used meth heavily but has recently cut down

His last use was 3 days ago

Clinical Presentation

37

Janice is a 36 year old female who presented to the ER seeking

help with methamphetamine addiction

She appears older than stated age and is very thin

She has several missing teeth and otherwise poor

dentition

Her skin has multiple lesions

ldquoWhen I first starting smoking ice it felt so good Now it no longer feels like that

I do not even get much pleasure out of it any more I do not get pleasure out

of anything anymore I have no desire to see family or friends or do the things

I used to love I wish I could have fun like I used tordquo

Clinical Presentation

38

Crystal Ice Glass

Leads to an acute increase in synaptic dopamine concentration through various mechanisms

Can be prescribed as Desoxyn for

ADHD

Prominent in the western region of US and made famous by Breaking Bad

television series

Many accidents and fires are associated

with ldquobackyardrdquo meth labs

Methamphetamine

39

Mental illness and co-morbid or co-occurring substance use disorder is common

Approximately 13 of all people with mental illness and 12 with severe mental illness also have a substance use disorder

Self medication hypothesis vs substance

induced disorder

Multi-modal parallel or integrated treatment approach is most effective

Dual Diagnosis

Data from SAMHSA

40

Toxicology Screening

Urine most common method given cost and ease of collection Problem adulteration and substitution

bull On-site rapid testing

bull Immunoassay (initial lab screen)

bull GCMS

Blood better for quantitative analysis detection of acute intoxication Problem invasive detection for shorter periods than urine

Saliva Non-invasive lower potential for adulteration than urine Problem higher detection threshold and greater cost

Sweat Can identify substances over longer period of time Problem difficult to collect and quantify

Hair Easy to collect less likelihood of adulteration provides qualitative account of history of ingestion Problem poor at detecting acute intoxication more labor-intensive to process

41

Screening for drugs in healthy individuals

with no prior suspicion

bull Workplace or athletic testing

Testing for drugs in ill persons with a prior suspicion of use

Monitoring for drugs as part of a pain management or treatment program

While reliable on-site urine drug testing offers preliminary results When making treatment altering decisions urine should always be sent for confirmatory testing

Urine Testing

42

Urine Detection Limits

Alcohol 6 - 12 hours

EtG (ethylglucuronide) 4 days

Amphetaminesmeth 2 - 3 days

Benzos (short-acting) 3 days

Cocaine 3 - 4 days

Morphine 2 days

Marijuana (THC) 3 - 30+ days

Methadone 2 - 4 days

Buprenorphine 2 - 4 days

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

Adapted from Helander et al 2009 Moeller et al 2008

NIDA Neurobio of Addiction (2016 In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

43

Urine Drug Testing Stimulants

Amphetamine Methamphetamine

bull False positives pseudoephedrine bupropion labetolol ranitidine trazodone TCAs

bull Low sensitivity for detection of MDMA

bull 2 methamphetamine isomers d (CNS) and l (peripheral)

Cocaine

bull Primary metabolite benzoyleconine

bull False positives rare (coca leaf tea adulterated natural products)

Opiates

bull Tests for morphine-based substances

bull Unreliable for synthetic opioids like oxycodone

44

Summary

Alcohol use disorder is a common and deadly illness

with significant comorbidities

Alcohol withdrawal management does not treat AUD

It is important to understand key concepts in other

drug use disorders

Urine drug testing is an important piece to clinical

decision making

45

References

Disease ImCenters for Disease Control and Prevention (CDC) Alcohol-Related pact (ARDI) Atlanta GA CDC

Epidemiology of DSM-5 Alcohol Use Disorder Results From the National Epidemiologic Survey on Alcohol and Related Conditions III Grant BF1 Goldstein RB1 Saha TD1 Chou SP1 Jung J1 Zhang H1 Pickering RP1 Ruan WJ1 Smith SM1 Huang B1 Hasin DS2

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment Levounis Zerbo and Aggarwal Eds

Stahre M Roeber J Kanny D Brewer RD Zhang X Contribution of excessive alcohol consumption to deaths and years of potential life lost in the United States Prev Chronic Dis 201411130293

15

16

Alcohol withdrawal

bull For most it is not

complicated

bull For some it is deadly

bull We must stratify risk

and triage appropriately

Risk Stratification

17

Risk Stratification

18

Detox is not treatment

Alcohol withdrawal is an

acute complication of a

chronic medical condition

Treating the acute

complication does not treat

the underlying condition

Most Importantly

19

Be aware of standard drink sizes and common terms

Understand the impact on BAL and clinical vs legal

intoxication

Routinely screen all patients for alcohol use disorders

Be able to identify alcohol withdrawal symptoms and

basic treatment strategies

Remember that Detox is not treatment

Alcohol Summary

20

Tom is a 61 year old man with an alcohol

use disorder

He was sober and in recovery from

36 ndash 60 years of age

At 60 he was prescribed Xanax for

anxiety

ldquoI did not even know what they gave me As soon as I took it I had a powerful urge to drink alcohol It was as if I had never stopped drinkingrdquo

He relapsed on alcohol and over the past year has struggled

He is now presenting for treatment of alcohol use disorder

Clinical Presentation

21

Alprazolam (Xanax) diazepam (Valium)

lorazepam (Ativan) clonazepam

(Klonopin) chlordiazepoxide (Librium)

and temazepam (Restoril) are the most

common

Indicated and useful for anxiety and

insomnia if properly monitored though

not considered first line for either

Pharmacologic overlap with alcohol

Benzodiazepines

22

Benzodiazepines (continued)

Do not fly the plane unless you know how to land

ldquoBarsrdquo = Xanax 2 mg

Can cause overdose death when mixed with opioids or alcohol

Often mixed with alcohol to magnify the high

Withdrawal can be protracted and dangerous

Common cause of falls and delirium in elderly

23

ldquoWhen I start to run out I begin crawling

around on the carpet looking for any

little bit I can find

Then I look around and think every car

car outside is the police and they

are after me

Then I look in the mirror my eyes are bloodshot and my heart is racing I feel awful and paranoid

Then I say to myself that I will NEVER do this again

Then I do it again the next dayrdquo

Clinical Presentation

24

Dopamine reuptake inhibitor

Leads to supraphysiologic dopamine release

Crack is mixed with a base smoked and is

highly addictive

Was widely used recreationally prior to 1914

including mixed with alcohol (Vin Mariani)

Snorting 146 minutes to peak

Injecting 31 minutes to peak

Smoking 14 minutes to peak

Cocaine

25

ldquoWoe to you my princess when I come I will

kiss you quite red and feed you til you are

plump And if you are forward you shall

see who is the stronger a gentle little girl

who doesnrsquot eat enough or a big wild man

who has cocaine in his body In my last

depression I took coca again and a small

dose lifted me to the heights in a wonderful

fashion I am just now busy collecting

literature for a song of praise to this magical

substancerdquo

Cocaine

26

Acute

bull Pleasure alertness energy sexuality tachycardia hallucinations paranoia hypertension

Crash

bull Peaks 2-4 days but up to a week of prolonged dysthymia hypersomnolence irritability suicidality cravings

Chronic

bull Profound anhedonia and other long term consequences dependent on route of admin

Cocaine

27

Chris is a 40-year old male who presents

to clinic seeking help with anxiety He reports

chronic anxiety with worry and ruminations

He also reports occasional panic attacks

He has tried SSRIs in the past with minimal

improvement He is currently smoking

marijuana daily and states that it is the only

thing that helps

He is willing to try a new medication but unwilling to stop smoking marijuana

Clinical Presentation

28

ldquoMarijuanardquo is the term for the plant Cannabis

THC = Tetrahydrocannabinol = psychoactive

CBD = Cannabidiol = sedating not psychoactive

Sativa and Indica differ in THCCBD ratio

Marijuana the herb is generally dried flowers

Hashish is a resin with higher THC levels and generally heated in a pipe or eaten

Hash oil is the most potent and can be smoked ingested or used topically

Marijuana

29

Joint marijuana rolled in paper

Fatty larger amount of marijuana

Doobie rolled with king size paper

Blunt Rolled with cigar wrapper and contains tobacco

Pipes (also known as bowls) are usually glass and rarely have a filter

Bongs contain water filter

Marijuana

30

Marijuana Legal Status

31

Marijuana Effects

Acute Intoxication

bull Improved mood increased well-being calmness relaxation

and sociability

bull Increased self-confidence magical thinking distorted

perception of time and space increased sensory perception

bull Tachycardia palpitations vasodilation conjunctival

irritation dry mouth increased appetite

bull Anxiety panic confusion hallucinations paranoia

psychosis

Withdrawal

bull Anxiety depression mood changes GI distress decreased

appetite insomnia irritability

32

First Illicit Drug Used

Figure from SAMHSA

33

Marijuana

34

ldquoIt bothers me that people are so stupid as to use

this stuffrdquo ndash John W Huffman developer

Sprayed on dried plant material or inhaled in

vaporizer

Marketed as ldquonot for human consumptionrdquo and were

sold legally under hundreds of brands most notably

K2 and Spice

Synthetic Cannabinoids

35

False belief that these are ldquonaturalrdquo and thus harmless

They are also not detected in routine drug screens

Acute effects are very unpredictable and generally

less pleasant than natural cannabis

Psychotic symptoms include extreme anxiety

confusion paranoia and hallucinations

Synthetic Cannabinoids

36

Mike is a 23 year old who presents

to the ER with paranoia

He reports holding a loaded gun

and pointing it at people outside of his

window thinking they were all trying

to kill him

He previously used meth heavily but has recently cut down

His last use was 3 days ago

Clinical Presentation

37

Janice is a 36 year old female who presented to the ER seeking

help with methamphetamine addiction

She appears older than stated age and is very thin

She has several missing teeth and otherwise poor

dentition

Her skin has multiple lesions

ldquoWhen I first starting smoking ice it felt so good Now it no longer feels like that

I do not even get much pleasure out of it any more I do not get pleasure out

of anything anymore I have no desire to see family or friends or do the things

I used to love I wish I could have fun like I used tordquo

Clinical Presentation

38

Crystal Ice Glass

Leads to an acute increase in synaptic dopamine concentration through various mechanisms

Can be prescribed as Desoxyn for

ADHD

Prominent in the western region of US and made famous by Breaking Bad

television series

Many accidents and fires are associated

with ldquobackyardrdquo meth labs

Methamphetamine

39

Mental illness and co-morbid or co-occurring substance use disorder is common

Approximately 13 of all people with mental illness and 12 with severe mental illness also have a substance use disorder

Self medication hypothesis vs substance

induced disorder

Multi-modal parallel or integrated treatment approach is most effective

Dual Diagnosis

Data from SAMHSA

40

Toxicology Screening

Urine most common method given cost and ease of collection Problem adulteration and substitution

bull On-site rapid testing

bull Immunoassay (initial lab screen)

bull GCMS

Blood better for quantitative analysis detection of acute intoxication Problem invasive detection for shorter periods than urine

Saliva Non-invasive lower potential for adulteration than urine Problem higher detection threshold and greater cost

Sweat Can identify substances over longer period of time Problem difficult to collect and quantify

Hair Easy to collect less likelihood of adulteration provides qualitative account of history of ingestion Problem poor at detecting acute intoxication more labor-intensive to process

41

Screening for drugs in healthy individuals

with no prior suspicion

bull Workplace or athletic testing

Testing for drugs in ill persons with a prior suspicion of use

Monitoring for drugs as part of a pain management or treatment program

While reliable on-site urine drug testing offers preliminary results When making treatment altering decisions urine should always be sent for confirmatory testing

Urine Testing

42

Urine Detection Limits

Alcohol 6 - 12 hours

EtG (ethylglucuronide) 4 days

Amphetaminesmeth 2 - 3 days

Benzos (short-acting) 3 days

Cocaine 3 - 4 days

Morphine 2 days

Marijuana (THC) 3 - 30+ days

Methadone 2 - 4 days

Buprenorphine 2 - 4 days

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

Adapted from Helander et al 2009 Moeller et al 2008

NIDA Neurobio of Addiction (2016 In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

43

Urine Drug Testing Stimulants

Amphetamine Methamphetamine

bull False positives pseudoephedrine bupropion labetolol ranitidine trazodone TCAs

bull Low sensitivity for detection of MDMA

bull 2 methamphetamine isomers d (CNS) and l (peripheral)

Cocaine

bull Primary metabolite benzoyleconine

bull False positives rare (coca leaf tea adulterated natural products)

Opiates

bull Tests for morphine-based substances

bull Unreliable for synthetic opioids like oxycodone

44

Summary

Alcohol use disorder is a common and deadly illness

with significant comorbidities

Alcohol withdrawal management does not treat AUD

It is important to understand key concepts in other

drug use disorders

Urine drug testing is an important piece to clinical

decision making

45

References

Disease ImCenters for Disease Control and Prevention (CDC) Alcohol-Related pact (ARDI) Atlanta GA CDC

Epidemiology of DSM-5 Alcohol Use Disorder Results From the National Epidemiologic Survey on Alcohol and Related Conditions III Grant BF1 Goldstein RB1 Saha TD1 Chou SP1 Jung J1 Zhang H1 Pickering RP1 Ruan WJ1 Smith SM1 Huang B1 Hasin DS2

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment Levounis Zerbo and Aggarwal Eds

Stahre M Roeber J Kanny D Brewer RD Zhang X Contribution of excessive alcohol consumption to deaths and years of potential life lost in the United States Prev Chronic Dis 201411130293

16

Alcohol withdrawal

bull For most it is not

complicated

bull For some it is deadly

bull We must stratify risk

and triage appropriately

Risk Stratification

17

Risk Stratification

18

Detox is not treatment

Alcohol withdrawal is an

acute complication of a

chronic medical condition

Treating the acute

complication does not treat

the underlying condition

Most Importantly

19

Be aware of standard drink sizes and common terms

Understand the impact on BAL and clinical vs legal

intoxication

Routinely screen all patients for alcohol use disorders

Be able to identify alcohol withdrawal symptoms and

basic treatment strategies

Remember that Detox is not treatment

Alcohol Summary

20

Tom is a 61 year old man with an alcohol

use disorder

He was sober and in recovery from

36 ndash 60 years of age

At 60 he was prescribed Xanax for

anxiety

ldquoI did not even know what they gave me As soon as I took it I had a powerful urge to drink alcohol It was as if I had never stopped drinkingrdquo

He relapsed on alcohol and over the past year has struggled

He is now presenting for treatment of alcohol use disorder

Clinical Presentation

21

Alprazolam (Xanax) diazepam (Valium)

lorazepam (Ativan) clonazepam

(Klonopin) chlordiazepoxide (Librium)

and temazepam (Restoril) are the most

common

Indicated and useful for anxiety and

insomnia if properly monitored though

not considered first line for either

Pharmacologic overlap with alcohol

Benzodiazepines

22

Benzodiazepines (continued)

Do not fly the plane unless you know how to land

ldquoBarsrdquo = Xanax 2 mg

Can cause overdose death when mixed with opioids or alcohol

Often mixed with alcohol to magnify the high

Withdrawal can be protracted and dangerous

Common cause of falls and delirium in elderly

23

ldquoWhen I start to run out I begin crawling

around on the carpet looking for any

little bit I can find

Then I look around and think every car

car outside is the police and they

are after me

Then I look in the mirror my eyes are bloodshot and my heart is racing I feel awful and paranoid

Then I say to myself that I will NEVER do this again

Then I do it again the next dayrdquo

Clinical Presentation

24

Dopamine reuptake inhibitor

Leads to supraphysiologic dopamine release

Crack is mixed with a base smoked and is

highly addictive

Was widely used recreationally prior to 1914

including mixed with alcohol (Vin Mariani)

Snorting 146 minutes to peak

Injecting 31 minutes to peak

Smoking 14 minutes to peak

Cocaine

25

ldquoWoe to you my princess when I come I will

kiss you quite red and feed you til you are

plump And if you are forward you shall

see who is the stronger a gentle little girl

who doesnrsquot eat enough or a big wild man

who has cocaine in his body In my last

depression I took coca again and a small

dose lifted me to the heights in a wonderful

fashion I am just now busy collecting

literature for a song of praise to this magical

substancerdquo

Cocaine

26

Acute

bull Pleasure alertness energy sexuality tachycardia hallucinations paranoia hypertension

Crash

bull Peaks 2-4 days but up to a week of prolonged dysthymia hypersomnolence irritability suicidality cravings

Chronic

bull Profound anhedonia and other long term consequences dependent on route of admin

Cocaine

27

Chris is a 40-year old male who presents

to clinic seeking help with anxiety He reports

chronic anxiety with worry and ruminations

He also reports occasional panic attacks

He has tried SSRIs in the past with minimal

improvement He is currently smoking

marijuana daily and states that it is the only

thing that helps

He is willing to try a new medication but unwilling to stop smoking marijuana

Clinical Presentation

28

ldquoMarijuanardquo is the term for the plant Cannabis

THC = Tetrahydrocannabinol = psychoactive

CBD = Cannabidiol = sedating not psychoactive

Sativa and Indica differ in THCCBD ratio

Marijuana the herb is generally dried flowers

Hashish is a resin with higher THC levels and generally heated in a pipe or eaten

Hash oil is the most potent and can be smoked ingested or used topically

Marijuana

29

Joint marijuana rolled in paper

Fatty larger amount of marijuana

Doobie rolled with king size paper

Blunt Rolled with cigar wrapper and contains tobacco

Pipes (also known as bowls) are usually glass and rarely have a filter

Bongs contain water filter

Marijuana

30

Marijuana Legal Status

31

Marijuana Effects

Acute Intoxication

bull Improved mood increased well-being calmness relaxation

and sociability

bull Increased self-confidence magical thinking distorted

perception of time and space increased sensory perception

bull Tachycardia palpitations vasodilation conjunctival

irritation dry mouth increased appetite

bull Anxiety panic confusion hallucinations paranoia

psychosis

Withdrawal

bull Anxiety depression mood changes GI distress decreased

appetite insomnia irritability

32

First Illicit Drug Used

Figure from SAMHSA

33

Marijuana

34

ldquoIt bothers me that people are so stupid as to use

this stuffrdquo ndash John W Huffman developer

Sprayed on dried plant material or inhaled in

vaporizer

Marketed as ldquonot for human consumptionrdquo and were

sold legally under hundreds of brands most notably

K2 and Spice

Synthetic Cannabinoids

35

False belief that these are ldquonaturalrdquo and thus harmless

They are also not detected in routine drug screens

Acute effects are very unpredictable and generally

less pleasant than natural cannabis

Psychotic symptoms include extreme anxiety

confusion paranoia and hallucinations

Synthetic Cannabinoids

36

Mike is a 23 year old who presents

to the ER with paranoia

He reports holding a loaded gun

and pointing it at people outside of his

window thinking they were all trying

to kill him

He previously used meth heavily but has recently cut down

His last use was 3 days ago

Clinical Presentation

37

Janice is a 36 year old female who presented to the ER seeking

help with methamphetamine addiction

She appears older than stated age and is very thin

She has several missing teeth and otherwise poor

dentition

Her skin has multiple lesions

ldquoWhen I first starting smoking ice it felt so good Now it no longer feels like that

I do not even get much pleasure out of it any more I do not get pleasure out

of anything anymore I have no desire to see family or friends or do the things

I used to love I wish I could have fun like I used tordquo

Clinical Presentation

38

Crystal Ice Glass

Leads to an acute increase in synaptic dopamine concentration through various mechanisms

Can be prescribed as Desoxyn for

ADHD

Prominent in the western region of US and made famous by Breaking Bad

television series

Many accidents and fires are associated

with ldquobackyardrdquo meth labs

Methamphetamine

39

Mental illness and co-morbid or co-occurring substance use disorder is common

Approximately 13 of all people with mental illness and 12 with severe mental illness also have a substance use disorder

Self medication hypothesis vs substance

induced disorder

Multi-modal parallel or integrated treatment approach is most effective

Dual Diagnosis

Data from SAMHSA

40

Toxicology Screening

Urine most common method given cost and ease of collection Problem adulteration and substitution

bull On-site rapid testing

bull Immunoassay (initial lab screen)

bull GCMS

Blood better for quantitative analysis detection of acute intoxication Problem invasive detection for shorter periods than urine

Saliva Non-invasive lower potential for adulteration than urine Problem higher detection threshold and greater cost

Sweat Can identify substances over longer period of time Problem difficult to collect and quantify

Hair Easy to collect less likelihood of adulteration provides qualitative account of history of ingestion Problem poor at detecting acute intoxication more labor-intensive to process

41

Screening for drugs in healthy individuals

with no prior suspicion

bull Workplace or athletic testing

Testing for drugs in ill persons with a prior suspicion of use

Monitoring for drugs as part of a pain management or treatment program

While reliable on-site urine drug testing offers preliminary results When making treatment altering decisions urine should always be sent for confirmatory testing

Urine Testing

42

Urine Detection Limits

Alcohol 6 - 12 hours

EtG (ethylglucuronide) 4 days

Amphetaminesmeth 2 - 3 days

Benzos (short-acting) 3 days

Cocaine 3 - 4 days

Morphine 2 days

Marijuana (THC) 3 - 30+ days

Methadone 2 - 4 days

Buprenorphine 2 - 4 days

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

Adapted from Helander et al 2009 Moeller et al 2008

NIDA Neurobio of Addiction (2016 In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

43

Urine Drug Testing Stimulants

Amphetamine Methamphetamine

bull False positives pseudoephedrine bupropion labetolol ranitidine trazodone TCAs

bull Low sensitivity for detection of MDMA

bull 2 methamphetamine isomers d (CNS) and l (peripheral)

Cocaine

bull Primary metabolite benzoyleconine

bull False positives rare (coca leaf tea adulterated natural products)

Opiates

bull Tests for morphine-based substances

bull Unreliable for synthetic opioids like oxycodone

44

Summary

Alcohol use disorder is a common and deadly illness

with significant comorbidities

Alcohol withdrawal management does not treat AUD

It is important to understand key concepts in other

drug use disorders

Urine drug testing is an important piece to clinical

decision making

45

References

Disease ImCenters for Disease Control and Prevention (CDC) Alcohol-Related pact (ARDI) Atlanta GA CDC

