MEDICAL MEDICAL COMORBIDITIES OF COMORBIDITIES OF

SUBSTANCE USE SUBSTANCE USE DISORDERSDISORDERS

Oregon Psychiatric AssociationOregon Psychiatric AssociationMarch 4, 2006March 4, 2006

ObjectivesObjectives

Review epidemiology of alcohol/substance Review epidemiology of alcohol/substance use disordersuse disorders

Review importance of these disorders in Review importance of these disorders in medicinemedicine

General overview of medical complications General overview of medical complications of alcohol/substance use disordersof alcohol/substance use disorders

Discuss specific complicationsDiscuss specific complications MethamphetaminesMethamphetamines AlcoholAlcohol OthersOthers

EpidemiologyEpidemiology

2/3 ever consumed alcohol2/3 ever consumed alcohol ~40% ever used illicit drugs~40% ever used illicit drugs 20% use tobacco20% use tobacco Lifetime prevalenceLifetime prevalence

Alcohol use disordersAlcohol use disorders Men - 15-20%Men - 15-20% Women - 8%Women - 8%

Drug use disordersDrug use disorders Men – 8%Men – 8% Women – 5%Women – 5%

ImportanceImportance

20-40% of general hospital admissions20-40% of general hospital admissions 20% of primary care visits20% of primary care visits One million ER visits per yearOne million ER visits per year

Drug use primary problemDrug use primary problem 50-75% of trauma visits50-75% of trauma visits Up to 200,000 deaths per yearUp to 200,000 deaths per year Alcohol decreases life expectancy by Alcohol decreases life expectancy by

15 yrs15 yrs ~40% of suicides involve drugs/alcohol~40% of suicides involve drugs/alcohol

Societal Costs – Alcohol Use Societal Costs – Alcohol Use DisordersDisorders

Total: ~$185 BillionTotal: ~$185 Billion

Source: Harwood, H. Report prepared by the Lewin Group for the National Institute on Alcohol Abuse and Alcoholism; 2000. National Institutes of Health, NIH Publication No. 98-4327. Rockville, MD.

http://www.niaaa.nih.gov

†FAS = fetal alcohol syndrome.

47%

20%

2%

9%

4%13%

5%

1%

Specialty Alcohol Services*

Medical Consequences (except FAS†)

Medical Consequences of FAS

Lost Future Earnings Due toPremature Deaths

Lost Earnings Due toAlcohol-Related Illness

Lost Earnings Due to FAS

Lost Earnings Due to Crime/Victims

Crashes, Fires, Criminal Justice, etc

Medical ConsequencesMedical Consequences

Direct EffectsDirect Effects Toxicity of substance of abuseToxicity of substance of abuse Toxicity of contaminantsToxicity of contaminants

Indirect EffectsIndirect Effects Infectious diseasesInfectious diseases TraumaTrauma Nutritional deficienciesNutritional deficiencies Consequences of intoxication/withdrawal Consequences of intoxication/withdrawal

statesstates

Case #1Case #1

43 yo woman c/o dyspepsia, epigastric 43 yo woman c/o dyspepsia, epigastric burning and anxietyburning and anxiety

PMH – hypertensionPMH – hypertension Meds: Atenolol 25mg qdMeds: Atenolol 25mg qd HPI, ROS – unremarkableHPI, ROS – unremarkable Labs in past year – all WNLLabs in past year – all WNL

Case #1Case #1

PE:PE: Looks anxiousLooks anxious Hands are cold,clammy, slightly shakyHands are cold,clammy, slightly shaky Wearing strong perfumeWearing strong perfume P: 102 regularP: 102 regular BP: 155/101BP: 155/101 Temp, respirations – normalTemp, respirations – normal Remainder of PE only remarkable for mild Remainder of PE only remarkable for mild

tachycardiatachycardia

What’s Your Diagnosis?What’s Your Diagnosis?Differential – substance use disordersDifferential – substance use disorders

Mild intoxication – stimulantsMild intoxication – stimulantsWithdrawal – alcohol, opioids, Withdrawal – alcohol, opioids, sedative/hypnoticssedative/hypnotics

Clues Clues GI symptoms – gastritisGI symptoms – gastritisHypertensionHypertensionSymptoms of alcohol withdrawalSymptoms of alcohol withdrawalUse of perfume, aftershave, mouthwash to cover Use of perfume, aftershave, mouthwash to cover smell of alcoholsmell of alcohol

