<v ->Hello, this is the Overview of Substance Use Disorders</v> for the Providers Clinical Support System MAT SUD 101 series. I am Dr. Myra Mathis, Addiction Psychiatrist and Assistant Professor at the University of Rochester Department of Psychiatry, and Medical Director at Strong Recovery Outpatient Addiction Services Clinic. I have no disclosures for this educational activity and no relevant financial relationships. The overarching goal of PCSS is to train healthcare professionals in evidence-based practices for the prevention and treatment of opioid use disorders, particularly in prescribing medications as well as the prevention and treatment of other substance use disorders. At the conclusion of this educational experience, participants should be able to identify the spectrum of substance use, utilize accurate clinical terminology, describe the basic epidemiology and public health impact of substance use disorders, describe neurobiological responses to substances, describe how chronic disease treatment applies to addiction, and list common comorbidities in people with substance use disorders. In order to accomplish these objectives, we will follow this outline. First, discussing the spectrum of substance use, then accurate terminology, epidemiology, neurobiology, addiction as a chronic disease, association of addiction with other convictions, harm reduction, and the integration of addiction treatment into general medical and psychiatric care. The spectrum of substance use. In looking at this graphic, we will discuss various components of the spectrum of substance use. Beginning at the bottom of this triangle and on both the left and the right hand side, we see that there is no substance use, but as we go from the bottom to the top with increasing in the degree of consumption, we also can see the increase in severe consequences. So, at the very base of this pyramid is abstinence or no use at all. Next, we see the category of low risk use and this primarily refers to classifications for alcohol use and/or cannabis use where there can be occasional use of these substances that does not lead to significant health risk. As we move from the bottom of this period, going from low risk use to unhealthy use, it includes two categories, risky use, at-risk or hazardous use, and at the very top, harmful use. Unhealthy use and harmful use are included in this spectrum because they are still utilized as diagnostic categories in the international classification of diseases. While they may not be reflected in the Diagnostic Statistical Manuals Edition 5 which helps us to classify substance use disorders. Risky use, at-risk use or hazardous use refers primarily to alcohol use disorder where there are certain thresholds of consumption that can lend itself to risky or unhealthy use. At the very top of this pyramid is harmful use, and in this section, we are able to present the diagnosis of substance use disorders. This is when patients are experiencing more consequences of their use and the substance use disorder can be classified as mild, moderate, or severe. Criteria for diagnosing a substance use disorder according to the Diagnostic Statistical Manual Edition 5 are as follows: A substance use disorder is defined as a problematic pattern of substance use leading to clinically significant impairment or distress as manifested by at least two of the following criteria occurring within a 12 month period. The substance is taken in larger amounts over a longer period than was intended. There is a persistent desire or unsuccessful effort to cut down or control substance use. A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects. A craving, or a strong desire, or urge to use the substance. I will pause here and just reflect briefly on what is craving. Again, a strong urge to use a substance in a way that a person cannot think of anything else. It is not just the time spent in activities necessary to obtain the substance as signified by criteria number three, but it is the time spent thinking about use and this feeling that it is increasingly difficult to resist use. The fifth criteria, recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home. Continued substance use despite having persistent or recurring social or interpersonal problems caused or exacerbated by the effects of the substance. Important social, occupational, or recreational activities are given up or reduced because of substance use. Recurrent use in situations in which it is physically hazardous. And ongoing substance use despite knowledge of having a persistent or recurring physical or psychological problem that is likely had to have been caused or exacerbated by substance use. As you can see through the outline of these first nine criteria, there is an escalation in the consequences of substance use impacting various aspects of the individual's life, including their psychosocial functioning and their physical and mental health. The last two criteria focus on the physiological response that individuals have to substance use. It is important to note that these last two criteria, tolerance and withdrawal, do not apply when an individual is using a medication