Epidemiology of DSM-5 Alcohol Use Disorder Results From the National Epidemiologic Survey on Alcohol and Related Conditions III Grant BF1 Goldstein RB1 Saha TD1 Chou SP1 Jung J1 Zhang H1 Pickering RP1 Ruan WJ1 Smith SM1 Huang B1 Hasin DS2

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment Levounis Zerbo and Aggarwal Eds

Stahre M Roeber J Kanny D Brewer RD Zhang X Contribution of excessive alcohol consumption to deaths and years of potential life lost in the United States Prev Chronic Dis 201411130293

17

Risk Stratification

18

Detox is not treatment

Alcohol withdrawal is an

acute complication of a

chronic medical condition

Treating the acute

complication does not treat

the underlying condition

Most Importantly

19

Be aware of standard drink sizes and common terms

Understand the impact on BAL and clinical vs legal

intoxication

Routinely screen all patients for alcohol use disorders

Be able to identify alcohol withdrawal symptoms and

basic treatment strategies

Remember that Detox is not treatment

Alcohol Summary

20

Tom is a 61 year old man with an alcohol

use disorder

He was sober and in recovery from

36 ndash 60 years of age

At 60 he was prescribed Xanax for

anxiety

ldquoI did not even know what they gave me As soon as I took it I had a powerful urge to drink alcohol It was as if I had never stopped drinkingrdquo

He relapsed on alcohol and over the past year has struggled

He is now presenting for treatment of alcohol use disorder

Clinical Presentation

21

Alprazolam (Xanax) diazepam (Valium)

lorazepam (Ativan) clonazepam

(Klonopin) chlordiazepoxide (Librium)

and temazepam (Restoril) are the most

common

Indicated and useful for anxiety and

insomnia if properly monitored though

not considered first line for either

Pharmacologic overlap with alcohol

Benzodiazepines

22

Benzodiazepines (continued)

Do not fly the plane unless you know how to land

ldquoBarsrdquo = Xanax 2 mg

Can cause overdose death when mixed with opioids or alcohol

Often mixed with alcohol to magnify the high

Withdrawal can be protracted and dangerous

Common cause of falls and delirium in elderly

23

ldquoWhen I start to run out I begin crawling

around on the carpet looking for any

little bit I can find

Then I look around and think every car

car outside is the police and they

are after me

Then I look in the mirror my eyes are bloodshot and my heart is racing I feel awful and paranoid

Then I say to myself that I will NEVER do this again

Then I do it again the next dayrdquo

Clinical Presentation

24

Dopamine reuptake inhibitor

Leads to supraphysiologic dopamine release

Crack is mixed with a base smoked and is

highly addictive

Was widely used recreationally prior to 1914

including mixed with alcohol (Vin Mariani)

Snorting 146 minutes to peak

Injecting 31 minutes to peak

Smoking 14 minutes to peak

Cocaine

25

ldquoWoe to you my princess when I come I will

kiss you quite red and feed you til you are

plump And if you are forward you shall

see who is the stronger a gentle little girl

who doesnrsquot eat enough or a big wild man

who has cocaine in his body In my last

depression I took coca again and a small

dose lifted me to the heights in a wonderful

fashion I am just now busy collecting

literature for a song of praise to this magical

substancerdquo

Cocaine

26

Acute

bull Pleasure alertness energy sexuality tachycardia hallucinations paranoia hypertension

Crash

bull Peaks 2-4 days but up to a week of prolonged dysthymia hypersomnolence irritability suicidality cravings

Chronic

bull Profound anhedonia and other long term consequences dependent on route of admin

Cocaine

27

Chris is a 40-year old male who presents

to clinic seeking help with anxiety He reports

chronic anxiety with worry and ruminations

He also reports occasional panic attacks

He has tried SSRIs in the past with minimal

improvement He is currently smoking

marijuana daily and states that it is the only

thing that helps

He is willing to try a new medication but unwilling to stop smoking marijuana

Clinical Presentation

28

ldquoMarijuanardquo is the term for the plant Cannabis

THC = Tetrahydrocannabinol = psychoactive

CBD = Cannabidiol = sedating not psychoactive

Sativa and Indica differ in THCCBD ratio

Marijuana the herb is generally dried flowers

Hashish is a resin with higher THC levels and generally heated in a pipe or eaten

Hash oil is the most potent and can be smoked ingested or used topically

Marijuana

29

Joint marijuana rolled in paper

Fatty larger amount of marijuana

Doobie rolled with king size paper

Blunt Rolled with cigar wrapper and contains tobacco

Pipes (also known as bowls) are usually glass and rarely have a filter

Bongs contain water filter

Marijuana

30

Marijuana Legal Status

31

Marijuana Effects

Acute Intoxication

bull Improved mood increased well-being calmness relaxation

and sociability

bull Increased self-confidence magical thinking distorted

perception of time and space increased sensory perception

bull Tachycardia palpitations vasodilation conjunctival

irritation dry mouth increased appetite

bull Anxiety panic confusion hallucinations paranoia

psychosis

Withdrawal

bull Anxiety depression mood changes GI distress decreased

appetite insomnia irritability

32

First Illicit Drug Used

Figure from SAMHSA

33

Marijuana

34

ldquoIt bothers me that people are so stupid as to use

this stuffrdquo ndash John W Huffman developer

Sprayed on dried plant material or inhaled in

vaporizer

Marketed as ldquonot for human consumptionrdquo and were

sold legally under hundreds of brands most notably

K2 and Spice

Synthetic Cannabinoids

35

False belief that these are ldquonaturalrdquo and thus harmless

They are also not detected in routine drug screens

Acute effects are very unpredictable and generally

less pleasant than natural cannabis

Psychotic symptoms include extreme anxiety

confusion paranoia and hallucinations

Synthetic Cannabinoids

36

Mike is a 23 year old who presents

to the ER with paranoia

He reports holding a loaded gun

and pointing it at people outside of his

window thinking they were all trying

to kill him

He previously used meth heavily but has recently cut down

His last use was 3 days ago

Clinical Presentation

37

Janice is a 36 year old female who presented to the ER seeking

help with methamphetamine addiction

She appears older than stated age and is very thin

She has several missing teeth and otherwise poor

dentition

Her skin has multiple lesions

ldquoWhen I first starting smoking ice it felt so good Now it no longer feels like that

I do not even get much pleasure out of it any more I do not get pleasure out

of anything anymore I have no desire to see family or friends or do the things

I used to love I wish I could have fun like I used tordquo

Clinical Presentation

38

Crystal Ice Glass

Leads to an acute increase in synaptic dopamine concentration through various mechanisms

Can be prescribed as Desoxyn for

ADHD

Prominent in the western region of US and made famous by Breaking Bad

television series

Many accidents and fires are associated

with ldquobackyardrdquo meth labs

Methamphetamine

39

Mental illness and co-morbid or co-occurring substance use disorder is common

Approximately 13 of all people with mental illness and 12 with severe mental illness also have a substance use disorder

Self medication hypothesis vs substance

induced disorder

Multi-modal parallel or integrated treatment approach is most effective

Dual Diagnosis

Data from SAMHSA

40

Toxicology Screening

Urine most common method given cost and ease of collection Problem adulteration and substitution

bull On-site rapid testing

bull Immunoassay (initial lab screen)

bull GCMS

Blood better for quantitative analysis detection of acute intoxication Problem invasive detection for shorter periods than urine

Saliva Non-invasive lower potential for adulteration than urine Problem higher detection threshold and greater cost

Sweat Can identify substances over longer period of time Problem difficult to collect and quantify

Hair Easy to collect less likelihood of adulteration provides qualitative account of history of ingestion Problem poor at detecting acute intoxication more labor-intensive to process

41

Screening for drugs in healthy individuals

with no prior suspicion

bull Workplace or athletic testing

Testing for drugs in ill persons with a prior suspicion of use

Monitoring for drugs as part of a pain management or treatment program

While reliable on-site urine drug testing offers preliminary results When making treatment altering decisions urine should always be sent for confirmatory testing

Urine Testing

42

Urine Detection Limits

Alcohol 6 - 12 hours

EtG (ethylglucuronide) 4 days

Amphetaminesmeth 2 - 3 days

Benzos (short-acting) 3 days

Cocaine 3 - 4 days

Morphine 2 days

Marijuana (THC) 3 - 30+ days

Methadone 2 - 4 days

Buprenorphine 2 - 4 days

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

Adapted from Helander et al 2009 Moeller et al 2008

NIDA Neurobio of Addiction (2016 In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

43

Urine Drug Testing Stimulants

Amphetamine Methamphetamine

bull False positives pseudoephedrine bupropion labetolol ranitidine trazodone TCAs

bull Low sensitivity for detection of MDMA

bull 2 methamphetamine isomers d (CNS) and l (peripheral)

Cocaine

bull Primary metabolite benzoyleconine

bull False positives rare (coca leaf tea adulterated natural products)

Opiates

bull Tests for morphine-based substances

bull Unreliable for synthetic opioids like oxycodone

44

Summary

Alcohol use disorder is a common and deadly illness

with significant comorbidities

Alcohol withdrawal management does not treat AUD

It is important to understand key concepts in other

drug use disorders

Urine drug testing is an important piece to clinical

decision making

45

References

Disease ImCenters for Disease Control and Prevention (CDC) Alcohol-Related pact (ARDI) Atlanta GA CDC

Epidemiology of DSM-5 Alcohol Use Disorder Results From the National Epidemiologic Survey on Alcohol and Related Conditions III Grant BF1 Goldstein RB1 Saha TD1 Chou SP1 Jung J1 Zhang H1 Pickering RP1 Ruan WJ1 Smith SM1 Huang B1 Hasin DS2

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment Levounis Zerbo and Aggarwal Eds

Stahre M Roeber J Kanny D Brewer RD Zhang X Contribution of excessive alcohol consumption to deaths and years of potential life lost in the United States Prev Chronic Dis 201411130293

18

Detox is not treatment

Alcohol withdrawal is an

acute complication of a

chronic medical condition

Treating the acute

complication does not treat

the underlying condition

Most Importantly

19

Be aware of standard drink sizes and common terms

Understand the impact on BAL and clinical vs legal

intoxication

Routinely screen all patients for alcohol use disorders

Be able to identify alcohol withdrawal symptoms and

basic treatment strategies

Remember that Detox is not treatment

Alcohol Summary

20

Tom is a 61 year old man with an alcohol

use disorder

He was sober and in recovery from

36 ndash 60 years of age

At 60 he was prescribed Xanax for

anxiety

ldquoI did not even know what they gave me As soon as I took it I had a powerful urge to drink alcohol It was as if I had never stopped drinkingrdquo

He relapsed on alcohol and over the past year has struggled

He is now presenting for treatment of alcohol use disorder

Clinical Presentation

21

Alprazolam (Xanax) diazepam (Valium)

lorazepam (Ativan) clonazepam

(Klonopin) chlordiazepoxide (Librium)

and temazepam (Restoril) are the most

common

Indicated and useful for anxiety and

insomnia if properly monitored though

not considered first line for either

Pharmacologic overlap with alcohol

Benzodiazepines

22

Benzodiazepines (continued)

Do not fly the plane unless you know how to land

ldquoBarsrdquo = Xanax 2 mg

Can cause overdose death when mixed with opioids or alcohol

Often mixed with alcohol to magnify the high

Withdrawal can be protracted and dangerous

Common cause of falls and delirium in elderly

23

ldquoWhen I start to run out I begin crawling

around on the carpet looking for any

little bit I can find

Then I look around and think every car

car outside is the police and they

are after me

Then I look in the mirror my eyes are bloodshot and my heart is racing I feel awful and paranoid

Then I say to myself that I will NEVER do this again

Then I do it again the next dayrdquo

Clinical Presentation

24

Dopamine reuptake inhibitor

Leads to supraphysiologic dopamine release

Crack is mixed with a base smoked and is

highly addictive

Was widely used recreationally prior to 1914

including mixed with alcohol (Vin Mariani)

Snorting 146 minutes to peak

Injecting 31 minutes to peak

Smoking 14 minutes to peak

Cocaine

25

ldquoWoe to you my princess when I come I will

kiss you quite red and feed you til you are

plump And if you are forward you shall

see who is the stronger a gentle little girl

who doesnrsquot eat enough or a big wild man

who has cocaine in his body In my last

depression I took coca again and a small

dose lifted me to the heights in a wonderful

fashion I am just now busy collecting

literature for a song of praise to this magical

substancerdquo

Cocaine

26

Acute

bull Pleasure alertness energy sexuality tachycardia hallucinations paranoia hypertension

Crash

bull Peaks 2-4 days but up to a week of prolonged dysthymia hypersomnolence irritability suicidality cravings

Chronic

bull Profound anhedonia and other long term consequences dependent on route of admin

Cocaine

27

Chris is a 40-year old male who presents

to clinic seeking help with anxiety He reports

chronic anxiety with worry and ruminations

He also reports occasional panic attacks

He has tried SSRIs in the past with minimal

improvement He is currently smoking

marijuana daily and states that it is the only

thing that helps

He is willing to try a new medication but unwilling to stop smoking marijuana

Clinical Presentation

28

ldquoMarijuanardquo is the term for the plant Cannabis

THC = Tetrahydrocannabinol = psychoactive

CBD = Cannabidiol = sedating not psychoactive

Sativa and Indica differ in THCCBD ratio

Marijuana the herb is generally dried flowers

Hashish is a resin with higher THC levels and generally heated in a pipe or eaten

Hash oil is the most potent and can be smoked ingested or used topically

Marijuana

29

Joint marijuana rolled in paper

Fatty larger amount of marijuana

Doobie rolled with king size paper

Blunt Rolled with cigar wrapper and contains tobacco

Pipes (also known as bowls) are usually glass and rarely have a filter

Bongs contain water filter

Marijuana

30

Marijuana Legal Status

31

Marijuana Effects

Acute Intoxication

bull Improved mood increased well-being calmness relaxation

and sociability

bull Increased self-confidence magical thinking distorted

perception of time and space increased sensory perception

bull Tachycardia palpitations vasodilation conjunctival

irritation dry mouth increased appetite

bull Anxiety panic confusion hallucinations paranoia

psychosis

Withdrawal

bull Anxiety depression mood changes GI distress decreased

appetite insomnia irritability

32

First Illicit Drug Used

Figure from SAMHSA

33

Marijuana

34

ldquoIt bothers me that people are so stupid as to use

this stuffrdquo ndash John W Huffman developer

Sprayed on dried plant material or inhaled in

vaporizer

Marketed as ldquonot for human consumptionrdquo and were

sold legally under hundreds of brands most notably

K2 and Spice

Synthetic Cannabinoids

35

False belief that these are ldquonaturalrdquo and thus harmless

They are also not detected in routine drug screens

Acute effects are very unpredictable and generally

less pleasant than natural cannabis

Psychotic symptoms include extreme anxiety

confusion paranoia and hallucinations

Synthetic Cannabinoids

36

Mike is a 23 year old who presents

to the ER with paranoia

He reports holding a loaded gun

and pointing it at people outside of his

window thinking they were all trying

to kill him

He previously used meth heavily but has recently cut down

His last use was 3 days ago

Clinical Presentation

37

Janice is a 36 year old female who presented to the ER seeking

help with methamphetamine addiction

She appears older than stated age and is very thin

She has several missing teeth and otherwise poor

dentition

Her skin has multiple lesions

ldquoWhen I first starting smoking ice it felt so good Now it no longer feels like that

I do not even get much pleasure out of it any more I do not get pleasure out

of anything anymore I have no desire to see family or friends or do the things

I used to love I wish I could have fun like I used tordquo

Clinical Presentation

38

Crystal Ice Glass

Leads to an acute increase in synaptic dopamine concentration through various mechanisms

Can be prescribed as Desoxyn for

ADHD

Prominent in the western region of US and made famous by Breaking Bad

television series

Many accidents and fires are associated

with ldquobackyardrdquo meth labs

Methamphetamine

39

Mental illness and co-morbid or co-occurring substance use disorder is common

Approximately 13 of all people with mental illness and 12 with severe mental illness also have a substance use disorder

Self medication hypothesis vs substance

induced disorder

Multi-modal parallel or integrated treatment approach is most effective

Dual Diagnosis

Data from SAMHSA

40

Toxicology Screening

Urine most common method given cost and ease of collection Problem adulteration and substitution

bull On-site rapid testing

bull Immunoassay (initial lab screen)

bull GCMS

Blood better for quantitative analysis detection of acute intoxication Problem invasive detection for shorter periods than urine

Saliva Non-invasive lower potential for adulteration than urine Problem higher detection threshold and greater cost

Sweat Can identify substances over longer period of time Problem difficult to collect and quantify

Hair Easy to collect less likelihood of adulteration provides qualitative account of history of ingestion Problem poor at detecting acute intoxication more labor-intensive to process

41

Screening for drugs in healthy individuals

with no prior suspicion

bull Workplace or athletic testing

Testing for drugs in ill persons with a prior suspicion of use

Monitoring for drugs as part of a pain management or treatment program

While reliable on-site urine drug testing offers preliminary results When making treatment altering decisions urine should always be sent for confirmatory testing

Urine Testing

42

Urine Detection Limits

Alcohol 6 - 12 hours

EtG (ethylglucuronide) 4 days

Amphetaminesmeth 2 - 3 days

Benzos (short-acting) 3 days

Cocaine 3 - 4 days

Morphine 2 days

Marijuana (THC) 3 - 30+ days

Methadone 2 - 4 days

Buprenorphine 2 - 4 days

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

Adapted from Helander et al 2009 Moeller et al 2008

NIDA Neurobio of Addiction (2016 In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

43

Urine Drug Testing Stimulants

Amphetamine Methamphetamine

bull False positives pseudoephedrine bupropion labetolol ranitidine trazodone TCAs

bull Low sensitivity for detection of MDMA

bull 2 methamphetamine isomers d (CNS) and l (peripheral)

Cocaine

bull Primary metabolite benzoyleconine

bull False positives rare (coca leaf tea adulterated natural products)

Opiates

bull Tests for morphine-based substances

bull Unreliable for synthetic opioids like oxycodone

44

Summary

Alcohol use disorder is a common and deadly illness

with significant comorbidities

Alcohol withdrawal management does not treat AUD

It is important to understand key concepts in other

drug use disorders

Urine drug testing is an important piece to clinical

decision making

45

References

Disease ImCenters for Disease Control and Prevention (CDC) Alcohol-Related pact (ARDI) Atlanta GA CDC

Epidemiology of DSM-5 Alcohol Use Disorder Results From the National Epidemiologic Survey on Alcohol and Related Conditions III Grant BF1 Goldstein RB1 Saha TD1 Chou SP1 Jung J1 Zhang H1 Pickering RP1 Ruan WJ1 Smith SM1 Huang B1 Hasin DS2

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment Levounis Zerbo and Aggarwal Eds

Stahre M Roeber J Kanny D Brewer RD Zhang X Contribution of excessive alcohol consumption to deaths and years of potential life lost in the United States Prev Chronic Dis 201411130293

19

Be aware of standard drink sizes and common terms

Understand the impact on BAL and clinical vs legal

intoxication

Routinely screen all patients for alcohol use disorders

Be able to identify alcohol withdrawal symptoms and

basic treatment strategies

Remember that Detox is not treatment

Alcohol Summary

20

Tom is a 61 year old man with an alcohol

use disorder

He was sober and in recovery from

36 ndash 60 years of age

At 60 he was prescribed Xanax for

anxiety

ldquoI did not even know what they gave me As soon as I took it I had a powerful urge to drink alcohol It was as if I had never stopped drinkingrdquo

He relapsed on alcohol and over the past year has struggled

He is now presenting for treatment of alcohol use disorder

Clinical Presentation

21

Alprazolam (Xanax) diazepam (Valium)

lorazepam (Ativan) clonazepam

(Klonopin) chlordiazepoxide (Librium)

and temazepam (Restoril) are the most

common

Indicated and useful for anxiety and

insomnia if properly monitored though

not considered first line for either

Pharmacologic overlap with alcohol

Benzodiazepines

22

Benzodiazepines (continued)

Do not fly the plane unless you know how to land

ldquoBarsrdquo = Xanax 2 mg

Can cause overdose death when mixed with opioids or alcohol

Often mixed with alcohol to magnify the high

Withdrawal can be protracted and dangerous

Common cause of falls and delirium in elderly

23

ldquoWhen I start to run out I begin crawling

around on the carpet looking for any

little bit I can find

Then I look around and think every car

car outside is the police and they

are after me

Then I look in the mirror my eyes are bloodshot and my heart is racing I feel awful and paranoid

Then I say to myself that I will NEVER do this again

Then I do it again the next dayrdquo

Clinical Presentation

24

Dopamine reuptake inhibitor

Leads to supraphysiologic dopamine release

Crack is mixed with a base smoked and is

highly addictive

Was widely used recreationally prior to 1914

including mixed with alcohol (Vin Mariani)

Snorting 146 minutes to peak

Injecting 31 minutes to peak

Smoking 14 minutes to peak

Cocaine

25

ldquoWoe to you my princess when I come I will

kiss you quite red and feed you til you are

plump And if you are forward you shall

see who is the stronger a gentle little girl

who doesnrsquot eat enough or a big wild man

who has cocaine in his body In my last

depression I took coca again and a small

dose lifted me to the heights in a wonderful

fashion I am just now busy collecting

literature for a song of praise to this magical

substancerdquo

Cocaine

26

Acute

bull Pleasure alertness energy sexuality tachycardia hallucinations paranoia hypertension

Crash

bull Peaks 2-4 days but up to a week of prolonged dysthymia hypersomnolence irritability suicidality cravings

Chronic

bull Profound anhedonia and other long term consequences dependent on route of admin

Cocaine

27

Chris is a 40-year old male who presents

to clinic seeking help with anxiety He reports

chronic anxiety with worry and ruminations

He also reports occasional panic attacks

He has tried SSRIs in the past with minimal

improvement He is currently smoking

marijuana daily and states that it is the only

thing that helps

He is willing to try a new medication but unwilling to stop smoking marijuana

Clinical Presentation

28

ldquoMarijuanardquo is the term for the plant Cannabis

THC = Tetrahydrocannabinol = psychoactive

CBD = Cannabidiol = sedating not psychoactive

Sativa and Indica differ in THCCBD ratio

Marijuana the herb is generally dried flowers

Hashish is a resin with higher THC levels and generally heated in a pipe or eaten