Defining the “Standard Drink”Defining the “Standard Drink” 10-15g ethanol 10-15g ethanol

12 oz of regular beer or cooler (5% alcohol)12 oz of regular beer or cooler (5% alcohol)

5 oz of table wine (12% alcohol)5 oz of table wine (12% alcohol)

1.5 oz of hard liquor (40% alcohol, 80 proof)1.5 oz of hard liquor (40% alcohol, 80 proof)

The average person metabolizes about 1 standard drink per The average person metabolizes about 1 standard drink per hourhour

12 oz12 oz 8.5 oz8.5 oz 5 oz5 oz 3.5 oz3.5 oz 2.5 oz2.5 oz 1.5 oz1.5 oz 1.5 oz1.5 oz

12 oz12 ozbeer beer

ororcoolercooler

8-9 oz8-9 ozmalt liquormalt liquor

5 oz5 ozwinewine

3-4 oz3-4 ozfortified winefortified wine

2-3 oz2-3 ozcordial,cordial,liqueur,liqueur,

or or aperitifaperitif

1.5 oz1.5 ozbrandybrandy

1.5 oz1.5 ozhard hard

liquorliquor

Source: National Institute on Alcohol Abuse and Alcoholism. Bethesda, Md: NIAAA; 2004. NIH Publication No. 04-3769.

Chronic Alcohol UseChronic Alcohol Use

Liver DiseaseLiver DiseaseCirrhosisCirrhosis

Coronary Artery DiseaseCoronary Artery DiseaseCardiomyopathyCardiomyopathyArrhythmiasArrhythmiasHypertension Hypertension StrokeStroke

Duodenal ulcersDuodenal ulcers

Cognitive disordersCognitive disordersCVACVAPsychosisPsychosis

PancreatitisPancreatitisDiabetesDiabetes

Head, Neck, GI cancersHead, Neck, GI cancers

Stomach ulcersStomach ulcersGastritisGastritis

Adapted from: Schuckit MA. In: Harrison’s Principles of Internal Medicine. New York: McGraw-Hill; 2001:2561-2566. .

NeuropathiesNeuropathiesAnemias Anemias Nutritional DeficienciesNutritional Deficiencies

Diseases Associated with Diseases Associated with Chronic Alcohol UseChronic Alcohol Use

CardiomyopathyCardiomyopathy

Gastritis, other GI Gastritis, other GI complicationscomplications

Liver diseaseLiver disease

DementiaDementia

NeuropathyNeuropathy

PancreatitisPancreatitis

AnemiasAnemias

Head, Neck, GI Head, Neck, GI cancerscancers

DiabetesDiabetes

Coronary artery Coronary artery diseasedisease

CVACVA

Nutritional Nutritional deficienciesdeficiencies

HypertensionHypertension

Sources: Schuckit MA. In: Harrison’s Principles of Internal Medicine. New York: McGraw-Hill; 2001:2561-2566. American Psychiatric Association. DSM-IV-TR. American Psychiatric Association: Washington, DC; 2000.

Nutritional ConsequencesNutritional Consequences

Heavy drinkers – up to 50% of daily Heavy drinkers – up to 50% of daily caloric intakecaloric intake >25% - >25% - significant decrease in necessary significant decrease in necessary

nutrientsnutrients MalnutritionMalnutrition Vitamin deficienciesVitamin deficiencies Impairs activation and utilization of Impairs activation and utilization of

nutrientsnutrients Maldigestion (GI complications)Maldigestion (GI complications)

Specific DeficienciesSpecific Deficiencies ThiamineThiamine

Wernicke-Korsakoff’sWernicke-Korsakoff’s Neuropathies Neuropathies

FolateFolate Megaloblastic anemiaMegaloblastic anemia

Vitamin C – with high alcohol intakeVitamin C – with high alcohol intake Vitamin DVitamin D

Decreased intake, poor absorption, insufficient Decreased intake, poor absorption, insufficient sunlightsunlight

Decreased bone mass, densityDecreased bone mass, density Increased osteoporosis, bone fracturesIncreased osteoporosis, bone fractures

GI ComplicationsGI Complications

LiverLiver ETOH toxic to hepatocytesETOH toxic to hepatocytes AST>ALTAST>ALT Accelerates liver damage in hepatitis C Accelerates liver damage in hepatitis C

infectioninfection Increases risk of acetaminophen toxicityIncreases risk of acetaminophen toxicity Range of diseaseRange of disease