appropriately under medical supervision. Tolerance, defined as either a need for markedly increased amounts of the substance to achieve intoxication or desired effect, or B, a markedly diminished effect with continued use of the same amount of the substance. And withdrawal, as manifested by either of the following. The characteristic withdrawal syndrome for the substance and, of course, we are most familiar with alcohol withdrawal and opioid withdrawal. Alcohol and benzodiazepine withdrawal being life-threatening medical conditions. And B, a substance or a closely-related substance is taken to relieve or avoid withdrawal symptoms. From these 11 criteria, we then go on to specify the current severity of the substance use disorder. It would be classified as mild if there's the presence of two to three criteria, moderate for the presence of four to five criteria, and severe for greater than six criteria. In diagnosis, we would also specify the substance being used, for example, cocaine use disorder or alcohol use disorder. And it is important to note that polysubstance use was removed from the Diagnostic Statistical Manual 5. For patients with utilizing multiple substances, they should be assessed for the criteria of substance use disorder for each of those substances, and if they meet criteria for substance use disorder with each of those substances, then all disorders and relevant substances should be listed. Accurate clinical terminology. Here, we review clinical terminology that should be used in describing substance use. The classification of unhealthy use, this is harmful or hazardous use, as well as non-prescribed use of prescribed medications. It is important to avoid the term "misuse" as this can reflect some stigmatizing language. Binge is a way in which heavy use is often described, however, this is not very clinically accurate. Instead, it is helpful to qualify the type of use that is occurring. Is this a heavy episode of use in one sitting? Or use over multiple days in which a patient has had a period of abstinence and then returns to use for multiple days in a row, signifying a binge? Multiple days of use that can... That are often commonly reflected as a binge can include the use of cocaine over multiple days, whereas in alcohol use, sometimes an episode of use referred to as a binge is an episode of heavy use on one day. It is important then, rather than using the term "binge" to qualify what type of use is occurring with what substance. The Diagnostic Statistical Manual Version 5 updated the description of substance use from abuse and dependence to disorder. And so, it is important to utilize the term "substance use disorder" when describing an addiction. Dependence can have multiple meanings and so it is important to be thoughtful about how this term is being used as it may not reflect the same thing from one clinician to another. Often, dependence is thought about as a physical dependence, meaning that there is the physiologic response of tolerance or withdrawal to a particular substance. Dependence is still utilized by the current version of the ICD, ICD-10, but it was primarily utilized in the DSM 4 and prior. Again, in the DSM 5, these classifications of abuse and dependence have been removed and we utilize the terminology substance use disorder with the qualifiers of mild, moderate, or severe. For toxicology screens, the appropriate terminology is either positive or negative. For example, a screen was positive for methamphetamines but negative for opiates. We avoid the use of the term "clean" or "dirty" to describe toxicology screens, as this is not a clinically accurate term and can reflect stigmatizing language. It's also important to utilize the term "return to use" when an individual who has had a period of abstinence for an amount of time, then returns to use of a substance. When an individual has an episode of returning to use, it is then important to further qualify what has occurred during that return to use. For example, is there a recurrence then, of the diagnostic criteria for a substance use disorder? An individual may have one episode of a return to use but is not experiencing the consequences of a substance use disorder and therefore would not have a recurrence of that disorder. It is important to avoid the term "relapse" as again, this can reflect stigmatizing language and is not clinically accurate in terms of the definition of an episode of use versus a recurrence of the substance use disorder. When speaking about medications for addiction treatment, we can utilize the terminology "agonist" because we are thinking about the action of the medication at the receptor. This is a more clinically accurate and non-stigmatizing way to describe medications for addiction treatment and in particular, those utilized to treat opioid use disorder. It's important to avoid terms like "substitution", "assisted", or "replacement", as they may connote the idea that we are substituting one substance for another or replacing one substance with another. Again, these can be terms that are stigmatizing both towards the patient but also towards the medication that is being utilized to treat the substance