Hash oil is the most potent and can be smoked ingested or used topically

Marijuana

29

Joint marijuana rolled in paper

Fatty larger amount of marijuana

Doobie rolled with king size paper

Blunt Rolled with cigar wrapper and contains tobacco

Pipes (also known as bowls) are usually glass and rarely have a filter

Bongs contain water filter

Marijuana

30

Marijuana Legal Status

31

Marijuana Effects

Acute Intoxication

bull Improved mood increased well-being calmness relaxation

and sociability

bull Increased self-confidence magical thinking distorted

perception of time and space increased sensory perception

bull Tachycardia palpitations vasodilation conjunctival

irritation dry mouth increased appetite

bull Anxiety panic confusion hallucinations paranoia

psychosis

Withdrawal

bull Anxiety depression mood changes GI distress decreased

appetite insomnia irritability

32

First Illicit Drug Used

Figure from SAMHSA

33

Marijuana

34

ldquoIt bothers me that people are so stupid as to use

this stuffrdquo ndash John W Huffman developer

Sprayed on dried plant material or inhaled in

vaporizer

Marketed as ldquonot for human consumptionrdquo and were

sold legally under hundreds of brands most notably

K2 and Spice

Synthetic Cannabinoids

35

False belief that these are ldquonaturalrdquo and thus harmless

They are also not detected in routine drug screens

Acute effects are very unpredictable and generally

less pleasant than natural cannabis

Psychotic symptoms include extreme anxiety

confusion paranoia and hallucinations

Synthetic Cannabinoids

36

Mike is a 23 year old who presents

to the ER with paranoia

He reports holding a loaded gun

and pointing it at people outside of his

window thinking they were all trying

to kill him

He previously used meth heavily but has recently cut down

His last use was 3 days ago

Clinical Presentation

37

Janice is a 36 year old female who presented to the ER seeking

help with methamphetamine addiction

She appears older than stated age and is very thin

She has several missing teeth and otherwise poor

dentition

Her skin has multiple lesions

ldquoWhen I first starting smoking ice it felt so good Now it no longer feels like that

I do not even get much pleasure out of it any more I do not get pleasure out

of anything anymore I have no desire to see family or friends or do the things

I used to love I wish I could have fun like I used tordquo

Clinical Presentation

38

Crystal Ice Glass

Leads to an acute increase in synaptic dopamine concentration through various mechanisms

Can be prescribed as Desoxyn for

ADHD

Prominent in the western region of US and made famous by Breaking Bad

television series

Many accidents and fires are associated

with ldquobackyardrdquo meth labs

Methamphetamine

39

Mental illness and co-morbid or co-occurring substance use disorder is common

Approximately 13 of all people with mental illness and 12 with severe mental illness also have a substance use disorder

Self medication hypothesis vs substance

induced disorder

Multi-modal parallel or integrated treatment approach is most effective

Dual Diagnosis

Data from SAMHSA

40

Toxicology Screening

Urine most common method given cost and ease of collection Problem adulteration and substitution

bull On-site rapid testing

bull Immunoassay (initial lab screen)

bull GCMS

Blood better for quantitative analysis detection of acute intoxication Problem invasive detection for shorter periods than urine

Saliva Non-invasive lower potential for adulteration than urine Problem higher detection threshold and greater cost

Sweat Can identify substances over longer period of time Problem difficult to collect and quantify

Hair Easy to collect less likelihood of adulteration provides qualitative account of history of ingestion Problem poor at detecting acute intoxication more labor-intensive to process

41

Screening for drugs in healthy individuals

with no prior suspicion

bull Workplace or athletic testing

Testing for drugs in ill persons with a prior suspicion of use

Monitoring for drugs as part of a pain management or treatment program

While reliable on-site urine drug testing offers preliminary results When making treatment altering decisions urine should always be sent for confirmatory testing

Urine Testing

42

Urine Detection Limits

Alcohol 6 - 12 hours

EtG (ethylglucuronide) 4 days

Amphetaminesmeth 2 - 3 days

Benzos (short-acting) 3 days

Cocaine 3 - 4 days

Morphine 2 days

Marijuana (THC) 3 - 30+ days

Methadone 2 - 4 days

Buprenorphine 2 - 4 days

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

Adapted from Helander et al 2009 Moeller et al 2008

NIDA Neurobio of Addiction (2016 In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

43

Urine Drug Testing Stimulants

Amphetamine Methamphetamine

bull False positives pseudoephedrine bupropion labetolol ranitidine trazodone TCAs

bull Low sensitivity for detection of MDMA

bull 2 methamphetamine isomers d (CNS) and l (peripheral)

Cocaine

bull Primary metabolite benzoyleconine

bull False positives rare (coca leaf tea adulterated natural products)

Opiates

bull Tests for morphine-based substances

bull Unreliable for synthetic opioids like oxycodone

44

Summary

Alcohol use disorder is a common and deadly illness

with significant comorbidities

Alcohol withdrawal management does not treat AUD

It is important to understand key concepts in other

drug use disorders

Urine drug testing is an important piece to clinical

decision making

45

References

Disease ImCenters for Disease Control and Prevention (CDC) Alcohol-Related pact (ARDI) Atlanta GA CDC

Epidemiology of DSM-5 Alcohol Use Disorder Results From the National Epidemiologic Survey on Alcohol and Related Conditions III Grant BF1 Goldstein RB1 Saha TD1 Chou SP1 Jung J1 Zhang H1 Pickering RP1 Ruan WJ1 Smith SM1 Huang B1 Hasin DS2

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment Levounis Zerbo and Aggarwal Eds

Stahre M Roeber J Kanny D Brewer RD Zhang X Contribution of excessive alcohol consumption to deaths and years of potential life lost in the United States Prev Chronic Dis 201411130293

20

Tom is a 61 year old man with an alcohol

use disorder

He was sober and in recovery from

36 ndash 60 years of age

At 60 he was prescribed Xanax for

anxiety

ldquoI did not even know what they gave me As soon as I took it I had a powerful urge to drink alcohol It was as if I had never stopped drinkingrdquo

He relapsed on alcohol and over the past year has struggled

He is now presenting for treatment of alcohol use disorder

Clinical Presentation

21

Alprazolam (Xanax) diazepam (Valium)

lorazepam (Ativan) clonazepam

(Klonopin) chlordiazepoxide (Librium)

and temazepam (Restoril) are the most

common

Indicated and useful for anxiety and

insomnia if properly monitored though

not considered first line for either

Pharmacologic overlap with alcohol

Benzodiazepines

22

Benzodiazepines (continued)

Do not fly the plane unless you know how to land

ldquoBarsrdquo = Xanax 2 mg

Can cause overdose death when mixed with opioids or alcohol

Often mixed with alcohol to magnify the high

Withdrawal can be protracted and dangerous

Common cause of falls and delirium in elderly

23

ldquoWhen I start to run out I begin crawling

around on the carpet looking for any

little bit I can find

Then I look around and think every car

car outside is the police and they

are after me

Then I look in the mirror my eyes are bloodshot and my heart is racing I feel awful and paranoid

Then I say to myself that I will NEVER do this again

Then I do it again the next dayrdquo

Clinical Presentation

24

Dopamine reuptake inhibitor

Leads to supraphysiologic dopamine release

Crack is mixed with a base smoked and is

highly addictive

Was widely used recreationally prior to 1914

including mixed with alcohol (Vin Mariani)

Snorting 146 minutes to peak

Injecting 31 minutes to peak

Smoking 14 minutes to peak

Cocaine

25

ldquoWoe to you my princess when I come I will

kiss you quite red and feed you til you are

plump And if you are forward you shall

see who is the stronger a gentle little girl

who doesnrsquot eat enough or a big wild man

who has cocaine in his body In my last

depression I took coca again and a small

dose lifted me to the heights in a wonderful

fashion I am just now busy collecting

literature for a song of praise to this magical

substancerdquo

Cocaine

26

Acute

bull Pleasure alertness energy sexuality tachycardia hallucinations paranoia hypertension

Crash

bull Peaks 2-4 days but up to a week of prolonged dysthymia hypersomnolence irritability suicidality cravings

Chronic

bull Profound anhedonia and other long term consequences dependent on route of admin

Cocaine

27

Chris is a 40-year old male who presents

to clinic seeking help with anxiety He reports

chronic anxiety with worry and ruminations

He also reports occasional panic attacks

He has tried SSRIs in the past with minimal

improvement He is currently smoking

marijuana daily and states that it is the only

thing that helps

He is willing to try a new medication but unwilling to stop smoking marijuana

Clinical Presentation

28

ldquoMarijuanardquo is the term for the plant Cannabis

THC = Tetrahydrocannabinol = psychoactive

CBD = Cannabidiol = sedating not psychoactive

Sativa and Indica differ in THCCBD ratio

Marijuana the herb is generally dried flowers

Hashish is a resin with higher THC levels and generally heated in a pipe or eaten

Hash oil is the most potent and can be smoked ingested or used topically

Marijuana

29

Joint marijuana rolled in paper

Fatty larger amount of marijuana

Doobie rolled with king size paper

Blunt Rolled with cigar wrapper and contains tobacco

Pipes (also known as bowls) are usually glass and rarely have a filter

Bongs contain water filter

Marijuana

30

Marijuana Legal Status

31

Marijuana Effects

Acute Intoxication

bull Improved mood increased well-being calmness relaxation

and sociability

bull Increased self-confidence magical thinking distorted

perception of time and space increased sensory perception

bull Tachycardia palpitations vasodilation conjunctival

irritation dry mouth increased appetite

bull Anxiety panic confusion hallucinations paranoia

psychosis

Withdrawal

bull Anxiety depression mood changes GI distress decreased

appetite insomnia irritability

32

First Illicit Drug Used

Figure from SAMHSA

33

Marijuana

34

ldquoIt bothers me that people are so stupid as to use

this stuffrdquo ndash John W Huffman developer

Sprayed on dried plant material or inhaled in

vaporizer

Marketed as ldquonot for human consumptionrdquo and were

sold legally under hundreds of brands most notably

K2 and Spice

Synthetic Cannabinoids

35

False belief that these are ldquonaturalrdquo and thus harmless

They are also not detected in routine drug screens

Acute effects are very unpredictable and generally

less pleasant than natural cannabis

Psychotic symptoms include extreme anxiety

confusion paranoia and hallucinations

Synthetic Cannabinoids

36

Mike is a 23 year old who presents

to the ER with paranoia

He reports holding a loaded gun

and pointing it at people outside of his

window thinking they were all trying

to kill him

He previously used meth heavily but has recently cut down

His last use was 3 days ago

Clinical Presentation

37

Janice is a 36 year old female who presented to the ER seeking

help with methamphetamine addiction

She appears older than stated age and is very thin

She has several missing teeth and otherwise poor

dentition

Her skin has multiple lesions

ldquoWhen I first starting smoking ice it felt so good Now it no longer feels like that

I do not even get much pleasure out of it any more I do not get pleasure out

of anything anymore I have no desire to see family or friends or do the things

I used to love I wish I could have fun like I used tordquo

Clinical Presentation

38

Crystal Ice Glass

Leads to an acute increase in synaptic dopamine concentration through various mechanisms

Can be prescribed as Desoxyn for

ADHD

Prominent in the western region of US and made famous by Breaking Bad

television series

Many accidents and fires are associated

with ldquobackyardrdquo meth labs

Methamphetamine

39

Mental illness and co-morbid or co-occurring substance use disorder is common

Approximately 13 of all people with mental illness and 12 with severe mental illness also have a substance use disorder

Self medication hypothesis vs substance

induced disorder

Multi-modal parallel or integrated treatment approach is most effective

Dual Diagnosis

Data from SAMHSA

40

Toxicology Screening

Urine most common method given cost and ease of collection Problem adulteration and substitution

bull On-site rapid testing

bull Immunoassay (initial lab screen)

bull GCMS

Blood better for quantitative analysis detection of acute intoxication Problem invasive detection for shorter periods than urine

Saliva Non-invasive lower potential for adulteration than urine Problem higher detection threshold and greater cost

Sweat Can identify substances over longer period of time Problem difficult to collect and quantify

Hair Easy to collect less likelihood of adulteration provides qualitative account of history of ingestion Problem poor at detecting acute intoxication more labor-intensive to process

41

Screening for drugs in healthy individuals

with no prior suspicion

bull Workplace or athletic testing

Testing for drugs in ill persons with a prior suspicion of use

Monitoring for drugs as part of a pain management or treatment program

While reliable on-site urine drug testing offers preliminary results When making treatment altering decisions urine should always be sent for confirmatory testing

Urine Testing

42

Urine Detection Limits

Alcohol 6 - 12 hours

EtG (ethylglucuronide) 4 days

Amphetaminesmeth 2 - 3 days

Benzos (short-acting) 3 days

Cocaine 3 - 4 days

Morphine 2 days

Marijuana (THC) 3 - 30+ days

Methadone 2 - 4 days

Buprenorphine 2 - 4 days

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

Adapted from Helander et al 2009 Moeller et al 2008

NIDA Neurobio of Addiction (2016 In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

43

Urine Drug Testing Stimulants

Amphetamine Methamphetamine

bull False positives pseudoephedrine bupropion labetolol ranitidine trazodone TCAs

bull Low sensitivity for detection of MDMA

bull 2 methamphetamine isomers d (CNS) and l (peripheral)

Cocaine

bull Primary metabolite benzoyleconine

bull False positives rare (coca leaf tea adulterated natural products)

Opiates

bull Tests for morphine-based substances

bull Unreliable for synthetic opioids like oxycodone

44

Summary

Alcohol use disorder is a common and deadly illness

with significant comorbidities

Alcohol withdrawal management does not treat AUD

It is important to understand key concepts in other

drug use disorders

Urine drug testing is an important piece to clinical

decision making

45

References

Disease ImCenters for Disease Control and Prevention (CDC) Alcohol-Related pact (ARDI) Atlanta GA CDC

Epidemiology of DSM-5 Alcohol Use Disorder Results From the National Epidemiologic Survey on Alcohol and Related Conditions III Grant BF1 Goldstein RB1 Saha TD1 Chou SP1 Jung J1 Zhang H1 Pickering RP1 Ruan WJ1 Smith SM1 Huang B1 Hasin DS2

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment Levounis Zerbo and Aggarwal Eds

Stahre M Roeber J Kanny D Brewer RD Zhang X Contribution of excessive alcohol consumption to deaths and years of potential life lost in the United States Prev Chronic Dis 201411130293

21

Alprazolam (Xanax) diazepam (Valium)

lorazepam (Ativan) clonazepam

(Klonopin) chlordiazepoxide (Librium)

and temazepam (Restoril) are the most

common

Indicated and useful for anxiety and

insomnia if properly monitored though

not considered first line for either

Pharmacologic overlap with alcohol

Benzodiazepines

22

Benzodiazepines (continued)

Do not fly the plane unless you know how to land

ldquoBarsrdquo = Xanax 2 mg

Can cause overdose death when mixed with opioids or alcohol

Often mixed with alcohol to magnify the high

Withdrawal can be protracted and dangerous

Common cause of falls and delirium in elderly

23

ldquoWhen I start to run out I begin crawling

around on the carpet looking for any

little bit I can find

Then I look around and think every car

car outside is the police and they

are after me

Then I look in the mirror my eyes are bloodshot and my heart is racing I feel awful and paranoid

Then I say to myself that I will NEVER do this again

Then I do it again the next dayrdquo

Clinical Presentation

24

Dopamine reuptake inhibitor

Leads to supraphysiologic dopamine release

Crack is mixed with a base smoked and is

highly addictive

Was widely used recreationally prior to 1914

including mixed with alcohol (Vin Mariani)

Snorting 146 minutes to peak

Injecting 31 minutes to peak

Smoking 14 minutes to peak

Cocaine

25

ldquoWoe to you my princess when I come I will

kiss you quite red and feed you til you are

plump And if you are forward you shall

see who is the stronger a gentle little girl

who doesnrsquot eat enough or a big wild man

who has cocaine in his body In my last

depression I took coca again and a small

dose lifted me to the heights in a wonderful

fashion I am just now busy collecting

literature for a song of praise to this magical

substancerdquo

Cocaine

26

Acute

bull Pleasure alertness energy sexuality tachycardia hallucinations paranoia hypertension

Crash

bull Peaks 2-4 days but up to a week of prolonged dysthymia hypersomnolence irritability suicidality cravings

Chronic

bull Profound anhedonia and other long term consequences dependent on route of admin

Cocaine

27

Chris is a 40-year old male who presents

to clinic seeking help with anxiety He reports

chronic anxiety with worry and ruminations

He also reports occasional panic attacks

He has tried SSRIs in the past with minimal

improvement He is currently smoking

marijuana daily and states that it is the only

thing that helps

He is willing to try a new medication but unwilling to stop smoking marijuana

Clinical Presentation

28

ldquoMarijuanardquo is the term for the plant Cannabis

THC = Tetrahydrocannabinol = psychoactive

CBD = Cannabidiol = sedating not psychoactive

Sativa and Indica differ in THCCBD ratio

Marijuana the herb is generally dried flowers

Hashish is a resin with higher THC levels and generally heated in a pipe or eaten

Hash oil is the most potent and can be smoked ingested or used topically

Marijuana

29

Joint marijuana rolled in paper

Fatty larger amount of marijuana

Doobie rolled with king size paper

Blunt Rolled with cigar wrapper and contains tobacco

Pipes (also known as bowls) are usually glass and rarely have a filter

Bongs contain water filter

Marijuana

30

Marijuana Legal Status

31

Marijuana Effects

Acute Intoxication

bull Improved mood increased well-being calmness relaxation

and sociability

bull Increased self-confidence magical thinking distorted

perception of time and space increased sensory perception

bull Tachycardia palpitations vasodilation conjunctival

irritation dry mouth increased appetite

bull Anxiety panic confusion hallucinations paranoia

psychosis

Withdrawal

bull Anxiety depression mood changes GI distress decreased

appetite insomnia irritability

32

First Illicit Drug Used

Figure from SAMHSA

33

Marijuana

34

ldquoIt bothers me that people are so stupid as to use

this stuffrdquo ndash John W Huffman developer

Sprayed on dried plant material or inhaled in

vaporizer

Marketed as ldquonot for human consumptionrdquo and were

sold legally under hundreds of brands most notably

K2 and Spice

Synthetic Cannabinoids

35

False belief that these are ldquonaturalrdquo and thus harmless

They are also not detected in routine drug screens

Acute effects are very unpredictable and generally

less pleasant than natural cannabis

Psychotic symptoms include extreme anxiety

confusion paranoia and hallucinations

Synthetic Cannabinoids

36

Mike is a 23 year old who presents

to the ER with paranoia

He reports holding a loaded gun

and pointing it at people outside of his

window thinking they were all trying

to kill him

He previously used meth heavily but has recently cut down

His last use was 3 days ago

Clinical Presentation

37

Janice is a 36 year old female who presented to the ER seeking

help with methamphetamine addiction

She appears older than stated age and is very thin

She has several missing teeth and otherwise poor

dentition

Her skin has multiple lesions

ldquoWhen I first starting smoking ice it felt so good Now it no longer feels like that

I do not even get much pleasure out of it any more I do not get pleasure out

of anything anymore I have no desire to see family or friends or do the things

I used to love I wish I could have fun like I used tordquo

Clinical Presentation

38

Crystal Ice Glass

Leads to an acute increase in synaptic dopamine concentration through various mechanisms

Can be prescribed as Desoxyn for

ADHD

Prominent in the western region of US and made famous by Breaking Bad

television series

Many accidents and fires are associated

with ldquobackyardrdquo meth labs

Methamphetamine

39

Mental illness and co-morbid or co-occurring substance use disorder is common

Approximately 13 of all people with mental illness and 12 with severe mental illness also have a substance use disorder

Self medication hypothesis vs substance

induced disorder

Multi-modal parallel or integrated treatment approach is most effective

Dual Diagnosis

Data from SAMHSA

40

Toxicology Screening

Urine most common method given cost and ease of collection Problem adulteration and substitution

bull On-site rapid testing

bull Immunoassay (initial lab screen)

bull GCMS

Blood better for quantitative analysis detection of acute intoxication Problem invasive detection for shorter periods than urine

Saliva Non-invasive lower potential for adulteration than urine Problem higher detection threshold and greater cost

Sweat Can identify substances over longer period of time Problem difficult to collect and quantify

Hair Easy to collect less likelihood of adulteration provides qualitative account of history of ingestion Problem poor at detecting acute intoxication more labor-intensive to process

41

Screening for drugs in healthy individuals

with no prior suspicion

bull Workplace or athletic testing

Testing for drugs in ill persons with a prior suspicion of use

Monitoring for drugs as part of a pain management or treatment program

While reliable on-site urine drug testing offers preliminary results When making treatment altering decisions urine should always be sent for confirmatory testing

Urine Testing

42

Urine Detection Limits

Alcohol 6 - 12 hours

EtG (ethylglucuronide) 4 days

Amphetaminesmeth 2 - 3 days

Benzos (short-acting) 3 days

Cocaine 3 - 4 days

Morphine 2 days

Marijuana (THC) 3 - 30+ days

Methadone 2 - 4 days

Buprenorphine 2 - 4 days

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

Adapted from Helander et al 2009 Moeller et al 2008

NIDA Neurobio of Addiction (2016 In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

43

Urine Drug Testing Stimulants

Amphetamine Methamphetamine

bull False positives pseudoephedrine bupropion labetolol ranitidine trazodone TCAs

bull Low sensitivity for detection of MDMA

bull 2 methamphetamine isomers d (CNS) and l (peripheral)

Cocaine

bull Primary metabolite benzoyleconine

bull False positives rare (coca leaf tea adulterated natural products)

Opiates

bull Tests for morphine-based substances

bull Unreliable for synthetic opioids like oxycodone

44

Summary

Alcohol use disorder is a common and deadly illness

with significant comorbidities

Alcohol withdrawal management does not treat AUD

It is important to understand key concepts in other

drug use disorders

Urine drug testing is an important piece to clinical

decision making

45

References

Disease ImCenters for Disease Control and Prevention (CDC) Alcohol-Related pact (ARDI) Atlanta GA CDC