Fatty liverFatty liver Alcoholic hepatitisAlcoholic hepatitis FibrosisFibrosis CirrhosisCirrhosis

GI ComplicationsGI Complications

PancreatitisPancreatitis Generally after 10-15 years of heavy ETOHGenerally after 10-15 years of heavy ETOH

GI bleedingGI bleeding GastritisGastritis Peptic ulcer diseasePeptic ulcer disease Esophageal varicesEsophageal varices DuodenitisDuodenitis EsophagitisEsophagitis

Neurologic ComplicationsNeurologic Complications Wernicke’s encephalopathyWernicke’s encephalopathy

Delirium, ataxia, ophthalmoplegiaDelirium, ataxia, ophthalmoplegia Thiamine deficiencyThiamine deficiency Necrosis of mammillary bodies and Necrosis of mammillary bodies and

thalamusthalamus 50-85% 50-85% Korsakoff’s psychosis Korsakoff’s psychosis Few regain cognitive functionFew regain cognitive function

Korsakoff’s PsychosisKorsakoff’s Psychosis

Common pathology and etiology as Common pathology and etiology as Wernicke’sWernicke’s

Severe memory impairmentSevere memory impairment Recent and ongoing eventsRecent and ongoing events

Confabulation, lack of insightConfabulation, lack of insight Other intellectual functions may be Other intellectual functions may be

intactintact Treat with thiamineTreat with thiamine

Alcoholic DementiaAlcoholic Dementia

Prominent effects – frontal cortex, Prominent effects – frontal cortex, putamenputamen

Extreme variabilityExtreme variability EtiologyEtiology

NeurotoxicNeurotoxic Effects on neurotransmittersEffects on neurotransmitters Decreased cerebral blood flowDecreased cerebral blood flow Vitamin deficienciesVitamin deficiencies

Alcoholic DementiaAlcoholic Dementia

ImpairmentsImpairments Abstract thinkingAbstract thinking Problem solvingProblem solving Visual, spatial, motor abilitiesVisual, spatial, motor abilities New learningNew learning Remote memoryRemote memory Personal carePersonal care

Other Neurologic ComplicationsOther Neurologic Complications

““Blackouts” – transient anterograde amnesiaBlackouts” – transient anterograde amnesia ↑↑risk of CVArisk of CVA ↑↑risk of cerebral traumarisk of cerebral trauma Cerebellar degenerationCerebellar degeneration Metabolic encephalopathiesMetabolic encephalopathies Peripheral neuropathiesPeripheral neuropathies

Sensory, motor or autonomicSensory, motor or autonomic ““Stocking-glove” distributionStocking-glove” distribution

Other Organ SystemsOther Organ Systems HematologicHematologic

Anemias – Fe deficiency, folate deficiencyAnemias – Fe deficiency, folate deficiency Pancytopenia – alcohol toxic to bone marrowPancytopenia – alcohol toxic to bone marrow

MusculoskeletalMusculoskeletal RhabdomyolysisRhabdomyolysis Osteopenia/osteoporosis, fracturesOsteopenia/osteoporosis, fractures MyopathyMyopathy

CardiovascularCardiovascular CardiomyopathyCardiomyopathy HypertensionHypertension

DermatologicDermatologic Facial edema, rosacea, rhinophymaFacial edema, rosacea, rhinophyma

Metabolic/endocrineMetabolic/endocrine GoutGout Decreased testosteroneDecreased testosterone Menstrual abnormalitiesMenstrual abnormalities

MarijuanaMarijuana

Pulmonary toxicityPulmonary toxicity COPDCOPD

Head, neck cancersHead, neck cancers Cognitive deficitsCognitive deficits

Attention, short term Attention, short term memorymemory

Information processingInformation processing Motor impairmentMotor impairment

↓ ↓ Immune responseImmune response ↓ ↓ Testosterone levelsTestosterone levels Menstrual abnormalitiesMenstrual abnormalities

SummarySummary

Common disordersCommon disorders Many medical complicationsMany medical complications Patients frequently present to ERs, Patients frequently present to ERs,

general medical settingsgeneral medical settings Important to assess all patients for Important to assess all patients for

alcohol, tobacco, other substance usealcohol, tobacco, other substance use Complaints may caused/exacerbated by Complaints may caused/exacerbated by

substance use substance use