use disorder. An agonist treatment then refers to the mechanism of action by which the medication has its effect to treat the substance use disorder. And finally, when discussing the impact of substance use in pregnancy on a fetus, the appropriate clinical terminology is "neonatal withdrawal syndrome" and it is important to avoid the term "addicted", as in "The baby was born addicted." This is not clinically accurate and again, can reflect stigmatizing language. Epidemiology. According to the National Survey of Drug Use and Health in the year 2020, these are the numbers of individuals aged 12 and older with a past year's substance use disorder in 2020. Alcohol use disorder was the most common outside of tobacco use disorder with 28.3 million individuals. A broad category of illicit substance use disorder then follows with 18.4 million individuals, and the types of substances are listed below. So, cannabis use disorder, 14.2 million individuals, individuals with what's described as a pain reliever use disorder or opioid use disorder for the use of prescribed opioids, 2.3, methamphetamines, 1.5, cocaine use disorder, 1.3, other type of stimulant use disorder, 758,000 individuals, and heroin use disorder, 691,000 individuals. Overall, 40.3 million individuals in the United States had a past year substance use disorder reflecting 14.5% of the U.S. population aged 12 or older. Those numbers break down to the following percentage, again, for all substance use disorders, that includes various substances and alcohol, 14.5%, for alcohol use disorder, 10.2% of the U.S. population aged 12 or older, opioid use disorder, which includes the broader category of non-medical prescription opioid use and heroin use disorder, 0.8% of the U.S. population. It's important to note that fentanyl use was not included in the survey collection and so this may be an underestimate of the prevalence of opioid use disorder in the U.S. population. Prevalence of drug use disorder by socioeconomic status. In this study conducted by Compton and colleagues from 2007, they look at the prevalence, correlates, disability, and comorbidity, of DSM-4 drug abuse and dependence according to the diagnostic statistical manual at that time in the United States, utilizing results from the National Epidemiologic Survey on alcohol and related conditions. And so, this study then looks at the percentage of individuals with a substance use disorder or more specifically, a non-alcohol based substance use disorder over a 12 month period of time. Within that sample, 2.8% of males had a substance use disorder whereas 1.2% of females had a substance use disorder. We see that from a racial and ethnic demographic, Native American or indigenous communities were noted to have had the highest rate of substance use disorder at 4.9%, followed by Black individuals at 2.4%, and then white individuals at 1.9%. Again, this study is from 2007 and more recent data may reflect less spread across the populations and changes in the prevalence of substance use disorder both from the standpoint of gender and race and ethnicity. Moving on to age, 5.3% of individuals from age 18-29 years old had a substance use disorder and this continues to follow with current epidemiological data. Married individuals had the lowest rate of substance use disorder and individuals who were never married had the highest rate of substance use disorder in this study. Continuing on, individuals with some college had the lowest rate of substance use disorder when looking at educational characteristics. Those with a high school education and those with less than a high school education are very close, at 2.4 and 2.3% respectively. We see that individuals with the lowest annual income also are noted to have the highest rate of substance use disorder at 2.8%. And while it is clear that substance use affects individuals across the socioeconomic spectrum, the consequences of substance use may lead individuals to have a loss of their employment or loss of other financial means, which may reflect their representation in the lower income range. Very similar characteristics between urban and rural populations at 2.0 and 1.9. And based on these demographics, individuals who were characterized as living in the south, southern part of the United States, had the lowest rate of substance use at 1.5%, and those living in the west had the highest at 2.7%. Continuing on to describe the demographics of opioid use disorder more specifically. Males younger than 45 have higher rates of opioid use disorder than women, but women age 45 and older have higher rates of opioid use disorder than men. The rates of opioid use disorder are similar across racial ethnic groups, but currently, during this current overdose crisis, we see that the highest rates of overdose are among Black and Indigenous populations. The rates of OUD are higher for individuals with a lower income and higher rates for the unemployed and uninsured. But it is important to note that over half of those with a substance use disorder are employed full-time. In looking at the demographics of overdose during this overdose crisis, we see at the x-axis, time from 1999 until 2019 