Epidemiology of DSM-5 Alcohol Use Disorder Results From the National Epidemiologic Survey on Alcohol and Related Conditions III Grant BF1 Goldstein RB1 Saha TD1 Chou SP1 Jung J1 Zhang H1 Pickering RP1 Ruan WJ1 Smith SM1 Huang B1 Hasin DS2

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment Levounis Zerbo and Aggarwal Eds

Stahre M Roeber J Kanny D Brewer RD Zhang X Contribution of excessive alcohol consumption to deaths and years of potential life lost in the United States Prev Chronic Dis 201411130293

22

Benzodiazepines (continued)

Do not fly the plane unless you know how to land

ldquoBarsrdquo = Xanax 2 mg

Can cause overdose death when mixed with opioids or alcohol

Often mixed with alcohol to magnify the high

Withdrawal can be protracted and dangerous

Common cause of falls and delirium in elderly

23

ldquoWhen I start to run out I begin crawling

around on the carpet looking for any

little bit I can find

Then I look around and think every car

car outside is the police and they

are after me

Then I look in the mirror my eyes are bloodshot and my heart is racing I feel awful and paranoid

Then I say to myself that I will NEVER do this again

Then I do it again the next dayrdquo

Clinical Presentation

24

Dopamine reuptake inhibitor

Leads to supraphysiologic dopamine release

Crack is mixed with a base smoked and is

highly addictive

Was widely used recreationally prior to 1914

including mixed with alcohol (Vin Mariani)

Snorting 146 minutes to peak

Injecting 31 minutes to peak

Smoking 14 minutes to peak

Cocaine

25

ldquoWoe to you my princess when I come I will

kiss you quite red and feed you til you are

plump And if you are forward you shall

see who is the stronger a gentle little girl

who doesnrsquot eat enough or a big wild man

who has cocaine in his body In my last

depression I took coca again and a small

dose lifted me to the heights in a wonderful

fashion I am just now busy collecting

literature for a song of praise to this magical

substancerdquo

Cocaine

26

Acute

bull Pleasure alertness energy sexuality tachycardia hallucinations paranoia hypertension

Crash

bull Peaks 2-4 days but up to a week of prolonged dysthymia hypersomnolence irritability suicidality cravings

Chronic

bull Profound anhedonia and other long term consequences dependent on route of admin

Cocaine

27

Chris is a 40-year old male who presents

to clinic seeking help with anxiety He reports

chronic anxiety with worry and ruminations

He also reports occasional panic attacks

He has tried SSRIs in the past with minimal

improvement He is currently smoking

marijuana daily and states that it is the only

thing that helps

He is willing to try a new medication but unwilling to stop smoking marijuana

Clinical Presentation

28

ldquoMarijuanardquo is the term for the plant Cannabis

THC = Tetrahydrocannabinol = psychoactive

CBD = Cannabidiol = sedating not psychoactive

Sativa and Indica differ in THCCBD ratio

Marijuana the herb is generally dried flowers

Hashish is a resin with higher THC levels and generally heated in a pipe or eaten

Hash oil is the most potent and can be smoked ingested or used topically

Marijuana

29

Joint marijuana rolled in paper

Fatty larger amount of marijuana

Doobie rolled with king size paper

Blunt Rolled with cigar wrapper and contains tobacco

Pipes (also known as bowls) are usually glass and rarely have a filter

Bongs contain water filter

Marijuana

30

Marijuana Legal Status

31

Marijuana Effects

Acute Intoxication

bull Improved mood increased well-being calmness relaxation

and sociability

bull Increased self-confidence magical thinking distorted

perception of time and space increased sensory perception

bull Tachycardia palpitations vasodilation conjunctival

irritation dry mouth increased appetite

bull Anxiety panic confusion hallucinations paranoia

psychosis

Withdrawal

bull Anxiety depression mood changes GI distress decreased

appetite insomnia irritability

32

First Illicit Drug Used

Figure from SAMHSA

33

Marijuana

34

ldquoIt bothers me that people are so stupid as to use

this stuffrdquo ndash John W Huffman developer

Sprayed on dried plant material or inhaled in

vaporizer

Marketed as ldquonot for human consumptionrdquo and were

sold legally under hundreds of brands most notably

K2 and Spice

Synthetic Cannabinoids

35

False belief that these are ldquonaturalrdquo and thus harmless

They are also not detected in routine drug screens

Acute effects are very unpredictable and generally

less pleasant than natural cannabis

Psychotic symptoms include extreme anxiety

confusion paranoia and hallucinations

Synthetic Cannabinoids

36

Mike is a 23 year old who presents

to the ER with paranoia

He reports holding a loaded gun

and pointing it at people outside of his

window thinking they were all trying

to kill him

He previously used meth heavily but has recently cut down

His last use was 3 days ago

Clinical Presentation

37

Janice is a 36 year old female who presented to the ER seeking

help with methamphetamine addiction

She appears older than stated age and is very thin

She has several missing teeth and otherwise poor

dentition

Her skin has multiple lesions

ldquoWhen I first starting smoking ice it felt so good Now it no longer feels like that

I do not even get much pleasure out of it any more I do not get pleasure out

of anything anymore I have no desire to see family or friends or do the things

I used to love I wish I could have fun like I used tordquo

Clinical Presentation

38

Crystal Ice Glass

Leads to an acute increase in synaptic dopamine concentration through various mechanisms

Can be prescribed as Desoxyn for

ADHD

Prominent in the western region of US and made famous by Breaking Bad

television series

Many accidents and fires are associated

with ldquobackyardrdquo meth labs

Methamphetamine

39

Mental illness and co-morbid or co-occurring substance use disorder is common

Approximately 13 of all people with mental illness and 12 with severe mental illness also have a substance use disorder

Self medication hypothesis vs substance

induced disorder

Multi-modal parallel or integrated treatment approach is most effective

Dual Diagnosis

Data from SAMHSA

40

Toxicology Screening

Urine most common method given cost and ease of collection Problem adulteration and substitution

bull On-site rapid testing

bull Immunoassay (initial lab screen)

bull GCMS

Blood better for quantitative analysis detection of acute intoxication Problem invasive detection for shorter periods than urine

Saliva Non-invasive lower potential for adulteration than urine Problem higher detection threshold and greater cost

Sweat Can identify substances over longer period of time Problem difficult to collect and quantify

Hair Easy to collect less likelihood of adulteration provides qualitative account of history of ingestion Problem poor at detecting acute intoxication more labor-intensive to process

41

Screening for drugs in healthy individuals

with no prior suspicion

bull Workplace or athletic testing

Testing for drugs in ill persons with a prior suspicion of use

Monitoring for drugs as part of a pain management or treatment program

While reliable on-site urine drug testing offers preliminary results When making treatment altering decisions urine should always be sent for confirmatory testing

Urine Testing

42

Urine Detection Limits

Alcohol 6 - 12 hours

EtG (ethylglucuronide) 4 days

Amphetaminesmeth 2 - 3 days

Benzos (short-acting) 3 days

Cocaine 3 - 4 days

Morphine 2 days

Marijuana (THC) 3 - 30+ days

Methadone 2 - 4 days

Buprenorphine 2 - 4 days

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

Adapted from Helander et al 2009 Moeller et al 2008

NIDA Neurobio of Addiction (2016 In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

43

Urine Drug Testing Stimulants

Amphetamine Methamphetamine

bull False positives pseudoephedrine bupropion labetolol ranitidine trazodone TCAs

bull Low sensitivity for detection of MDMA

bull 2 methamphetamine isomers d (CNS) and l (peripheral)

Cocaine

bull Primary metabolite benzoyleconine

bull False positives rare (coca leaf tea adulterated natural products)

Opiates

bull Tests for morphine-based substances

bull Unreliable for synthetic opioids like oxycodone

44

Summary

Alcohol use disorder is a common and deadly illness

with significant comorbidities

Alcohol withdrawal management does not treat AUD

It is important to understand key concepts in other

drug use disorders

Urine drug testing is an important piece to clinical

decision making

45

References

Disease ImCenters for Disease Control and Prevention (CDC) Alcohol-Related pact (ARDI) Atlanta GA CDC

Epidemiology of DSM-5 Alcohol Use Disorder Results From the National Epidemiologic Survey on Alcohol and Related Conditions III Grant BF1 Goldstein RB1 Saha TD1 Chou SP1 Jung J1 Zhang H1 Pickering RP1 Ruan WJ1 Smith SM1 Huang B1 Hasin DS2

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment Levounis Zerbo and Aggarwal Eds

Stahre M Roeber J Kanny D Brewer RD Zhang X Contribution of excessive alcohol consumption to deaths and years of potential life lost in the United States Prev Chronic Dis 201411130293

23

ldquoWhen I start to run out I begin crawling

around on the carpet looking for any

little bit I can find

Then I look around and think every car

car outside is the police and they

are after me

Then I look in the mirror my eyes are bloodshot and my heart is racing I feel awful and paranoid

Then I say to myself that I will NEVER do this again

Then I do it again the next dayrdquo

Clinical Presentation

24

Dopamine reuptake inhibitor

Leads to supraphysiologic dopamine release

Crack is mixed with a base smoked and is

highly addictive

Was widely used recreationally prior to 1914

including mixed with alcohol (Vin Mariani)

Snorting 146 minutes to peak

Injecting 31 minutes to peak

Smoking 14 minutes to peak

Cocaine

25

ldquoWoe to you my princess when I come I will

kiss you quite red and feed you til you are

plump And if you are forward you shall

see who is the stronger a gentle little girl

who doesnrsquot eat enough or a big wild man

who has cocaine in his body In my last

depression I took coca again and a small

dose lifted me to the heights in a wonderful

fashion I am just now busy collecting

literature for a song of praise to this magical

substancerdquo

Cocaine

26

Acute

bull Pleasure alertness energy sexuality tachycardia hallucinations paranoia hypertension

Crash

bull Peaks 2-4 days but up to a week of prolonged dysthymia hypersomnolence irritability suicidality cravings

Chronic

bull Profound anhedonia and other long term consequences dependent on route of admin

Cocaine

27

Chris is a 40-year old male who presents

to clinic seeking help with anxiety He reports

chronic anxiety with worry and ruminations

He also reports occasional panic attacks

He has tried SSRIs in the past with minimal

improvement He is currently smoking

marijuana daily and states that it is the only

thing that helps

He is willing to try a new medication but unwilling to stop smoking marijuana

Clinical Presentation

28

ldquoMarijuanardquo is the term for the plant Cannabis

THC = Tetrahydrocannabinol = psychoactive

CBD = Cannabidiol = sedating not psychoactive

Sativa and Indica differ in THCCBD ratio

Marijuana the herb is generally dried flowers

Hashish is a resin with higher THC levels and generally heated in a pipe or eaten

Hash oil is the most potent and can be smoked ingested or used topically

Marijuana

29

Joint marijuana rolled in paper

Fatty larger amount of marijuana

Doobie rolled with king size paper

Blunt Rolled with cigar wrapper and contains tobacco

Pipes (also known as bowls) are usually glass and rarely have a filter

Bongs contain water filter

Marijuana

30

Marijuana Legal Status

31

Marijuana Effects

Acute Intoxication

bull Improved mood increased well-being calmness relaxation

and sociability

bull Increased self-confidence magical thinking distorted

perception of time and space increased sensory perception

bull Tachycardia palpitations vasodilation conjunctival

irritation dry mouth increased appetite

bull Anxiety panic confusion hallucinations paranoia

psychosis

Withdrawal

bull Anxiety depression mood changes GI distress decreased

appetite insomnia irritability

32

First Illicit Drug Used

Figure from SAMHSA

33

Marijuana

34

ldquoIt bothers me that people are so stupid as to use

this stuffrdquo ndash John W Huffman developer

Sprayed on dried plant material or inhaled in

vaporizer

Marketed as ldquonot for human consumptionrdquo and were

sold legally under hundreds of brands most notably

K2 and Spice

Synthetic Cannabinoids

35

False belief that these are ldquonaturalrdquo and thus harmless

They are also not detected in routine drug screens

Acute effects are very unpredictable and generally

less pleasant than natural cannabis

Psychotic symptoms include extreme anxiety

confusion paranoia and hallucinations

Synthetic Cannabinoids

36

Mike is a 23 year old who presents

to the ER with paranoia

He reports holding a loaded gun

and pointing it at people outside of his

window thinking they were all trying

to kill him

He previously used meth heavily but has recently cut down

His last use was 3 days ago

Clinical Presentation

37

Janice is a 36 year old female who presented to the ER seeking

help with methamphetamine addiction

She appears older than stated age and is very thin

She has several missing teeth and otherwise poor

dentition

Her skin has multiple lesions

ldquoWhen I first starting smoking ice it felt so good Now it no longer feels like that

I do not even get much pleasure out of it any more I do not get pleasure out

of anything anymore I have no desire to see family or friends or do the things

I used to love I wish I could have fun like I used tordquo

Clinical Presentation

38

Crystal Ice Glass

Leads to an acute increase in synaptic dopamine concentration through various mechanisms

Can be prescribed as Desoxyn for

ADHD

Prominent in the western region of US and made famous by Breaking Bad

television series

Many accidents and fires are associated

with ldquobackyardrdquo meth labs

Methamphetamine

39

Mental illness and co-morbid or co-occurring substance use disorder is common

Approximately 13 of all people with mental illness and 12 with severe mental illness also have a substance use disorder

Self medication hypothesis vs substance

induced disorder

Multi-modal parallel or integrated treatment approach is most effective

Dual Diagnosis

Data from SAMHSA

40

Toxicology Screening

Urine most common method given cost and ease of collection Problem adulteration and substitution

bull On-site rapid testing

bull Immunoassay (initial lab screen)

bull GCMS

Blood better for quantitative analysis detection of acute intoxication Problem invasive detection for shorter periods than urine

Saliva Non-invasive lower potential for adulteration than urine Problem higher detection threshold and greater cost

Sweat Can identify substances over longer period of time Problem difficult to collect and quantify

Hair Easy to collect less likelihood of adulteration provides qualitative account of history of ingestion Problem poor at detecting acute intoxication more labor-intensive to process

41

Screening for drugs in healthy individuals

with no prior suspicion

bull Workplace or athletic testing

Testing for drugs in ill persons with a prior suspicion of use

Monitoring for drugs as part of a pain management or treatment program

While reliable on-site urine drug testing offers preliminary results When making treatment altering decisions urine should always be sent for confirmatory testing

Urine Testing

42

Urine Detection Limits

Alcohol 6 - 12 hours

EtG (ethylglucuronide) 4 days

Amphetaminesmeth 2 - 3 days

Benzos (short-acting) 3 days

Cocaine 3 - 4 days

Morphine 2 days

Marijuana (THC) 3 - 30+ days

Methadone 2 - 4 days

Buprenorphine 2 - 4 days

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

Adapted from Helander et al 2009 Moeller et al 2008

NIDA Neurobio of Addiction (2016 In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

43

Urine Drug Testing Stimulants

Amphetamine Methamphetamine

bull False positives pseudoephedrine bupropion labetolol ranitidine trazodone TCAs

bull Low sensitivity for detection of MDMA

bull 2 methamphetamine isomers d (CNS) and l (peripheral)

Cocaine

bull Primary metabolite benzoyleconine

bull False positives rare (coca leaf tea adulterated natural products)

Opiates

bull Tests for morphine-based substances

bull Unreliable for synthetic opioids like oxycodone

44

Summary

Alcohol use disorder is a common and deadly illness

with significant comorbidities

Alcohol withdrawal management does not treat AUD

It is important to understand key concepts in other

drug use disorders

Urine drug testing is an important piece to clinical

decision making

45

References

Disease ImCenters for Disease Control and Prevention (CDC) Alcohol-Related pact (ARDI) Atlanta GA CDC

Epidemiology of DSM-5 Alcohol Use Disorder Results From the National Epidemiologic Survey on Alcohol and Related Conditions III Grant BF1 Goldstein RB1 Saha TD1 Chou SP1 Jung J1 Zhang H1 Pickering RP1 Ruan WJ1 Smith SM1 Huang B1 Hasin DS2

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment Levounis Zerbo and Aggarwal Eds

Stahre M Roeber J Kanny D Brewer RD Zhang X Contribution of excessive alcohol consumption to deaths and years of potential life lost in the United States Prev Chronic Dis 201411130293

24

Dopamine reuptake inhibitor

Leads to supraphysiologic dopamine release

Crack is mixed with a base smoked and is

highly addictive

Was widely used recreationally prior to 1914

including mixed with alcohol (Vin Mariani)

Snorting 146 minutes to peak

Injecting 31 minutes to peak

Smoking 14 minutes to peak

Cocaine

25

ldquoWoe to you my princess when I come I will

kiss you quite red and feed you til you are

plump And if you are forward you shall

see who is the stronger a gentle little girl

who doesnrsquot eat enough or a big wild man

who has cocaine in his body In my last

depression I took coca again and a small

dose lifted me to the heights in a wonderful

fashion I am just now busy collecting

literature for a song of praise to this magical

substancerdquo

Cocaine

26

Acute

bull Pleasure alertness energy sexuality tachycardia hallucinations paranoia hypertension

Crash

bull Peaks 2-4 days but up to a week of prolonged dysthymia hypersomnolence irritability suicidality cravings

Chronic

bull Profound anhedonia and other long term consequences dependent on route of admin

Cocaine

27

Chris is a 40-year old male who presents

to clinic seeking help with anxiety He reports

chronic anxiety with worry and ruminations

He also reports occasional panic attacks

He has tried SSRIs in the past with minimal

improvement He is currently smoking

marijuana daily and states that it is the only

thing that helps

He is willing to try a new medication but unwilling to stop smoking marijuana

Clinical Presentation

28

ldquoMarijuanardquo is the term for the plant Cannabis

THC = Tetrahydrocannabinol = psychoactive

CBD = Cannabidiol = sedating not psychoactive

Sativa and Indica differ in THCCBD ratio

Marijuana the herb is generally dried flowers

Hashish is a resin with higher THC levels and generally heated in a pipe or eaten

Hash oil is the most potent and can be smoked ingested or used topically

Marijuana

29

Joint marijuana rolled in paper

Fatty larger amount of marijuana

Doobie rolled with king size paper

Blunt Rolled with cigar wrapper and contains tobacco

Pipes (also known as bowls) are usually glass and rarely have a filter

Bongs contain water filter

Marijuana

30

Marijuana Legal Status

31

Marijuana Effects

Acute Intoxication

bull Improved mood increased well-being calmness relaxation

and sociability

bull Increased self-confidence magical thinking distorted

perception of time and space increased sensory perception

bull Tachycardia palpitations vasodilation conjunctival

irritation dry mouth increased appetite

bull Anxiety panic confusion hallucinations paranoia

psychosis

Withdrawal

bull Anxiety depression mood changes GI distress decreased

appetite insomnia irritability

32

First Illicit Drug Used

Figure from SAMHSA

33

Marijuana

34

ldquoIt bothers me that people are so stupid as to use

this stuffrdquo ndash John W Huffman developer

Sprayed on dried plant material or inhaled in

vaporizer

Marketed as ldquonot for human consumptionrdquo and were

sold legally under hundreds of brands most notably

K2 and Spice

Synthetic Cannabinoids

35

False belief that these are ldquonaturalrdquo and thus harmless

They are also not detected in routine drug screens

Acute effects are very unpredictable and generally

less pleasant than natural cannabis

Psychotic symptoms include extreme anxiety

confusion paranoia and hallucinations

Synthetic Cannabinoids

36

Mike is a 23 year old who presents

to the ER with paranoia

He reports holding a loaded gun

and pointing it at people outside of his

window thinking they were all trying

to kill him

He previously used meth heavily but has recently cut down

His last use was 3 days ago

Clinical Presentation

37

Janice is a 36 year old female who presented to the ER seeking

help with methamphetamine addiction

She appears older than stated age and is very thin

She has several missing teeth and otherwise poor

dentition

Her skin has multiple lesions

ldquoWhen I first starting smoking ice it felt so good Now it no longer feels like that

I do not even get much pleasure out of it any more I do not get pleasure out

of anything anymore I have no desire to see family or friends or do the things

I used to love I wish I could have fun like I used tordquo

Clinical Presentation

38

Crystal Ice Glass

Leads to an acute increase in synaptic dopamine concentration through various mechanisms

Can be prescribed as Desoxyn for

ADHD

Prominent in the western region of US and made famous by Breaking Bad

television series

Many accidents and fires are associated

with ldquobackyardrdquo meth labs

Methamphetamine

39

Mental illness and co-morbid or co-occurring substance use disorder is common

Approximately 13 of all people with mental illness and 12 with severe mental illness also have a substance use disorder

Self medication hypothesis vs substance

induced disorder

Multi-modal parallel or integrated treatment approach is most effective

Dual Diagnosis

Data from SAMHSA

40

Toxicology Screening

Urine most common method given cost and ease of collection Problem adulteration and substitution

bull On-site rapid testing

bull Immunoassay (initial lab screen)

bull GCMS

Blood better for quantitative analysis detection of acute intoxication Problem invasive detection for shorter periods than urine

Saliva Non-invasive lower potential for adulteration than urine Problem higher detection threshold and greater cost

Sweat Can identify substances over longer period of time Problem difficult to collect and quantify

Hair Easy to collect less likelihood of adulteration provides qualitative account of history of ingestion Problem poor at detecting acute intoxication more labor-intensive to process

41

Screening for drugs in healthy individuals

with no prior suspicion

bull Workplace or athletic testing

Testing for drugs in ill persons with a prior suspicion of use

Monitoring for drugs as part of a pain management or treatment program

While reliable on-site urine drug testing offers preliminary results When making treatment altering decisions urine should always be sent for confirmatory testing

Urine Testing

42

Urine Detection Limits

Alcohol 6 - 12 hours

EtG (ethylglucuronide) 4 days

Amphetaminesmeth 2 - 3 days

Benzos (short-acting) 3 days

Cocaine 3 - 4 days

Morphine 2 days

Marijuana (THC) 3 - 30+ days

Methadone 2 - 4 days

Buprenorphine 2 - 4 days

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

Adapted from Helander et al 2009 Moeller et al 2008

NIDA Neurobio of Addiction (2016 In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

43

Urine Drug Testing Stimulants

Amphetamine Methamphetamine

bull False positives pseudoephedrine bupropion labetolol ranitidine trazodone TCAs

bull Low sensitivity for detection of MDMA

bull 2 methamphetamine isomers d (CNS) and l (peripheral)

Cocaine

bull Primary metabolite benzoyleconine

bull False positives rare (coca leaf tea adulterated natural products)

Opiates

bull Tests for morphine-based substances

bull Unreliable for synthetic opioids like oxycodone

44

Summary

Alcohol use disorder is a common and deadly illness

with significant comorbidities

Alcohol withdrawal management does not treat AUD

It is important to understand key concepts in other

drug use disorders

Urine drug testing is an important piece to clinical

decision making

45

References

Disease ImCenters for Disease Control and Prevention (CDC) Alcohol-Related pact (ARDI) Atlanta GA CDC

Epidemiology of DSM-5 Alcohol Use Disorder Results From the National Epidemiologic Survey on Alcohol and Related Conditions III Grant BF1 Goldstein RB1 Saha TD1 Chou SP1 Jung J1 Zhang H1 Pickering RP1 Ruan WJ1 Smith SM1 Huang B1 Hasin DS2

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment Levounis Zerbo and Aggarwal Eds

Stahre M Roeber J Kanny D Brewer RD Zhang X Contribution of excessive alcohol consumption to deaths and years of potential life lost in the United States Prev Chronic Dis 201411130293

25

ldquoWoe to you my princess when I come I will

kiss you quite red and feed you til you are

plump And if you are forward you shall

see who is the stronger a gentle little girl

who doesnrsquot eat enough or a big wild man

who has cocaine in his body In my last

depression I took coca again and a small

dose lifted me to the heights in a wonderful

fashion I am just now busy collecting

literature for a song of praise to this magical

substancerdquo

Cocaine

26

Acute

bull Pleasure alertness energy sexuality tachycardia hallucinations paranoia hypertension

Crash

bull Peaks 2-4 days but up to a week of prolonged dysthymia hypersomnolence irritability suicidality cravings

Chronic

bull Profound anhedonia and other long term consequences dependent on route of admin

Cocaine

27

Chris is a 40-year old male who presents

to clinic seeking help with anxiety He reports

chronic anxiety with worry and ruminations

He also reports occasional panic attacks

He has tried SSRIs in the past with minimal

improvement He is currently smoking

marijuana daily and states that it is the only

thing that helps

He is willing to try a new medication but unwilling to stop smoking marijuana

Clinical Presentation

28

ldquoMarijuanardquo is the term for the plant Cannabis

THC = Tetrahydrocannabinol = psychoactive

CBD = Cannabidiol = sedating not psychoactive

Sativa and Indica differ in THCCBD ratio

Marijuana the herb is generally dried flowers

Hashish is a resin with higher THC levels and generally heated in a pipe or eaten

Hash oil is the most potent and can be smoked ingested or used topically

Marijuana

29

Joint marijuana rolled in paper

Fatty larger amount of marijuana

Doobie rolled with king size paper

Blunt Rolled with cigar wrapper and contains tobacco

Pipes (also known as bowls) are usually glass and rarely have a filter

Bongs contain water filter

Marijuana

30

Marijuana Legal Status

31

Marijuana Effects

Acute Intoxication

bull Improved mood increased well-being calmness relaxation

and sociability

bull Increased self-confidence magical thinking distorted

perception of time and space increased sensory perception

bull Tachycardia palpitations vasodilation conjunctival

irritation dry mouth increased appetite

bull Anxiety panic confusion hallucinations paranoia

psychosis

Withdrawal

bull Anxiety depression mood changes GI distress decreased

appetite insomnia irritability

32

First Illicit Drug Used

Figure from SAMHSA

33

Marijuana

34

ldquoIt bothers me that people are so stupid as to use

this stuffrdquo ndash John W Huffman developer

Sprayed on dried plant material or inhaled in

vaporizer

Marketed as ldquonot for human consumptionrdquo and were

sold legally under hundreds of brands most notably

K2 and Spice

Synthetic Cannabinoids

35

False belief that these are ldquonaturalrdquo and thus harmless

They are also not detected in routine drug screens

Acute effects are very unpredictable and generally

less pleasant than natural cannabis

Psychotic symptoms include extreme anxiety

confusion paranoia and hallucinations

Synthetic Cannabinoids

36

Mike is a 23 year old who presents

to the ER with paranoia

He reports holding a loaded gun

and pointing it at people outside of his

window thinking they were all trying

to kill him

He previously used meth heavily but has recently cut down

His last use was 3 days ago

Clinical Presentation

37

Janice is a 36 year old female who presented to the ER seeking

help with methamphetamine addiction

She appears older than stated age and is very thin

She has several missing teeth and otherwise poor

dentition

Her skin has multiple lesions

ldquoWhen I first starting smoking ice it felt so good Now it no longer feels like that

I do not even get much pleasure out of it any more I do not get pleasure out

of anything anymore I have no desire to see family or friends or do the things

I used to love I wish I could have fun like I used tordquo

Clinical Presentation

38

Crystal Ice Glass

Leads to an acute increase in synaptic dopamine concentration through various mechanisms

Can be prescribed as Desoxyn for

ADHD

Prominent in the western region of US and made famous by Breaking Bad

television series

Many accidents and fires are associated

with ldquobackyardrdquo meth labs

Methamphetamine

39

Mental illness and co-morbid or co-occurring substance use disorder is common

Approximately 13 of all people with mental illness and 12 with severe mental illness also have a substance use disorder

Self medication hypothesis vs substance

induced disorder

Multi-modal parallel or integrated treatment approach is most effective

Dual Diagnosis

Data from SAMHSA

40

Toxicology Screening

Urine most common method given cost and ease of collection Problem adulteration and substitution

bull On-site rapid testing

bull Immunoassay (initial lab screen)

bull GCMS

Blood better for quantitative analysis detection of acute intoxication Problem invasive detection for shorter periods than urine

Saliva Non-invasive lower potential for adulteration than urine Problem higher detection threshold and greater cost

Sweat Can identify substances over longer period of time Problem difficult to collect and quantify

Hair Easy to collect less likelihood of adulteration provides qualitative account of history of ingestion Problem poor at detecting acute intoxication more labor-intensive to process

41

Screening for drugs in healthy individuals

with no prior suspicion

bull Workplace or athletic testing

Testing for drugs in ill persons with a prior suspicion of use

Monitoring for drugs as part of a pain management or treatment program

While reliable on-site urine drug testing offers preliminary results When making treatment altering decisions urine should always be sent for confirmatory testing

Urine Testing

42

Urine Detection Limits

Alcohol 6 - 12 hours

EtG (ethylglucuronide) 4 days

Amphetaminesmeth 2 - 3 days

Benzos (short-acting) 3 days

Cocaine 3 - 4 days

Morphine 2 days

Marijuana (THC) 3 - 30+ days

Methadone 2 - 4 days

Buprenorphine 2 - 4 days

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

Adapted from Helander et al 2009 Moeller et al 2008

NIDA Neurobio of Addiction (2016 In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

43

Urine Drug Testing Stimulants

Amphetamine Methamphetamine

bull False positives pseudoephedrine bupropion labetolol ranitidine trazodone TCAs

bull Low sensitivity for detection of MDMA

bull 2 methamphetamine isomers d (CNS) and l (peripheral)

Cocaine

bull Primary metabolite benzoyleconine

bull False positives rare (coca leaf tea adulterated natural products)

Opiates

bull Tests for morphine-based substances

bull Unreliable for synthetic opioids like oxycodone

44

Summary

Alcohol use disorder is a common and deadly illness

with significant comorbidities

Alcohol withdrawal management does not treat AUD

It is important to understand key concepts in other

drug use disorders

Urine drug testing is an important piece to clinical

decision making

45

References

Disease ImCenters for Disease Control and Prevention (CDC) Alcohol-Related pact (ARDI) Atlanta GA CDC

Epidemiology of DSM-5 Alcohol Use Disorder Results From the National Epidemiologic Survey on Alcohol and Related Conditions III Grant BF1 Goldstein RB1 Saha TD1 Chou SP1 Jung J1 Zhang H1 Pickering RP1 Ruan WJ1 Smith SM1 Huang B1 Hasin DS2

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment Levounis Zerbo and Aggarwal Eds

Stahre M Roeber J Kanny D Brewer RD Zhang X Contribution of excessive alcohol consumption to deaths and years of potential life lost in the United States Prev Chronic Dis 201411130293

26

Acute

bull Pleasure alertness energy sexuality tachycardia hallucinations paranoia hypertension

Crash

bull Peaks 2-4 days but up to a week of prolonged dysthymia hypersomnolence irritability suicidality cravings

Chronic

bull Profound anhedonia and other long term consequences dependent on route of admin

Cocaine

27

Chris is a 40-year old male who presents

to clinic seeking help with anxiety He reports

chronic anxiety with worry and ruminations

He also reports occasional panic attacks

He has tried SSRIs in the past with minimal

improvement He is currently smoking

marijuana daily and states that it is the only

thing that helps

He is willing to try a new medication but unwilling to stop smoking marijuana

Clinical Presentation

28

ldquoMarijuanardquo is the term for the plant Cannabis

THC = Tetrahydrocannabinol = psychoactive

CBD = Cannabidiol = sedating not psychoactive

Sativa and Indica differ in THCCBD ratio

Marijuana the herb is generally dried flowers

Hashish is a resin with higher THC levels and generally heated in a pipe or eaten

Hash oil is the most potent and can be smoked ingested or used topically

Marijuana

29

Joint marijuana rolled in paper

Fatty larger amount of marijuana

Doobie rolled with king size paper

Blunt Rolled with cigar wrapper and contains tobacco

Pipes (also known as bowls) are usually glass and rarely have a filter

Bongs contain water filter

Marijuana

30

Marijuana Legal Status

31

Marijuana Effects

Acute Intoxication

bull Improved mood increased well-being calmness relaxation

and sociability

bull Increased self-confidence magical thinking distorted

perception of time and space increased sensory perception

bull Tachycardia palpitations vasodilation conjunctival

irritation dry mouth increased appetite

bull Anxiety panic confusion hallucinations paranoia

psychosis

Withdrawal

bull Anxiety depression mood changes GI distress decreased

appetite insomnia irritability

32

First Illicit Drug Used

Figure from SAMHSA

33

Marijuana

34

ldquoIt bothers me that people are so stupid as to use

this stuffrdquo ndash John W Huffman developer

Sprayed on dried plant material or inhaled in

vaporizer

Marketed as ldquonot for human consumptionrdquo and were

sold legally under hundreds of brands most notably

K2 and Spice

Synthetic Cannabinoids

35

False belief that these are ldquonaturalrdquo and thus harmless

They are also not detected in routine drug screens

Acute effects are very unpredictable and generally

less pleasant than natural cannabis

Psychotic symptoms include extreme anxiety

confusion paranoia and hallucinations

Synthetic Cannabinoids

36

Mike is a 23 year old who presents

to the ER with paranoia

He reports holding a loaded gun

and pointing it at people outside of his

window thinking they were all trying

to kill him

He previously used meth heavily but has recently cut down

His last use was 3 days ago

Clinical Presentation

37

Janice is a 36 year old female who presented to the ER seeking

help with methamphetamine addiction

She appears older than stated age and is very thin

She has several missing teeth and otherwise poor

dentition

Her skin has multiple lesions

ldquoWhen I first starting smoking ice it felt so good Now it no longer feels like that

I do not even get much pleasure out of it any more I do not get pleasure out

of anything anymore I have no desire to see family or friends or do the things

I used to love I wish I could have fun like I used tordquo

Clinical Presentation

38

Crystal Ice Glass

Leads to an acute increase in synaptic dopamine concentration through various mechanisms

Can be prescribed as Desoxyn for

ADHD

Prominent in the western region of US and made famous by Breaking Bad

television series

Many accidents and fires are associated

with ldquobackyardrdquo meth labs

Methamphetamine

39

Mental illness and co-morbid or co-occurring substance use disorder is common

Approximately 13 of all people with mental illness and 12 with severe mental illness also have a substance use disorder

Self medication hypothesis vs substance

induced disorder

Multi-modal parallel or integrated treatment approach is most effective

Dual Diagnosis

Data from SAMHSA

40

Toxicology Screening

Urine most common method given cost and ease of collection Problem adulteration and substitution

bull On-site rapid testing

bull Immunoassay (initial lab screen)

bull GCMS

Blood better for quantitative analysis detection of acute intoxication Problem invasive detection for shorter periods than urine

Saliva Non-invasive lower potential for adulteration than urine Problem higher detection threshold and greater cost

Sweat Can identify substances over longer period of time Problem difficult to collect and quantify

Hair Easy to collect less likelihood of adulteration provides qualitative account of history of ingestion Problem poor at detecting acute intoxication more labor-intensive to process

41

Screening for drugs in healthy individuals

with no prior suspicion

bull Workplace or athletic testing

Testing for drugs in ill persons with a prior suspicion of use

Monitoring for drugs as part of a pain management or treatment program

While reliable on-site urine drug testing offers preliminary results When making treatment altering decisions urine should always be sent for confirmatory testing

Urine Testing

42

Urine Detection Limits

Alcohol 6 - 12 hours

EtG (ethylglucuronide) 4 days

Amphetaminesmeth 2 - 3 days

Benzos (short-acting) 3 days

Cocaine 3 - 4 days

Morphine 2 days

Marijuana (THC) 3 - 30+ days

Methadone 2 - 4 days

Buprenorphine 2 - 4 days

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

Adapted from Helander et al 2009 Moeller et al 2008

NIDA Neurobio of Addiction (2016 In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

43

Urine Drug Testing Stimulants

Amphetamine Methamphetamine

bull False positives pseudoephedrine bupropion labetolol ranitidine trazodone TCAs

bull Low sensitivity for detection of MDMA

bull 2 methamphetamine isomers d (CNS) and l (peripheral)

Cocaine

bull Primary metabolite benzoyleconine

bull False positives rare (coca leaf tea adulterated natural products)

Opiates

bull Tests for morphine-based substances

bull Unreliable for synthetic opioids like oxycodone

44

Summary

Alcohol use disorder is a common and deadly illness

with significant comorbidities

Alcohol withdrawal management does not treat AUD

It is important to understand key concepts in other

drug use disorders

Urine drug testing is an important piece to clinical

decision making

45

References

Disease ImCenters for Disease Control and Prevention (CDC) Alcohol-Related pact (ARDI) Atlanta GA CDC

Epidemiology of DSM-5 Alcohol Use Disorder Results From the National Epidemiologic Survey on Alcohol and Related Conditions III Grant BF1 Goldstein RB1 Saha TD1 Chou SP1 Jung J1 Zhang H1 Pickering RP1 Ruan WJ1 Smith SM1 Huang B1 Hasin DS2

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment Levounis Zerbo and Aggarwal Eds

Stahre M Roeber J Kanny D Brewer RD Zhang X Contribution of excessive alcohol consumption to deaths and years of potential life lost in the United States Prev Chronic Dis 201411130293

27

Chris is a 40-year old male who presents

to clinic seeking help with anxiety He reports

chronic anxiety with worry and ruminations

He also reports occasional panic attacks

He has tried SSRIs in the past with minimal

improvement He is currently smoking

marijuana daily and states that it is the only

thing that helps

He is willing to try a new medication but unwilling to stop smoking marijuana

Clinical Presentation

28

ldquoMarijuanardquo is the term for the plant Cannabis

THC = Tetrahydrocannabinol = psychoactive

CBD = Cannabidiol = sedating not psychoactive

Sativa and Indica differ in THCCBD ratio

Marijuana the herb is generally dried flowers

Hashish is a resin with higher THC levels and generally heated in a pipe or eaten

Hash oil is the most potent and can be smoked ingested or used topically

Marijuana

29

Joint marijuana rolled in paper

Fatty larger amount of marijuana

Doobie rolled with king size paper

Blunt Rolled with cigar wrapper and contains tobacco

Pipes (also known as bowls) are usually glass and rarely have a filter

Bongs contain water filter

Marijuana

30

Marijuana Legal Status

31

Marijuana Effects

Acute Intoxication

bull Improved mood increased well-being calmness relaxation

and sociability

bull Increased self-confidence magical thinking distorted

perception of time and space increased sensory perception

bull Tachycardia palpitations vasodilation conjunctival

irritation dry mouth increased appetite

bull Anxiety panic confusion hallucinations paranoia

psychosis

Withdrawal

bull Anxiety depression mood changes GI distress decreased

appetite insomnia irritability

32

First Illicit Drug Used

Figure from SAMHSA

33

Marijuana

34

ldquoIt bothers me that people are so stupid as to use

this stuffrdquo ndash John W Huffman developer

Sprayed on dried plant material or inhaled in

vaporizer

Marketed as ldquonot for human consumptionrdquo and were

sold legally under hundreds of brands most notably

K2 and Spice

Synthetic Cannabinoids

35

False belief that these are ldquonaturalrdquo and thus harmless

They are also not detected in routine drug screens

Acute effects are very unpredictable and generally

less pleasant than natural cannabis

Psychotic symptoms include extreme anxiety

confusion paranoia and hallucinations

Synthetic Cannabinoids

36

Mike is a 23 year old who presents

to the ER with paranoia

He reports holding a loaded gun

and pointing it at people outside of his

window thinking they were all trying

to kill him

He previously used meth heavily but has recently cut down

His last use was 3 days ago

Clinical Presentation

37

Janice is a 36 year old female who presented to the ER seeking

help with methamphetamine addiction

She appears older than stated age and is very thin

She has several missing teeth and otherwise poor

dentition

Her skin has multiple lesions

ldquoWhen I first starting smoking ice it felt so good Now it no longer feels like that

I do not even get much pleasure out of it any more I do not get pleasure out

of anything anymore I have no desire to see family or friends or do the things

I used to love I wish I could have fun like I used tordquo

Clinical Presentation

38

Crystal Ice Glass

Leads to an acute increase in synaptic dopamine concentration through various mechanisms

Can be prescribed as Desoxyn for

ADHD

Prominent in the western region of US and made famous by Breaking Bad

television series

Many accidents and fires are associated

with ldquobackyardrdquo meth labs

Methamphetamine

39

Mental illness and co-morbid or co-occurring substance use disorder is common

Approximately 13 of all people with mental illness and 12 with severe mental illness also have a substance use disorder

Self medication hypothesis vs substance

induced disorder

Multi-modal parallel or integrated treatment approach is most effective

Dual Diagnosis

Data from SAMHSA

40

Toxicology Screening

Urine most common method given cost and ease of collection Problem adulteration and substitution

bull On-site rapid testing

bull Immunoassay (initial lab screen)

bull GCMS

Blood better for quantitative analysis detection of acute intoxication Problem invasive detection for shorter periods than urine

Saliva Non-invasive lower potential for adulteration than urine Problem higher detection threshold and greater cost

Sweat Can identify substances over longer period of time Problem difficult to collect and quantify

Hair Easy to collect less likelihood of adulteration provides qualitative account of history of ingestion Problem poor at detecting acute intoxication more labor-intensive to process

41

Screening for drugs in healthy individuals

with no prior suspicion

bull Workplace or athletic testing

Testing for drugs in ill persons with a prior suspicion of use

Monitoring for drugs as part of a pain management or treatment program

While reliable on-site urine drug testing offers preliminary results When making treatment altering decisions urine should always be sent for confirmatory testing

Urine Testing

42

Urine Detection Limits

Alcohol 6 - 12 hours

EtG (ethylglucuronide) 4 days

Amphetaminesmeth 2 - 3 days

Benzos (short-acting) 3 days

Cocaine 3 - 4 days

Morphine 2 days

Marijuana (THC) 3 - 30+ days

Methadone 2 - 4 days

Buprenorphine 2 - 4 days

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

Adapted from Helander et al 2009 Moeller et al 2008

NIDA Neurobio of Addiction (2016 In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

43

Urine Drug Testing Stimulants

Amphetamine Methamphetamine

bull False positives pseudoephedrine bupropion labetolol ranitidine trazodone TCAs

bull Low sensitivity for detection of MDMA

bull 2 methamphetamine isomers d (CNS) and l (peripheral)

Cocaine

bull Primary metabolite benzoyleconine

bull False positives rare (coca leaf tea adulterated natural products)

Opiates

bull Tests for morphine-based substances

bull Unreliable for synthetic opioids like oxycodone

44

Summary

Alcohol use disorder is a common and deadly illness

with significant comorbidities

Alcohol withdrawal management does not treat AUD

It is important to understand key concepts in other

drug use disorders

Urine drug testing is an important piece to clinical

decision making

45

References

Disease ImCenters for Disease Control and Prevention (CDC) Alcohol-Related pact (ARDI) Atlanta GA CDC

Epidemiology of DSM-5 Alcohol Use Disorder Results From the National Epidemiologic Survey on Alcohol and Related Conditions III Grant BF1 Goldstein RB1 Saha TD1 Chou SP1 Jung J1 Zhang H1 Pickering RP1 Ruan WJ1 Smith SM1 Huang B1 Hasin DS2

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment Levounis Zerbo and Aggarwal Eds

Stahre M Roeber J Kanny D Brewer RD Zhang X Contribution of excessive alcohol consumption to deaths and years of potential life lost in the United States Prev Chronic Dis 201411130293

28

ldquoMarijuanardquo is the term for the plant Cannabis

THC = Tetrahydrocannabinol = psychoactive

CBD = Cannabidiol = sedating not psychoactive

Sativa and Indica differ in THCCBD ratio

Marijuana the herb is generally dried flowers

Hashish is a resin with higher THC levels and generally heated in a pipe or eaten