with a dotted line representing the start of the COVID-19 pandemic. And on the y-axis, death rates per 100,000. American Indian and Alaskan Native individuals are represented by a purple line, Black and African American individuals, non-Hispanic, represented by the blue line. Latinx individuals represented by the green line, and white individuals represented by a red line. And what we see over time, is a steady increase in overdose deaths across all populations with a brief decrease among Black individuals from 2005 to roughly 2013. But I want to specifically draw attention to what has occurred from 2019 on, and this is looking specifically at the sharp increase in overdose deaths from 2019 on across all racial and ethnic demographics, and seeing specifically that the rates of overdose deaths in Black and Indigenous populations are now outpacing that of white populations, and something to be considering as we think about strategies to address the overdose crisis as it has evolved over the last 20 years. It's also important to take a closer look at what is happening among adolescents and the demographics of overdose as they change and shift among adolescents during this overdose crisis. And so, what we see first, in the graph on the left, we are looking at overdose mortality among adolescents by substance type. The gray line is illicit fentanyls and synthetic opioids, orange benzodiazepines, blue methamphetamines. The open circle, cocaine, the darkened black circle, prescription opioids, and the light gray-blue circle, heroin. And what we see from 2019-2021 is a sharp increase in overdose mortality among adolescents due to fentanyl. Again, in this same age population, adolescents individuals under the age of 18 overdose mortality by race and ethnicity, and during that same period of time, from 2019-2021, and really, beginning for the American Indian and Alaskan Native population as early as 2016, a sharp increase in overdose mortality among American Indian and Alaskan Native individuals. The rates increased across all racial and ethnic demographics from 2020 onward, apart from the Black or African American demographic where there was a slight decrease in overdose deaths among adolescents. And the reasons for this difference still need to be studied. Neurobiology. These key brain structures and their functions are affected by addiction. There's normally a fine balance that connects these brain areas that are active in the reward, motivation, learning, and memory, and inhibitory control. They are necessary for survival and we will walk through ways in which they become disrupted through the process of addiction. In these graphs, we are looking at various stimuli over the course of time on the x-axis, and the degree to which dopamine is released on the y-axis, reflecting a reward response to natural stimuli like food and sex, and then onto substances. And so, we can see that food in animal models does cause an increase in dopamine, does activate reward centers in the brain. And similarly, that sexual activity activates reward centers in the brain. It is important for these activities to be reinforced for survival of a species. But as we move down to the graphs at the bottom part of the screen and we review how parts of the brain that are responsible for the reward mechanism are activated by amphetamines on the left and morphine on the right, we see that they are activated at levels multiple times higher than that of food or sex. And so, one of the ways that substance use disorders disrupts normal brain function is that it activates these reward centers at levels that are much higher than natural stimuli. Here, we look at repeated drug use and how it changes the brain. So, in the top of this graphic is the brain of an individual who does not use substances. We can see their dopamine receptors and how active their receptors are in the orbital frontal cortex, which is the part of the brain that helps with executive functioning and decision making. In the bottom part of this graphic, there's a brain of an individual who uses cocaine and we can see that their dopamine receptors are not activated as strongly and there is less activity in the orbital frontal cortex of the brain, which, again, is the part of the brain that helps with executive functioning and decision making. Here, we are looking at the brains of individuals who use cocaine and those who do not use cocaine and how they respond to various stimuli. In particular, to reflect how individuals who use cocaine respond to visual stimuli that can connote cocaine craving. And so, individuals who do not use cocaine, when they are shown a film with someone using cocaine, they did not have significant activation of various reward areas in the brain. However, when they are shown a film depicting erotic images, there is significant activation of those rewards centers in the brain. For an individual who uses cocaine, when they are shown images of a person using cocaine in a film, the reward centers of the brain are activated significantly. What is even more striking is that when individuals who use cocaine are shown an erotic film, there is a depression in that activation of