Hash oil is the most potent and can be smoked ingested or used topically

Marijuana

29

Joint marijuana rolled in paper

Fatty larger amount of marijuana

Doobie rolled with king size paper

Blunt Rolled with cigar wrapper and contains tobacco

Pipes (also known as bowls) are usually glass and rarely have a filter

Bongs contain water filter

Marijuana

30

Marijuana Legal Status

31

Marijuana Effects

Acute Intoxication

bull Improved mood increased well-being calmness relaxation

and sociability

bull Increased self-confidence magical thinking distorted

perception of time and space increased sensory perception

bull Tachycardia palpitations vasodilation conjunctival

irritation dry mouth increased appetite

bull Anxiety panic confusion hallucinations paranoia

psychosis

Withdrawal

bull Anxiety depression mood changes GI distress decreased

appetite insomnia irritability

32

First Illicit Drug Used

Figure from SAMHSA

33

Marijuana

34

ldquoIt bothers me that people are so stupid as to use

this stuffrdquo ndash John W Huffman developer

Sprayed on dried plant material or inhaled in

vaporizer

Marketed as ldquonot for human consumptionrdquo and were

sold legally under hundreds of brands most notably

K2 and Spice

Synthetic Cannabinoids

35

False belief that these are ldquonaturalrdquo and thus harmless

They are also not detected in routine drug screens

Acute effects are very unpredictable and generally

less pleasant than natural cannabis

Psychotic symptoms include extreme anxiety

confusion paranoia and hallucinations

Synthetic Cannabinoids

36

Mike is a 23 year old who presents

to the ER with paranoia

He reports holding a loaded gun

and pointing it at people outside of his

window thinking they were all trying

to kill him

He previously used meth heavily but has recently cut down

His last use was 3 days ago

Clinical Presentation

37

Janice is a 36 year old female who presented to the ER seeking

help with methamphetamine addiction

She appears older than stated age and is very thin

She has several missing teeth and otherwise poor

dentition

Her skin has multiple lesions

ldquoWhen I first starting smoking ice it felt so good Now it no longer feels like that

I do not even get much pleasure out of it any more I do not get pleasure out

of anything anymore I have no desire to see family or friends or do the things

I used to love I wish I could have fun like I used tordquo

Clinical Presentation

38

Crystal Ice Glass

Leads to an acute increase in synaptic dopamine concentration through various mechanisms

Can be prescribed as Desoxyn for

ADHD

Prominent in the western region of US and made famous by Breaking Bad

television series

Many accidents and fires are associated

with ldquobackyardrdquo meth labs

Methamphetamine

39

Mental illness and co-morbid or co-occurring substance use disorder is common

Approximately 13 of all people with mental illness and 12 with severe mental illness also have a substance use disorder

Self medication hypothesis vs substance

induced disorder

Multi-modal parallel or integrated treatment approach is most effective

Dual Diagnosis

Data from SAMHSA

40

Toxicology Screening

Urine most common method given cost and ease of collection Problem adulteration and substitution

bull On-site rapid testing

bull Immunoassay (initial lab screen)

bull GCMS

Blood better for quantitative analysis detection of acute intoxication Problem invasive detection for shorter periods than urine

Saliva Non-invasive lower potential for adulteration than urine Problem higher detection threshold and greater cost

Sweat Can identify substances over longer period of time Problem difficult to collect and quantify

Hair Easy to collect less likelihood of adulteration provides qualitative account of history of ingestion Problem poor at detecting acute intoxication more labor-intensive to process

41

Screening for drugs in healthy individuals

with no prior suspicion

bull Workplace or athletic testing

Testing for drugs in ill persons with a prior suspicion of use

Monitoring for drugs as part of a pain management or treatment program

While reliable on-site urine drug testing offers preliminary results When making treatment altering decisions urine should always be sent for confirmatory testing

Urine Testing

42

Urine Detection Limits

Alcohol 6 - 12 hours

EtG (ethylglucuronide) 4 days

Amphetaminesmeth 2 - 3 days

Benzos (short-acting) 3 days

Cocaine 3 - 4 days

Morphine 2 days

Marijuana (THC) 3 - 30+ days

Methadone 2 - 4 days

Buprenorphine 2 - 4 days

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

Adapted from Helander et al 2009 Moeller et al 2008

NIDA Neurobio of Addiction (2016 In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

43

Urine Drug Testing Stimulants

Amphetamine Methamphetamine

bull False positives pseudoephedrine bupropion labetolol ranitidine trazodone TCAs

bull Low sensitivity for detection of MDMA

bull 2 methamphetamine isomers d (CNS) and l (peripheral)

Cocaine

bull Primary metabolite benzoyleconine

bull False positives rare (coca leaf tea adulterated natural products)

Opiates

bull Tests for morphine-based substances

bull Unreliable for synthetic opioids like oxycodone

44

Summary

Alcohol use disorder is a common and deadly illness

with significant comorbidities

Alcohol withdrawal management does not treat AUD

It is important to understand key concepts in other

drug use disorders

Urine drug testing is an important piece to clinical

decision making

45

References

Disease ImCenters for Disease Control and Prevention (CDC) Alcohol-Related pact (ARDI) Atlanta GA CDC

Epidemiology of DSM-5 Alcohol Use Disorder Results From the National Epidemiologic Survey on Alcohol and Related Conditions III Grant BF1 Goldstein RB1 Saha TD1 Chou SP1 Jung J1 Zhang H1 Pickering RP1 Ruan WJ1 Smith SM1 Huang B1 Hasin DS2

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment Levounis Zerbo and Aggarwal Eds

Stahre M Roeber J Kanny D Brewer RD Zhang X Contribution of excessive alcohol consumption to deaths and years of potential life lost in the United States Prev Chronic Dis 201411130293

29

Joint marijuana rolled in paper

Fatty larger amount of marijuana

Doobie rolled with king size paper

Blunt Rolled with cigar wrapper and contains tobacco

Pipes (also known as bowls) are usually glass and rarely have a filter

Bongs contain water filter

Marijuana

30

Marijuana Legal Status

31

Marijuana Effects

Acute Intoxication

bull Improved mood increased well-being calmness relaxation

and sociability

bull Increased self-confidence magical thinking distorted

perception of time and space increased sensory perception

bull Tachycardia palpitations vasodilation conjunctival

irritation dry mouth increased appetite

bull Anxiety panic confusion hallucinations paranoia

psychosis

Withdrawal

bull Anxiety depression mood changes GI distress decreased

appetite insomnia irritability

32

First Illicit Drug Used

Figure from SAMHSA

33

Marijuana

34

ldquoIt bothers me that people are so stupid as to use

this stuffrdquo ndash John W Huffman developer

Sprayed on dried plant material or inhaled in

vaporizer

Marketed as ldquonot for human consumptionrdquo and were

sold legally under hundreds of brands most notably

K2 and Spice

Synthetic Cannabinoids

35

False belief that these are ldquonaturalrdquo and thus harmless

They are also not detected in routine drug screens

Acute effects are very unpredictable and generally

less pleasant than natural cannabis

Psychotic symptoms include extreme anxiety

confusion paranoia and hallucinations

Synthetic Cannabinoids

36

Mike is a 23 year old who presents

to the ER with paranoia

He reports holding a loaded gun

and pointing it at people outside of his

window thinking they were all trying

to kill him

He previously used meth heavily but has recently cut down

His last use was 3 days ago

Clinical Presentation

37

Janice is a 36 year old female who presented to the ER seeking

help with methamphetamine addiction

She appears older than stated age and is very thin

She has several missing teeth and otherwise poor

dentition

Her skin has multiple lesions

ldquoWhen I first starting smoking ice it felt so good Now it no longer feels like that

I do not even get much pleasure out of it any more I do not get pleasure out

of anything anymore I have no desire to see family or friends or do the things

I used to love I wish I could have fun like I used tordquo

Clinical Presentation

38

Crystal Ice Glass

Leads to an acute increase in synaptic dopamine concentration through various mechanisms

Can be prescribed as Desoxyn for

ADHD

Prominent in the western region of US and made famous by Breaking Bad

television series

Many accidents and fires are associated

with ldquobackyardrdquo meth labs

Methamphetamine

39

Mental illness and co-morbid or co-occurring substance use disorder is common

Approximately 13 of all people with mental illness and 12 with severe mental illness also have a substance use disorder

Self medication hypothesis vs substance

induced disorder

Multi-modal parallel or integrated treatment approach is most effective

Dual Diagnosis

Data from SAMHSA

40

Toxicology Screening

Urine most common method given cost and ease of collection Problem adulteration and substitution

bull On-site rapid testing

bull Immunoassay (initial lab screen)

bull GCMS

Blood better for quantitative analysis detection of acute intoxication Problem invasive detection for shorter periods than urine

Saliva Non-invasive lower potential for adulteration than urine Problem higher detection threshold and greater cost

Sweat Can identify substances over longer period of time Problem difficult to collect and quantify

Hair Easy to collect less likelihood of adulteration provides qualitative account of history of ingestion Problem poor at detecting acute intoxication more labor-intensive to process

41

Screening for drugs in healthy individuals

with no prior suspicion

bull Workplace or athletic testing

Testing for drugs in ill persons with a prior suspicion of use

Monitoring for drugs as part of a pain management or treatment program

While reliable on-site urine drug testing offers preliminary results When making treatment altering decisions urine should always be sent for confirmatory testing

Urine Testing

42

Urine Detection Limits

Alcohol 6 - 12 hours

EtG (ethylglucuronide) 4 days

Amphetaminesmeth 2 - 3 days

Benzos (short-acting) 3 days

Cocaine 3 - 4 days

Morphine 2 days

Marijuana (THC) 3 - 30+ days

Methadone 2 - 4 days

Buprenorphine 2 - 4 days

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

Adapted from Helander et al 2009 Moeller et al 2008

NIDA Neurobio of Addiction (2016 In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

43

Urine Drug Testing Stimulants

Amphetamine Methamphetamine

bull False positives pseudoephedrine bupropion labetolol ranitidine trazodone TCAs

bull Low sensitivity for detection of MDMA

bull 2 methamphetamine isomers d (CNS) and l (peripheral)

Cocaine

bull Primary metabolite benzoyleconine

bull False positives rare (coca leaf tea adulterated natural products)

Opiates

bull Tests for morphine-based substances

bull Unreliable for synthetic opioids like oxycodone

44

Summary

Alcohol use disorder is a common and deadly illness

with significant comorbidities

Alcohol withdrawal management does not treat AUD

It is important to understand key concepts in other

drug use disorders

Urine drug testing is an important piece to clinical

decision making

45

References

Disease ImCenters for Disease Control and Prevention (CDC) Alcohol-Related pact (ARDI) Atlanta GA CDC

Epidemiology of DSM-5 Alcohol Use Disorder Results From the National Epidemiologic Survey on Alcohol and Related Conditions III Grant BF1 Goldstein RB1 Saha TD1 Chou SP1 Jung J1 Zhang H1 Pickering RP1 Ruan WJ1 Smith SM1 Huang B1 Hasin DS2

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment Levounis Zerbo and Aggarwal Eds

Stahre M Roeber J Kanny D Brewer RD Zhang X Contribution of excessive alcohol consumption to deaths and years of potential life lost in the United States Prev Chronic Dis 201411130293

30

Marijuana Legal Status

31

Marijuana Effects

Acute Intoxication

bull Improved mood increased well-being calmness relaxation

and sociability

bull Increased self-confidence magical thinking distorted

perception of time and space increased sensory perception

bull Tachycardia palpitations vasodilation conjunctival

irritation dry mouth increased appetite

bull Anxiety panic confusion hallucinations paranoia

psychosis

Withdrawal

bull Anxiety depression mood changes GI distress decreased

appetite insomnia irritability

32

First Illicit Drug Used

Figure from SAMHSA

33

Marijuana

34

ldquoIt bothers me that people are so stupid as to use

this stuffrdquo ndash John W Huffman developer

Sprayed on dried plant material or inhaled in

vaporizer

Marketed as ldquonot for human consumptionrdquo and were

sold legally under hundreds of brands most notably

K2 and Spice

Synthetic Cannabinoids

35

False belief that these are ldquonaturalrdquo and thus harmless

They are also not detected in routine drug screens

Acute effects are very unpredictable and generally

less pleasant than natural cannabis

Psychotic symptoms include extreme anxiety

confusion paranoia and hallucinations

Synthetic Cannabinoids

36

Mike is a 23 year old who presents

to the ER with paranoia

He reports holding a loaded gun

and pointing it at people outside of his

window thinking they were all trying

to kill him

He previously used meth heavily but has recently cut down

His last use was 3 days ago

Clinical Presentation

37

Janice is a 36 year old female who presented to the ER seeking

help with methamphetamine addiction

She appears older than stated age and is very thin

She has several missing teeth and otherwise poor

dentition

Her skin has multiple lesions

ldquoWhen I first starting smoking ice it felt so good Now it no longer feels like that

I do not even get much pleasure out of it any more I do not get pleasure out

of anything anymore I have no desire to see family or friends or do the things

I used to love I wish I could have fun like I used tordquo

Clinical Presentation

38

Crystal Ice Glass

Leads to an acute increase in synaptic dopamine concentration through various mechanisms

Can be prescribed as Desoxyn for

ADHD

Prominent in the western region of US and made famous by Breaking Bad

television series

Many accidents and fires are associated

with ldquobackyardrdquo meth labs

Methamphetamine

39

Mental illness and co-morbid or co-occurring substance use disorder is common

Approximately 13 of all people with mental illness and 12 with severe mental illness also have a substance use disorder

Self medication hypothesis vs substance

induced disorder

Multi-modal parallel or integrated treatment approach is most effective

Dual Diagnosis

Data from SAMHSA

40

Toxicology Screening

Urine most common method given cost and ease of collection Problem adulteration and substitution

bull On-site rapid testing

bull Immunoassay (initial lab screen)

bull GCMS

Blood better for quantitative analysis detection of acute intoxication Problem invasive detection for shorter periods than urine

Saliva Non-invasive lower potential for adulteration than urine Problem higher detection threshold and greater cost

Sweat Can identify substances over longer period of time Problem difficult to collect and quantify

Hair Easy to collect less likelihood of adulteration provides qualitative account of history of ingestion Problem poor at detecting acute intoxication more labor-intensive to process

41

Screening for drugs in healthy individuals

with no prior suspicion

bull Workplace or athletic testing

Testing for drugs in ill persons with a prior suspicion of use

Monitoring for drugs as part of a pain management or treatment program

While reliable on-site urine drug testing offers preliminary results When making treatment altering decisions urine should always be sent for confirmatory testing

Urine Testing

42

Urine Detection Limits

Alcohol 6 - 12 hours

EtG (ethylglucuronide) 4 days

Amphetaminesmeth 2 - 3 days

Benzos (short-acting) 3 days

Cocaine 3 - 4 days

Morphine 2 days

Marijuana (THC) 3 - 30+ days

Methadone 2 - 4 days

Buprenorphine 2 - 4 days

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

Adapted from Helander et al 2009 Moeller et al 2008

NIDA Neurobio of Addiction (2016 In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

43

Urine Drug Testing Stimulants

Amphetamine Methamphetamine

bull False positives pseudoephedrine bupropion labetolol ranitidine trazodone TCAs

bull Low sensitivity for detection of MDMA

bull 2 methamphetamine isomers d (CNS) and l (peripheral)

Cocaine

bull Primary metabolite benzoyleconine

bull False positives rare (coca leaf tea adulterated natural products)

Opiates

bull Tests for morphine-based substances

bull Unreliable for synthetic opioids like oxycodone

44

Summary

Alcohol use disorder is a common and deadly illness

with significant comorbidities

Alcohol withdrawal management does not treat AUD

It is important to understand key concepts in other

drug use disorders

Urine drug testing is an important piece to clinical

decision making

45

References

Disease ImCenters for Disease Control and Prevention (CDC) Alcohol-Related pact (ARDI) Atlanta GA CDC

Epidemiology of DSM-5 Alcohol Use Disorder Results From the National Epidemiologic Survey on Alcohol and Related Conditions III Grant BF1 Goldstein RB1 Saha TD1 Chou SP1 Jung J1 Zhang H1 Pickering RP1 Ruan WJ1 Smith SM1 Huang B1 Hasin DS2

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment Levounis Zerbo and Aggarwal Eds

Stahre M Roeber J Kanny D Brewer RD Zhang X Contribution of excessive alcohol consumption to deaths and years of potential life lost in the United States Prev Chronic Dis 201411130293

31

Marijuana Effects

Acute Intoxication

bull Improved mood increased well-being calmness relaxation

and sociability

bull Increased self-confidence magical thinking distorted

perception of time and space increased sensory perception

bull Tachycardia palpitations vasodilation conjunctival

irritation dry mouth increased appetite

bull Anxiety panic confusion hallucinations paranoia

psychosis

Withdrawal

bull Anxiety depression mood changes GI distress decreased

appetite insomnia irritability

32

First Illicit Drug Used

Figure from SAMHSA

33

Marijuana

34

ldquoIt bothers me that people are so stupid as to use

this stuffrdquo ndash John W Huffman developer

Sprayed on dried plant material or inhaled in

vaporizer

Marketed as ldquonot for human consumptionrdquo and were

sold legally under hundreds of brands most notably

K2 and Spice

Synthetic Cannabinoids

35

False belief that these are ldquonaturalrdquo and thus harmless

They are also not detected in routine drug screens

Acute effects are very unpredictable and generally

less pleasant than natural cannabis

Psychotic symptoms include extreme anxiety

confusion paranoia and hallucinations

Synthetic Cannabinoids

36

Mike is a 23 year old who presents

to the ER with paranoia

He reports holding a loaded gun

and pointing it at people outside of his

window thinking they were all trying

to kill him

He previously used meth heavily but has recently cut down

His last use was 3 days ago

Clinical Presentation

37

Janice is a 36 year old female who presented to the ER seeking

help with methamphetamine addiction

She appears older than stated age and is very thin

She has several missing teeth and otherwise poor

dentition

Her skin has multiple lesions

ldquoWhen I first starting smoking ice it felt so good Now it no longer feels like that

I do not even get much pleasure out of it any more I do not get pleasure out

of anything anymore I have no desire to see family or friends or do the things

I used to love I wish I could have fun like I used tordquo

Clinical Presentation

38

Crystal Ice Glass

Leads to an acute increase in synaptic dopamine concentration through various mechanisms

Can be prescribed as Desoxyn for

ADHD

Prominent in the western region of US and made famous by Breaking Bad

television series

Many accidents and fires are associated

with ldquobackyardrdquo meth labs

Methamphetamine

39

Mental illness and co-morbid or co-occurring substance use disorder is common

Approximately 13 of all people with mental illness and 12 with severe mental illness also have a substance use disorder

Self medication hypothesis vs substance

induced disorder

Multi-modal parallel or integrated treatment approach is most effective

Dual Diagnosis

Data from SAMHSA

40

Toxicology Screening

Urine most common method given cost and ease of collection Problem adulteration and substitution

bull On-site rapid testing

bull Immunoassay (initial lab screen)

bull GCMS

Blood better for quantitative analysis detection of acute intoxication Problem invasive detection for shorter periods than urine

Saliva Non-invasive lower potential for adulteration than urine Problem higher detection threshold and greater cost

Sweat Can identify substances over longer period of time Problem difficult to collect and quantify

Hair Easy to collect less likelihood of adulteration provides qualitative account of history of ingestion Problem poor at detecting acute intoxication more labor-intensive to process

41

Screening for drugs in healthy individuals

with no prior suspicion

bull Workplace or athletic testing

Testing for drugs in ill persons with a prior suspicion of use

Monitoring for drugs as part of a pain management or treatment program

While reliable on-site urine drug testing offers preliminary results When making treatment altering decisions urine should always be sent for confirmatory testing

Urine Testing

42

Urine Detection Limits

Alcohol 6 - 12 hours

EtG (ethylglucuronide) 4 days

Amphetaminesmeth 2 - 3 days

Benzos (short-acting) 3 days

Cocaine 3 - 4 days

Morphine 2 days

Marijuana (THC) 3 - 30+ days

Methadone 2 - 4 days

Buprenorphine 2 - 4 days

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

Adapted from Helander et al 2009 Moeller et al 2008

NIDA Neurobio of Addiction (2016 In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

43

Urine Drug Testing Stimulants

Amphetamine Methamphetamine

bull False positives pseudoephedrine bupropion labetolol ranitidine trazodone TCAs

bull Low sensitivity for detection of MDMA

bull 2 methamphetamine isomers d (CNS) and l (peripheral)

Cocaine

bull Primary metabolite benzoyleconine

bull False positives rare (coca leaf tea adulterated natural products)

Opiates

bull Tests for morphine-based substances

bull Unreliable for synthetic opioids like oxycodone

44

Summary

Alcohol use disorder is a common and deadly illness

with significant comorbidities

Alcohol withdrawal management does not treat AUD

It is important to understand key concepts in other

drug use disorders

Urine drug testing is an important piece to clinical

decision making

45

References

Disease ImCenters for Disease Control and Prevention (CDC) Alcohol-Related pact (ARDI) Atlanta GA CDC

Epidemiology of DSM-5 Alcohol Use Disorder Results From the National Epidemiologic Survey on Alcohol and Related Conditions III Grant BF1 Goldstein RB1 Saha TD1 Chou SP1 Jung J1 Zhang H1 Pickering RP1 Ruan WJ1 Smith SM1 Huang B1 Hasin DS2

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment Levounis Zerbo and Aggarwal Eds

Stahre M Roeber J Kanny D Brewer RD Zhang X Contribution of excessive alcohol consumption to deaths and years of potential life lost in the United States Prev Chronic Dis 201411130293

32

First Illicit Drug Used

Figure from SAMHSA

33

Marijuana

34

ldquoIt bothers me that people are so stupid as to use

this stuffrdquo ndash John W Huffman developer

Sprayed on dried plant material or inhaled in

vaporizer

Marketed as ldquonot for human consumptionrdquo and were

sold legally under hundreds of brands most notably

K2 and Spice

Synthetic Cannabinoids

35

False belief that these are ldquonaturalrdquo and thus harmless

They are also not detected in routine drug screens

Acute effects are very unpredictable and generally

less pleasant than natural cannabis

Psychotic symptoms include extreme anxiety

confusion paranoia and hallucinations

Synthetic Cannabinoids

36

Mike is a 23 year old who presents

to the ER with paranoia

He reports holding a loaded gun

and pointing it at people outside of his

window thinking they were all trying

to kill him

He previously used meth heavily but has recently cut down

His last use was 3 days ago

Clinical Presentation

37

Janice is a 36 year old female who presented to the ER seeking

help with methamphetamine addiction

She appears older than stated age and is very thin

She has several missing teeth and otherwise poor

dentition

Her skin has multiple lesions

ldquoWhen I first starting smoking ice it felt so good Now it no longer feels like that

I do not even get much pleasure out of it any more I do not get pleasure out

of anything anymore I have no desire to see family or friends or do the things

I used to love I wish I could have fun like I used tordquo

Clinical Presentation

38

Crystal Ice Glass

Leads to an acute increase in synaptic dopamine concentration through various mechanisms

Can be prescribed as Desoxyn for

ADHD

Prominent in the western region of US and made famous by Breaking Bad

television series

Many accidents and fires are associated

with ldquobackyardrdquo meth labs

Methamphetamine

39

Mental illness and co-morbid or co-occurring substance use disorder is common

Approximately 13 of all people with mental illness and 12 with severe mental illness also have a substance use disorder

Self medication hypothesis vs substance

induced disorder

Multi-modal parallel or integrated treatment approach is most effective

Dual Diagnosis

Data from SAMHSA

40

Toxicology Screening

Urine most common method given cost and ease of collection Problem adulteration and substitution

bull On-site rapid testing

bull Immunoassay (initial lab screen)

bull GCMS

Blood better for quantitative analysis detection of acute intoxication Problem invasive detection for shorter periods than urine

Saliva Non-invasive lower potential for adulteration than urine Problem higher detection threshold and greater cost

Sweat Can identify substances over longer period of time Problem difficult to collect and quantify

Hair Easy to collect less likelihood of adulteration provides qualitative account of history of ingestion Problem poor at detecting acute intoxication more labor-intensive to process

41

Screening for drugs in healthy individuals

with no prior suspicion

bull Workplace or athletic testing

Testing for drugs in ill persons with a prior suspicion of use

Monitoring for drugs as part of a pain management or treatment program

While reliable on-site urine drug testing offers preliminary results When making treatment altering decisions urine should always be sent for confirmatory testing

Urine Testing

42

Urine Detection Limits

Alcohol 6 - 12 hours

EtG (ethylglucuronide) 4 days

Amphetaminesmeth 2 - 3 days

Benzos (short-acting) 3 days

Cocaine 3 - 4 days

Morphine 2 days

Marijuana (THC) 3 - 30+ days

Methadone 2 - 4 days

Buprenorphine 2 - 4 days

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

Adapted from Helander et al 2009 Moeller et al 2008

NIDA Neurobio of Addiction (2016 In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

43

Urine Drug Testing Stimulants

Amphetamine Methamphetamine

bull False positives pseudoephedrine bupropion labetolol ranitidine trazodone TCAs

bull Low sensitivity for detection of MDMA

bull 2 methamphetamine isomers d (CNS) and l (peripheral)

Cocaine

bull Primary metabolite benzoyleconine

bull False positives rare (coca leaf tea adulterated natural products)

Opiates

bull Tests for morphine-based substances

bull Unreliable for synthetic opioids like oxycodone

44

Summary

Alcohol use disorder is a common and deadly illness

with significant comorbidities

Alcohol withdrawal management does not treat AUD

It is important to understand key concepts in other

drug use disorders

Urine drug testing is an important piece to clinical

decision making

45

References

Disease ImCenters for Disease Control and Prevention (CDC) Alcohol-Related pact (ARDI) Atlanta GA CDC

Epidemiology of DSM-5 Alcohol Use Disorder Results From the National Epidemiologic Survey on Alcohol and Related Conditions III Grant BF1 Goldstein RB1 Saha TD1 Chou SP1 Jung J1 Zhang H1 Pickering RP1 Ruan WJ1 Smith SM1 Huang B1 Hasin DS2

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment Levounis Zerbo and Aggarwal Eds

Stahre M Roeber J Kanny D Brewer RD Zhang X Contribution of excessive alcohol consumption to deaths and years of potential life lost in the United States Prev Chronic Dis 201411130293

33

Marijuana

34

ldquoIt bothers me that people are so stupid as to use

this stuffrdquo ndash John W Huffman developer

Sprayed on dried plant material or inhaled in

vaporizer

Marketed as ldquonot for human consumptionrdquo and were

sold legally under hundreds of brands most notably

K2 and Spice

Synthetic Cannabinoids

35

False belief that these are ldquonaturalrdquo and thus harmless

They are also not detected in routine drug screens

Acute effects are very unpredictable and generally

less pleasant than natural cannabis

Psychotic symptoms include extreme anxiety

confusion paranoia and hallucinations

Synthetic Cannabinoids

36

Mike is a 23 year old who presents

to the ER with paranoia

He reports holding a loaded gun

and pointing it at people outside of his

window thinking they were all trying

to kill him

He previously used meth heavily but has recently cut down

His last use was 3 days ago

Clinical Presentation

37

Janice is a 36 year old female who presented to the ER seeking

help with methamphetamine addiction

She appears older than stated age and is very thin

She has several missing teeth and otherwise poor

dentition

Her skin has multiple lesions

ldquoWhen I first starting smoking ice it felt so good Now it no longer feels like that

I do not even get much pleasure out of it any more I do not get pleasure out

of anything anymore I have no desire to see family or friends or do the things

I used to love I wish I could have fun like I used tordquo

Clinical Presentation

38

Crystal Ice Glass

Leads to an acute increase in synaptic dopamine concentration through various mechanisms

Can be prescribed as Desoxyn for

ADHD

Prominent in the western region of US and made famous by Breaking Bad

television series

Many accidents and fires are associated

with ldquobackyardrdquo meth labs

Methamphetamine

39

Mental illness and co-morbid or co-occurring substance use disorder is common

Approximately 13 of all people with mental illness and 12 with severe mental illness also have a substance use disorder

Self medication hypothesis vs substance

induced disorder

Multi-modal parallel or integrated treatment approach is most effective

Dual Diagnosis

Data from SAMHSA

40

Toxicology Screening

Urine most common method given cost and ease of collection Problem adulteration and substitution

bull On-site rapid testing

bull Immunoassay (initial lab screen)

bull GCMS

Blood better for quantitative analysis detection of acute intoxication Problem invasive detection for shorter periods than urine

Saliva Non-invasive lower potential for adulteration than urine Problem higher detection threshold and greater cost

Sweat Can identify substances over longer period of time Problem difficult to collect and quantify

Hair Easy to collect less likelihood of adulteration provides qualitative account of history of ingestion Problem poor at detecting acute intoxication more labor-intensive to process

41

Screening for drugs in healthy individuals

with no prior suspicion

bull Workplace or athletic testing

Testing for drugs in ill persons with a prior suspicion of use

Monitoring for drugs as part of a pain management or treatment program

While reliable on-site urine drug testing offers preliminary results When making treatment altering decisions urine should always be sent for confirmatory testing

Urine Testing

42

Urine Detection Limits

Alcohol 6 - 12 hours

EtG (ethylglucuronide) 4 days

Amphetaminesmeth 2 - 3 days

Benzos (short-acting) 3 days

Cocaine 3 - 4 days

Morphine 2 days

Marijuana (THC) 3 - 30+ days

Methadone 2 - 4 days

Buprenorphine 2 - 4 days

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

Adapted from Helander et al 2009 Moeller et al 2008

NIDA Neurobio of Addiction (2016 In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

43

Urine Drug Testing Stimulants

Amphetamine Methamphetamine

bull False positives pseudoephedrine bupropion labetolol ranitidine trazodone TCAs

bull Low sensitivity for detection of MDMA

bull 2 methamphetamine isomers d (CNS) and l (peripheral)

Cocaine

bull Primary metabolite benzoyleconine

bull False positives rare (coca leaf tea adulterated natural products)

Opiates

bull Tests for morphine-based substances

bull Unreliable for synthetic opioids like oxycodone

44

Summary

Alcohol use disorder is a common and deadly illness

with significant comorbidities

Alcohol withdrawal management does not treat AUD

It is important to understand key concepts in other

drug use disorders

Urine drug testing is an important piece to clinical

decision making

45

References

Disease ImCenters for Disease Control and Prevention (CDC) Alcohol-Related pact (ARDI) Atlanta GA CDC

Epidemiology of DSM-5 Alcohol Use Disorder Results From the National Epidemiologic Survey on Alcohol and Related Conditions III Grant BF1 Goldstein RB1 Saha TD1 Chou SP1 Jung J1 Zhang H1 Pickering RP1 Ruan WJ1 Smith SM1 Huang B1 Hasin DS2

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment Levounis Zerbo and Aggarwal Eds

Stahre M Roeber J Kanny D Brewer RD Zhang X Contribution of excessive alcohol consumption to deaths and years of potential life lost in the United States Prev Chronic Dis 201411130293

34

ldquoIt bothers me that people are so stupid as to use

this stuffrdquo ndash John W Huffman developer

Sprayed on dried plant material or inhaled in

vaporizer

Marketed as ldquonot for human consumptionrdquo and were

sold legally under hundreds of brands most notably

K2 and Spice

Synthetic Cannabinoids

35

False belief that these are ldquonaturalrdquo and thus harmless

They are also not detected in routine drug screens

Acute effects are very unpredictable and generally

less pleasant than natural cannabis

Psychotic symptoms include extreme anxiety

confusion paranoia and hallucinations

Synthetic Cannabinoids

36

Mike is a 23 year old who presents

to the ER with paranoia

He reports holding a loaded gun

and pointing it at people outside of his

window thinking they were all trying

to kill him

He previously used meth heavily but has recently cut down

His last use was 3 days ago

Clinical Presentation

37

Janice is a 36 year old female who presented to the ER seeking

help with methamphetamine addiction

She appears older than stated age and is very thin

She has several missing teeth and otherwise poor

dentition

Her skin has multiple lesions

ldquoWhen I first starting smoking ice it felt so good Now it no longer feels like that

I do not even get much pleasure out of it any more I do not get pleasure out

of anything anymore I have no desire to see family or friends or do the things

I used to love I wish I could have fun like I used tordquo

Clinical Presentation

38

Crystal Ice Glass

Leads to an acute increase in synaptic dopamine concentration through various mechanisms

Can be prescribed as Desoxyn for

ADHD

Prominent in the western region of US and made famous by Breaking Bad

television series

Many accidents and fires are associated

with ldquobackyardrdquo meth labs

Methamphetamine

39

Mental illness and co-morbid or co-occurring substance use disorder is common

Approximately 13 of all people with mental illness and 12 with severe mental illness also have a substance use disorder

Self medication hypothesis vs substance

induced disorder

Multi-modal parallel or integrated treatment approach is most effective

Dual Diagnosis

Data from SAMHSA

40

Toxicology Screening

Urine most common method given cost and ease of collection Problem adulteration and substitution

bull On-site rapid testing

bull Immunoassay (initial lab screen)

bull GCMS

Blood better for quantitative analysis detection of acute intoxication Problem invasive detection for shorter periods than urine

Saliva Non-invasive lower potential for adulteration than urine Problem higher detection threshold and greater cost

Sweat Can identify substances over longer period of time Problem difficult to collect and quantify

Hair Easy to collect less likelihood of adulteration provides qualitative account of history of ingestion Problem poor at detecting acute intoxication more labor-intensive to process

41

Screening for drugs in healthy individuals

with no prior suspicion

bull Workplace or athletic testing

Testing for drugs in ill persons with a prior suspicion of use

Monitoring for drugs as part of a pain management or treatment program

While reliable on-site urine drug testing offers preliminary results When making treatment altering decisions urine should always be sent for confirmatory testing

Urine Testing

42

Urine Detection Limits

Alcohol 6 - 12 hours

EtG (ethylglucuronide) 4 days

Amphetaminesmeth 2 - 3 days

Benzos (short-acting) 3 days

Cocaine 3 - 4 days

Morphine 2 days

Marijuana (THC) 3 - 30+ days

Methadone 2 - 4 days

Buprenorphine 2 - 4 days

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

Adapted from Helander et al 2009 Moeller et al 2008

NIDA Neurobio of Addiction (2016 In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

43

Urine Drug Testing Stimulants

Amphetamine Methamphetamine

bull False positives pseudoephedrine bupropion labetolol ranitidine trazodone TCAs

bull Low sensitivity for detection of MDMA

bull 2 methamphetamine isomers d (CNS) and l (peripheral)

Cocaine

bull Primary metabolite benzoyleconine

bull False positives rare (coca leaf tea adulterated natural products)

Opiates

bull Tests for morphine-based substances

bull Unreliable for synthetic opioids like oxycodone

44

Summary

Alcohol use disorder is a common and deadly illness

with significant comorbidities

Alcohol withdrawal management does not treat AUD

It is important to understand key concepts in other

drug use disorders

Urine drug testing is an important piece to clinical

decision making

45

References

Disease ImCenters for Disease Control and Prevention (CDC) Alcohol-Related pact (ARDI) Atlanta GA CDC

Epidemiology of DSM-5 Alcohol Use Disorder Results From the National Epidemiologic Survey on Alcohol and Related Conditions III Grant BF1 Goldstein RB1 Saha TD1 Chou SP1 Jung J1 Zhang H1 Pickering RP1 Ruan WJ1 Smith SM1 Huang B1 Hasin DS2

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment Levounis Zerbo and Aggarwal Eds

Stahre M Roeber J Kanny D Brewer RD Zhang X Contribution of excessive alcohol consumption to deaths and years of potential life lost in the United States Prev Chronic Dis 201411130293

35

False belief that these are ldquonaturalrdquo and thus harmless

They are also not detected in routine drug screens

Acute effects are very unpredictable and generally

less pleasant than natural cannabis

Psychotic symptoms include extreme anxiety

confusion paranoia and hallucinations

Synthetic Cannabinoids

36

Mike is a 23 year old who presents

to the ER with paranoia

He reports holding a loaded gun

and pointing it at people outside of his

window thinking they were all trying

to kill him

He previously used meth heavily but has recently cut down

His last use was 3 days ago

Clinical Presentation

37

Janice is a 36 year old female who presented to the ER seeking

help with methamphetamine addiction

She appears older than stated age and is very thin

She has several missing teeth and otherwise poor

dentition

Her skin has multiple lesions

ldquoWhen I first starting smoking ice it felt so good Now it no longer feels like that

I do not even get much pleasure out of it any more I do not get pleasure out

of anything anymore I have no desire to see family or friends or do the things

I used to love I wish I could have fun like I used tordquo

Clinical Presentation

38

Crystal Ice Glass

Leads to an acute increase in synaptic dopamine concentration through various mechanisms

Can be prescribed as Desoxyn for

ADHD

Prominent in the western region of US and made famous by Breaking Bad

television series

Many accidents and fires are associated

with ldquobackyardrdquo meth labs

Methamphetamine

39

Mental illness and co-morbid or co-occurring substance use disorder is common

Approximately 13 of all people with mental illness and 12 with severe mental illness also have a substance use disorder

Self medication hypothesis vs substance

induced disorder

Multi-modal parallel or integrated treatment approach is most effective

Dual Diagnosis

Data from SAMHSA

40

Toxicology Screening

Urine most common method given cost and ease of collection Problem adulteration and substitution

bull On-site rapid testing

bull Immunoassay (initial lab screen)

bull GCMS

Blood better for quantitative analysis detection of acute intoxication Problem invasive detection for shorter periods than urine

Saliva Non-invasive lower potential for adulteration than urine Problem higher detection threshold and greater cost

Sweat Can identify substances over longer period of time Problem difficult to collect and quantify

Hair Easy to collect less likelihood of adulteration provides qualitative account of history of ingestion Problem poor at detecting acute intoxication more labor-intensive to process

41

Screening for drugs in healthy individuals

with no prior suspicion

bull Workplace or athletic testing

Testing for drugs in ill persons with a prior suspicion of use

Monitoring for drugs as part of a pain management or treatment program

While reliable on-site urine drug testing offers preliminary results When making treatment altering decisions urine should always be sent for confirmatory testing

Urine Testing

42

Urine Detection Limits

Alcohol 6 - 12 hours

EtG (ethylglucuronide) 4 days

Amphetaminesmeth 2 - 3 days

Benzos (short-acting) 3 days

Cocaine 3 - 4 days

Morphine 2 days

Marijuana (THC) 3 - 30+ days

Methadone 2 - 4 days

Buprenorphine 2 - 4 days

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

Adapted from Helander et al 2009 Moeller et al 2008

NIDA Neurobio of Addiction (2016 In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

43

Urine Drug Testing Stimulants

Amphetamine Methamphetamine

bull False positives pseudoephedrine bupropion labetolol ranitidine trazodone TCAs

bull Low sensitivity for detection of MDMA

bull 2 methamphetamine isomers d (CNS) and l (peripheral)

Cocaine

bull Primary metabolite benzoyleconine

bull False positives rare (coca leaf tea adulterated natural products)

Opiates

bull Tests for morphine-based substances

bull Unreliable for synthetic opioids like oxycodone

44

Summary

Alcohol use disorder is a common and deadly illness

with significant comorbidities

Alcohol withdrawal management does not treat AUD

It is important to understand key concepts in other

drug use disorders

Urine drug testing is an important piece to clinical

decision making

45

References

Disease ImCenters for Disease Control and Prevention (CDC) Alcohol-Related pact (ARDI) Atlanta GA CDC

Epidemiology of DSM-5 Alcohol Use Disorder Results From the National Epidemiologic Survey on Alcohol and Related Conditions III Grant BF1 Goldstein RB1 Saha TD1 Chou SP1 Jung J1 Zhang H1 Pickering RP1 Ruan WJ1 Smith SM1 Huang B1 Hasin DS2

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment Levounis Zerbo and Aggarwal Eds

Stahre M Roeber J Kanny D Brewer RD Zhang X Contribution of excessive alcohol consumption to deaths and years of potential life lost in the United States Prev Chronic Dis 201411130293

36

Mike is a 23 year old who presents

to the ER with paranoia

He reports holding a loaded gun

and pointing it at people outside of his

window thinking they were all trying

to kill him

He previously used meth heavily but has recently cut down

His last use was 3 days ago

Clinical Presentation

37

Janice is a 36 year old female who presented to the ER seeking

help with methamphetamine addiction

She appears older than stated age and is very thin

She has several missing teeth and otherwise poor

dentition

Her skin has multiple lesions

ldquoWhen I first starting smoking ice it felt so good Now it no longer feels like that

I do not even get much pleasure out of it any more I do not get pleasure out

of anything anymore I have no desire to see family or friends or do the things

I used to love I wish I could have fun like I used tordquo

Clinical Presentation

38

Crystal Ice Glass

Leads to an acute increase in synaptic dopamine concentration through various mechanisms

Can be prescribed as Desoxyn for

ADHD

Prominent in the western region of US and made famous by Breaking Bad

television series

Many accidents and fires are associated

with ldquobackyardrdquo meth labs

Methamphetamine

39

Mental illness and co-morbid or co-occurring substance use disorder is common

Approximately 13 of all people with mental illness and 12 with severe mental illness also have a substance use disorder

Self medication hypothesis vs substance

induced disorder

Multi-modal parallel or integrated treatment approach is most effective

Dual Diagnosis

Data from SAMHSA

40

Toxicology Screening

Urine most common method given cost and ease of collection Problem adulteration and substitution

bull On-site rapid testing

bull Immunoassay (initial lab screen)

bull GCMS

Blood better for quantitative analysis detection of acute intoxication Problem invasive detection for shorter periods than urine

Saliva Non-invasive lower potential for adulteration than urine Problem higher detection threshold and greater cost

Sweat Can identify substances over longer period of time Problem difficult to collect and quantify

Hair Easy to collect less likelihood of adulteration provides qualitative account of history of ingestion Problem poor at detecting acute intoxication more labor-intensive to process

41

Screening for drugs in healthy individuals

with no prior suspicion

bull Workplace or athletic testing

Testing for drugs in ill persons with a prior suspicion of use

Monitoring for drugs as part of a pain management or treatment program

While reliable on-site urine drug testing offers preliminary results When making treatment altering decisions urine should always be sent for confirmatory testing

Urine Testing

42

Urine Detection Limits

Alcohol 6 - 12 hours

EtG (ethylglucuronide) 4 days

Amphetaminesmeth 2 - 3 days

Benzos (short-acting) 3 days

Cocaine 3 - 4 days

Morphine 2 days

Marijuana (THC) 3 - 30+ days

Methadone 2 - 4 days

Buprenorphine 2 - 4 days

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

Adapted from Helander et al 2009 Moeller et al 2008

NIDA Neurobio of Addiction (2016 In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

43

Urine Drug Testing Stimulants

Amphetamine Methamphetamine

bull False positives pseudoephedrine bupropion labetolol ranitidine trazodone TCAs

bull Low sensitivity for detection of MDMA

bull 2 methamphetamine isomers d (CNS) and l (peripheral)

Cocaine

bull Primary metabolite benzoyleconine

bull False positives rare (coca leaf tea adulterated natural products)

Opiates

bull Tests for morphine-based substances

bull Unreliable for synthetic opioids like oxycodone

44

Summary

Alcohol use disorder is a common and deadly illness

with significant comorbidities

Alcohol withdrawal management does not treat AUD

It is important to understand key concepts in other

drug use disorders

Urine drug testing is an important piece to clinical

decision making

45

References

Disease ImCenters for Disease Control and Prevention (CDC) Alcohol-Related pact (ARDI) Atlanta GA CDC

Epidemiology of DSM-5 Alcohol Use Disorder Results From the National Epidemiologic Survey on Alcohol and Related Conditions III Grant BF1 Goldstein RB1 Saha TD1 Chou SP1 Jung J1 Zhang H1 Pickering RP1 Ruan WJ1 Smith SM1 Huang B1 Hasin DS2

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment Levounis Zerbo and Aggarwal Eds

Stahre M Roeber J Kanny D Brewer RD Zhang X Contribution of excessive alcohol consumption to deaths and years of potential life lost in the United States Prev Chronic Dis 201411130293

37

Janice is a 36 year old female who presented to the ER seeking

help with methamphetamine addiction

She appears older than stated age and is very thin

She has several missing teeth and otherwise poor

dentition

Her skin has multiple lesions

ldquoWhen I first starting smoking ice it felt so good Now it no longer feels like that

I do not even get much pleasure out of it any more I do not get pleasure out

of anything anymore I have no desire to see family or friends or do the things

I used to love I wish I could have fun like I used tordquo

Clinical Presentation

38

Crystal Ice Glass

Leads to an acute increase in synaptic dopamine concentration through various mechanisms

Can be prescribed as Desoxyn for

ADHD

Prominent in the western region of US and made famous by Breaking Bad

television series

Many accidents and fires are associated

with ldquobackyardrdquo meth labs

Methamphetamine

39

Mental illness and co-morbid or co-occurring substance use disorder is common

Approximately 13 of all people with mental illness and 12 with severe mental illness also have a substance use disorder

Self medication hypothesis vs substance

induced disorder

Multi-modal parallel or integrated treatment approach is most effective

Dual Diagnosis

Data from SAMHSA

40

Toxicology Screening

Urine most common method given cost and ease of collection Problem adulteration and substitution

bull On-site rapid testing

bull Immunoassay (initial lab screen)

bull GCMS

Blood better for quantitative analysis detection of acute intoxication Problem invasive detection for shorter periods than urine

Saliva Non-invasive lower potential for adulteration than urine Problem higher detection threshold and greater cost

Sweat Can identify substances over longer period of time Problem difficult to collect and quantify

Hair Easy to collect less likelihood of adulteration provides qualitative account of history of ingestion Problem poor at detecting acute intoxication more labor-intensive to process

41

Screening for drugs in healthy individuals

with no prior suspicion

bull Workplace or athletic testing

Testing for drugs in ill persons with a prior suspicion of use

Monitoring for drugs as part of a pain management or treatment program

While reliable on-site urine drug testing offers preliminary results When making treatment altering decisions urine should always be sent for confirmatory testing

Urine Testing

42

Urine Detection Limits

Alcohol 6 - 12 hours

EtG (ethylglucuronide) 4 days

Amphetaminesmeth 2 - 3 days

Benzos (short-acting) 3 days

Cocaine 3 - 4 days

Morphine 2 days

Marijuana (THC) 3 - 30+ days

Methadone 2 - 4 days

Buprenorphine 2 - 4 days

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

Adapted from Helander et al 2009 Moeller et al 2008

NIDA Neurobio of Addiction (2016 In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

43

Urine Drug Testing Stimulants

Amphetamine Methamphetamine

bull False positives pseudoephedrine bupropion labetolol ranitidine trazodone TCAs

bull Low sensitivity for detection of MDMA

bull 2 methamphetamine isomers d (CNS) and l (peripheral)

Cocaine

bull Primary metabolite benzoyleconine

bull False positives rare (coca leaf tea adulterated natural products)

Opiates

bull Tests for morphine-based substances

bull Unreliable for synthetic opioids like oxycodone

44

Summary

Alcohol use disorder is a common and deadly illness

with significant comorbidities

Alcohol withdrawal management does not treat AUD

It is important to understand key concepts in other

drug use disorders

Urine drug testing is an important piece to clinical

decision making

45

References

Disease ImCenters for Disease Control and Prevention (CDC) Alcohol-Related pact (ARDI) Atlanta GA CDC

Epidemiology of DSM-5 Alcohol Use Disorder Results From the National Epidemiologic Survey on Alcohol and Related Conditions III Grant BF1 Goldstein RB1 Saha TD1 Chou SP1 Jung J1 Zhang H1 Pickering RP1 Ruan WJ1 Smith SM1 Huang B1 Hasin DS2

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment Levounis Zerbo and Aggarwal Eds

Stahre M Roeber J Kanny D Brewer RD Zhang X Contribution of excessive alcohol consumption to deaths and years of potential life lost in the United States Prev Chronic Dis 201411130293

38

Crystal Ice Glass

Leads to an acute increase in synaptic dopamine concentration through various mechanisms

Can be prescribed as Desoxyn for

ADHD

Prominent in the western region of US and made famous by Breaking Bad

television series

Many accidents and fires are associated

with ldquobackyardrdquo meth labs

Methamphetamine

39

Mental illness and co-morbid or co-occurring substance use disorder is common

Approximately 13 of all people with mental illness and 12 with severe mental illness also have a substance use disorder

Self medication hypothesis vs substance

induced disorder

Multi-modal parallel or integrated treatment approach is most effective

Dual Diagnosis

Data from SAMHSA

40

Toxicology Screening

Urine most common method given cost and ease of collection Problem adulteration and substitution

bull On-site rapid testing

bull Immunoassay (initial lab screen)

bull GCMS

Blood better for quantitative analysis detection of acute intoxication Problem invasive detection for shorter periods than urine

Saliva Non-invasive lower potential for adulteration than urine Problem higher detection threshold and greater cost

Sweat Can identify substances over longer period of time Problem difficult to collect and quantify

Hair Easy to collect less likelihood of adulteration provides qualitative account of history of ingestion Problem poor at detecting acute intoxication more labor-intensive to process

41

Screening for drugs in healthy individuals

with no prior suspicion

bull Workplace or athletic testing

Testing for drugs in ill persons with a prior suspicion of use

Monitoring for drugs as part of a pain management or treatment program

While reliable on-site urine drug testing offers preliminary results When making treatment altering decisions urine should always be sent for confirmatory testing

Urine Testing

42

Urine Detection Limits

Alcohol 6 - 12 hours

EtG (ethylglucuronide) 4 days

Amphetaminesmeth 2 - 3 days

Benzos (short-acting) 3 days

Cocaine 3 - 4 days

Morphine 2 days

Marijuana (THC) 3 - 30+ days

Methadone 2 - 4 days

Buprenorphine 2 - 4 days

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

Adapted from Helander et al 2009 Moeller et al 2008

NIDA Neurobio of Addiction (2016 In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

43

Urine Drug Testing Stimulants

Amphetamine Methamphetamine

bull False positives pseudoephedrine bupropion labetolol ranitidine trazodone TCAs

bull Low sensitivity for detection of MDMA

bull 2 methamphetamine isomers d (CNS) and l (peripheral)

Cocaine

bull Primary metabolite benzoyleconine

bull False positives rare (coca leaf tea adulterated natural products)

Opiates

bull Tests for morphine-based substances

bull Unreliable for synthetic opioids like oxycodone

44

Summary

Alcohol use disorder is a common and deadly illness

with significant comorbidities

Alcohol withdrawal management does not treat AUD

It is important to understand key concepts in other

drug use disorders

Urine drug testing is an important piece to clinical

decision making

45

References

Disease ImCenters for Disease Control and Prevention (CDC) Alcohol-Related pact (ARDI) Atlanta GA CDC

Epidemiology of DSM-5 Alcohol Use Disorder Results From the National Epidemiologic Survey on Alcohol and Related Conditions III Grant BF1 Goldstein RB1 Saha TD1 Chou SP1 Jung J1 Zhang H1 Pickering RP1 Ruan WJ1 Smith SM1 Huang B1 Hasin DS2

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment Levounis Zerbo and Aggarwal Eds

Stahre M Roeber J Kanny D Brewer RD Zhang X Contribution of excessive alcohol consumption to deaths and years of potential life lost in the United States Prev Chronic Dis 201411130293

39

Mental illness and co-morbid or co-occurring substance use disorder is common

Approximately 13 of all people with mental illness and 12 with severe mental illness also have a substance use disorder

Self medication hypothesis vs substance

induced disorder

Multi-modal parallel or integrated treatment approach is most effective

Dual Diagnosis

Data from SAMHSA

40

Toxicology Screening

Urine most common method given cost and ease of collection Problem adulteration and substitution

bull On-site rapid testing

bull Immunoassay (initial lab screen)

bull GCMS

Blood better for quantitative analysis detection of acute intoxication Problem invasive detection for shorter periods than urine

Saliva Non-invasive lower potential for adulteration than urine Problem higher detection threshold and greater cost

Sweat Can identify substances over longer period of time Problem difficult to collect and quantify

Hair Easy to collect less likelihood of adulteration provides qualitative account of history of ingestion Problem poor at detecting acute intoxication more labor-intensive to process

41

Screening for drugs in healthy individuals

with no prior suspicion

bull Workplace or athletic testing

Testing for drugs in ill persons with a prior suspicion of use

Monitoring for drugs as part of a pain management or treatment program

While reliable on-site urine drug testing offers preliminary results When making treatment altering decisions urine should always be sent for confirmatory testing

Urine Testing

42

Urine Detection Limits

Alcohol 6 - 12 hours

EtG (ethylglucuronide) 4 days

Amphetaminesmeth 2 - 3 days

Benzos (short-acting) 3 days

Cocaine 3 - 4 days

Morphine 2 days

Marijuana (THC) 3 - 30+ days

Methadone 2 - 4 days

Buprenorphine 2 - 4 days

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

Adapted from Helander et al 2009 Moeller et al 2008

NIDA Neurobio of Addiction (2016 In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

43

Urine Drug Testing Stimulants

Amphetamine Methamphetamine

bull False positives pseudoephedrine bupropion labetolol ranitidine trazodone TCAs

bull Low sensitivity for detection of MDMA

bull 2 methamphetamine isomers d (CNS) and l (peripheral)

Cocaine

bull Primary metabolite benzoyleconine

bull False positives rare (coca leaf tea adulterated natural products)

Opiates

bull Tests for morphine-based substances

bull Unreliable for synthetic opioids like oxycodone

44

Summary

Alcohol use disorder is a common and deadly illness

with significant comorbidities

Alcohol withdrawal management does not treat AUD

It is important to understand key concepts in other

drug use disorders

Urine drug testing is an important piece to clinical

decision making

45

References

Disease ImCenters for Disease Control and Prevention (CDC) Alcohol-Related pact (ARDI) Atlanta GA CDC

Epidemiology of DSM-5 Alcohol Use Disorder Results From the National Epidemiologic Survey on Alcohol and Related Conditions III Grant BF1 Goldstein RB1 Saha TD1 Chou SP1 Jung J1 Zhang H1 Pickering RP1 Ruan WJ1 Smith SM1 Huang B1 Hasin DS2

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment Levounis Zerbo and Aggarwal Eds

Stahre M Roeber J Kanny D Brewer RD Zhang X Contribution of excessive alcohol consumption to deaths and years of potential life lost in the United States Prev Chronic Dis 201411130293

40

Toxicology Screening

Urine most common method given cost and ease of collection Problem adulteration and substitution

bull On-site rapid testing

bull Immunoassay (initial lab screen)

bull GCMS

Blood better for quantitative analysis detection of acute intoxication Problem invasive detection for shorter periods than urine

Saliva Non-invasive lower potential for adulteration than urine Problem higher detection threshold and greater cost

Sweat Can identify substances over longer period of time Problem difficult to collect and quantify

Hair Easy to collect less likelihood of adulteration provides qualitative account of history of ingestion Problem poor at detecting acute intoxication more labor-intensive to process

41

Screening for drugs in healthy individuals

with no prior suspicion

bull Workplace or athletic testing

Testing for drugs in ill persons with a prior suspicion of use

Monitoring for drugs as part of a pain management or treatment program

While reliable on-site urine drug testing offers preliminary results When making treatment altering decisions urine should always be sent for confirmatory testing

Urine Testing

42

Urine Detection Limits

Alcohol 6 - 12 hours

EtG (ethylglucuronide) 4 days

Amphetaminesmeth 2 - 3 days

Benzos (short-acting) 3 days

Cocaine 3 - 4 days

Morphine 2 days

Marijuana (THC) 3 - 30+ days

Methadone 2 - 4 days

Buprenorphine 2 - 4 days

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

Adapted from Helander et al 2009 Moeller et al 2008

NIDA Neurobio of Addiction (2016 In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

43

Urine Drug Testing Stimulants

Amphetamine Methamphetamine

bull False positives pseudoephedrine bupropion labetolol ranitidine trazodone TCAs

bull Low sensitivity for detection of MDMA

bull 2 methamphetamine isomers d (CNS) and l (peripheral)

Cocaine

bull Primary metabolite benzoyleconine

bull False positives rare (coca leaf tea adulterated natural products)

Opiates

bull Tests for morphine-based substances

bull Unreliable for synthetic opioids like oxycodone

44

Summary

Alcohol use disorder is a common and deadly illness

with significant comorbidities

Alcohol withdrawal management does not treat AUD

It is important to understand key concepts in other

drug use disorders

Urine drug testing is an important piece to clinical

decision making

45

References

Disease ImCenters for Disease Control and Prevention (CDC) Alcohol-Related pact (ARDI) Atlanta GA CDC

Epidemiology of DSM-5 Alcohol Use Disorder Results From the National Epidemiologic Survey on Alcohol and Related Conditions III Grant BF1 Goldstein RB1 Saha TD1 Chou SP1 Jung J1 Zhang H1 Pickering RP1 Ruan WJ1 Smith SM1 Huang B1 Hasin DS2

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment Levounis Zerbo and Aggarwal Eds

Stahre M Roeber J Kanny D Brewer RD Zhang X Contribution of excessive alcohol consumption to deaths and years of potential life lost in the United States Prev Chronic Dis 201411130293

41

Screening for drugs in healthy individuals

with no prior suspicion

bull Workplace or athletic testing

Testing for drugs in ill persons with a prior suspicion of use

Monitoring for drugs as part of a pain management or treatment program

While reliable on-site urine drug testing offers preliminary results When making treatment altering decisions urine should always be sent for confirmatory testing

Urine Testing

42

Urine Detection Limits

Alcohol 6 - 12 hours

EtG (ethylglucuronide) 4 days

Amphetaminesmeth 2 - 3 days

Benzos (short-acting) 3 days

Cocaine 3 - 4 days

Morphine 2 days

Marijuana (THC) 3 - 30+ days

Methadone 2 - 4 days

Buprenorphine 2 - 4 days

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

Adapted from Helander et al 2009 Moeller et al 2008

NIDA Neurobio of Addiction (2016 In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

43

Urine Drug Testing Stimulants

Amphetamine Methamphetamine

bull False positives pseudoephedrine bupropion labetolol ranitidine trazodone TCAs

bull Low sensitivity for detection of MDMA

bull 2 methamphetamine isomers d (CNS) and l (peripheral)

Cocaine

bull Primary metabolite benzoyleconine

bull False positives rare (coca leaf tea adulterated natural products)

Opiates

bull Tests for morphine-based substances

bull Unreliable for synthetic opioids like oxycodone

44

Summary

Alcohol use disorder is a common and deadly illness

with significant comorbidities

Alcohol withdrawal management does not treat AUD

It is important to understand key concepts in other

drug use disorders

Urine drug testing is an important piece to clinical

decision making

45

References

Disease ImCenters for Disease Control and Prevention (CDC) Alcohol-Related pact (ARDI) Atlanta GA CDC

Epidemiology of DSM-5 Alcohol Use Disorder Results From the National Epidemiologic Survey on Alcohol and Related Conditions III Grant BF1 Goldstein RB1 Saha TD1 Chou SP1 Jung J1 Zhang H1 Pickering RP1 Ruan WJ1 Smith SM1 Huang B1 Hasin DS2

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment Levounis Zerbo and Aggarwal Eds

Stahre M Roeber J Kanny D Brewer RD Zhang X Contribution of excessive alcohol consumption to deaths and years of potential life lost in the United States Prev Chronic Dis 201411130293

42

Urine Detection Limits

Alcohol 6 - 12 hours

EtG (ethylglucuronide) 4 days

Amphetaminesmeth 2 - 3 days

Benzos (short-acting) 3 days

Cocaine 3 - 4 days

Morphine 2 days

Marijuana (THC) 3 - 30+ days

Methadone 2 - 4 days

Buprenorphine 2 - 4 days

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

Adapted from Helander et al 2009 Moeller et al 2008

NIDA Neurobio of Addiction (2016 In Addiction Assessment and Treatment

Levounis Zerbo and Aggarwal Eds

43

Urine Drug Testing Stimulants

Amphetamine Methamphetamine

bull False positives pseudoephedrine bupropion labetolol ranitidine trazodone TCAs

bull Low sensitivity for detection of MDMA

bull 2 methamphetamine isomers d (CNS) and l (peripheral)

Cocaine

bull Primary metabolite benzoyleconine

bull False positives rare (coca leaf tea adulterated natural products)

Opiates

bull Tests for morphine-based substances

bull Unreliable for synthetic opioids like oxycodone

44

Summary

Alcohol use disorder is a common and deadly illness

with significant comorbidities

Alcohol withdrawal management does not treat AUD

It is important to understand key concepts in other

drug use disorders

Urine drug testing is an important piece to clinical

decision making

45

References

Disease ImCenters for Disease Control and Prevention (CDC) Alcohol-Related pact (ARDI) Atlanta GA CDC

Epidemiology of DSM-5 Alcohol Use Disorder Results From the National Epidemiologic Survey on Alcohol and Related Conditions III Grant BF1 Goldstein RB1 Saha TD1 Chou SP1 Jung J1 Zhang H1 Pickering RP1 Ruan WJ1 Smith SM1 Huang B1 Hasin DS2

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment Levounis Zerbo and Aggarwal Eds

Stahre M Roeber J Kanny D Brewer RD Zhang X Contribution of excessive alcohol consumption to deaths and years of potential life lost in the United States Prev Chronic Dis 201411130293

43

Urine Drug Testing Stimulants

Amphetamine Methamphetamine

bull False positives pseudoephedrine bupropion labetolol ranitidine trazodone TCAs

bull Low sensitivity for detection of MDMA

bull 2 methamphetamine isomers d (CNS) and l (peripheral)

Cocaine

bull Primary metabolite benzoyleconine

bull False positives rare (coca leaf tea adulterated natural products)

Opiates

bull Tests for morphine-based substances

bull Unreliable for synthetic opioids like oxycodone

44

Summary

Alcohol use disorder is a common and deadly illness

with significant comorbidities

Alcohol withdrawal management does not treat AUD

It is important to understand key concepts in other

drug use disorders

Urine drug testing is an important piece to clinical

decision making

45

References

Disease ImCenters for Disease Control and Prevention (CDC) Alcohol-Related pact (ARDI) Atlanta GA CDC

Epidemiology of DSM-5 Alcohol Use Disorder Results From the National Epidemiologic Survey on Alcohol and Related Conditions III Grant BF1 Goldstein RB1 Saha TD1 Chou SP1 Jung J1 Zhang H1 Pickering RP1 Ruan WJ1 Smith SM1 Huang B1 Hasin DS2

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment Levounis Zerbo and Aggarwal Eds

Stahre M Roeber J Kanny D Brewer RD Zhang X Contribution of excessive alcohol consumption to deaths and years of potential life lost in the United States Prev Chronic Dis 201411130293

44

Summary

Alcohol use disorder is a common and deadly illness

with significant comorbidities

Alcohol withdrawal management does not treat AUD

It is important to understand key concepts in other

drug use disorders

Urine drug testing is an important piece to clinical

decision making

45

References

Disease ImCenters for Disease Control and Prevention (CDC) Alcohol-Related pact (ARDI) Atlanta GA CDC

Epidemiology of DSM-5 Alcohol Use Disorder Results From the National Epidemiologic Survey on Alcohol and Related Conditions III Grant BF1 Goldstein RB1 Saha TD1 Chou SP1 Jung J1 Zhang H1 Pickering RP1 Ruan WJ1 Smith SM1 Huang B1 Hasin DS2

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment Levounis Zerbo and Aggarwal Eds

Stahre M Roeber J Kanny D Brewer RD Zhang X Contribution of excessive alcohol consumption to deaths and years of potential life lost in the United States Prev Chronic Dis 201411130293

45

References

Disease ImCenters for Disease Control and Prevention (CDC) Alcohol-Related pact (ARDI) Atlanta GA CDC

Epidemiology of DSM-5 Alcohol Use Disorder Results From the National Epidemiologic Survey on Alcohol and Related Conditions III Grant BF1 Goldstein RB1 Saha TD1 Chou SP1 Jung J1 Zhang H1 Pickering RP1 Ruan WJ1 Smith SM1 Huang B1 Hasin DS2

Levounis amp Lynch DSM-5 Diagnosis and Toxicology (2016) In Addiction Assessment and Treatment Levounis Zerbo and Aggarwal Eds

Stahre M Roeber J Kanny D Brewer RD Zhang X Contribution of excessive alcohol consumption to deaths and years of potential life lost in the United States Prev Chronic Dis 201411130293

46

PCSS-MAT Mentoring Program

PCSS-MAT Mentor Program is designed to offer general information to

clinicians about evidence-based clinical practices in prescribing

medications for opioid addiction

PCSS-MAT Mentors are a national network of providers with expertise in

medication-assisted treatment and addictions

3-tiered approach allows every mentormentee relationship to be unique

and catered to the specific needs of the mentee

No cost

For more information visit

pcssmatorgmentoring

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PCSS Discussion Forum

Have a clinical question

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Funding for this initiative was made possible (in part) by grant no 1U79TI026556-01 from SAMHSA The views expressed in written

conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department

of Health and Human Services nor does mention of trade names commercial practices or organizations imply endorsement by the

US Government

PCSS-MAT is a collaborative effort led by the American Academy of Addiction Psychiatry (AAAP) in

partnership with the Addiction Technology Transfer Center (ATTC) American Academy of Family

Physicians (AAFP) American Academy of Pain Medicine (AAPM) American Academy of Pediatrics

(AAP) American College of Emergency Physicians (ACEP) American College of Physicians (ACP)

American Dental Association (ADA) American Medical Association (AMA) American Osteopathic

Academy of Addiction Medicine (AOAAM) American Psychiatric Association (APA) American

Psychiatric Nurses Association (APNA) American Society of Addiction Medicine (ASAM) American

Society for Pain Management Nursing (ASPMN) Association for Medical Education and Research in

Substance Abuse (AMERSA) International Nurses Society on Addictions (IntNSA) National

Association of Community Health Centers (NACHC) and the National Association of Drug Court

Professionals (NADCP)

For more information wwwpcssmatorg

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PCSS-MAT Training Mentoring Resources