the reward pathway. And so, normal rewarding stimuli are not as activating for an individual who uses cocaine. Here, we'll discuss the effects of a social stressor on dopamine receptors and the propensity to administer drugs. And in particular, we're thinking about how neurobiology interacts with the psychosocial environment. So, this experiment was done in monkeys and we see the difference between a group of dominant monkeys and a group of subordinate monkeys, and that the group of subordinate monkeys had a higher propensity to administer drugs. And even when the subordinate monkeys were housed and not exposed to the dominant monkeys, that stressor remained and the impact of those social dynamics remained. So, regardless of housing, subordinate monkeys used more cocaine than the dominant monkeys. So, we'll take a look at a couple examples from animal models, again, to help reflect this principle that neurobiology and the social environment intersect with one another. So, this is a Skinner Box which is the typical environment that many rats are housed in when they are being utilized for biomedical research, and they can be isolated in this box and some of them can give foot shocks. And when rats in this isolated environment are given access to drugs, it has been demonstrated that they can use those drugs to the point of causing their own demise through the foot shocks. And this is contrasted with this experiment here, done by Bruce Alexander, called Rat Park. And while there are some methodological questions related to this experiment, there are important principles that we can draw from. In particular, we see that there are opportunities for rats to have social interactions. There are trees drawn on the wall, there are places for exercise and for diversion. What has been shown is that for rats who are caged in environments like the Skinner Box, there is more drug use. However, when rats are housed in a more conducive and socially supportive settings like Rat Park, there is less drug use. Coming back to humans, as we think about the impact of psychosocial stressors and how that contributes to substance use, many often reflect on opioid use or what was then termed narcotic use in Southeast Asia following the Vietnam War. But during the sixties and seventies, many veterans returning from the war had increased rates of opioid use and opioid use disorder. So, our key points from neurobiology in thinking about how our brains function and how this disordered brain function then is reflected in the disease of addiction, dopamine release leads to subjective feelings of pleasure or reward and a reduction in feelings of stress. Repeated use overrides impulse inhibition. Repeated use is also associated with more discomfort when stopping use, which therefore then leads to more use. There is this dysregulation of executive function, the ability to make complex decisions, and that environmental and social conditions influence substance use. Addiction as a chronic disease. A disease is a disorder of structure or function that produces specific signs or symptoms. Addiction has defined causes which can be drawn from genetics, social environment, and observable consequences through both behavior and biology. This disorder of structure and function is established through our understanding of the neurobiology as well as the diagnostic criteria for substance use disorder. As a chronic disease, there is behavior change in addiction. There is disordered, quote, choice. And again, we think about choice in a more complex and nuanced way, given that addiction disorders choice and leads to individuals selecting drug use over what would be naturally occurring stimuli. Changes in impulse and self-control. Learning and habit. So, really, when we think about addiction, it is a chronic condition of the motivational system with an abnormally high priority given to a particular activity. Again, the system is abnormal due to a substance or other behavior. And so, there are other factors that can contribute to the perpetuation of addiction, including other psychiatric illness, anxiety and depression, also affected by the environment, distressing circumstances, social relationships, and periods of isolation. Risk and protective factors. So, there are some risk factors that can be reflected through genetics, as well as protective factors. The heritability of addiction ranges from 39-72%. Examples of specific genes include CYP2A6, which results in fast metabolism of nicotine. Individuals smoke more cigarettes which progresses more quickly to addiction with more severe withdrawal, and makes it harder for them to maintain abstinence from nicotine products. For alcohol, individuals may have a biological low response to alcohol, which can lead to higher risk as an individual may not feel the effects of intoxication as early as others, and so they increase the amount of alcohol use in order to experience the sensation of intoxication. This will lead to a higher risk of development of an alcohol use disorder, versus an individual who has a flushing response to alcohol. This is mediated genetically when a person drinks alcohol, has a flushing facial response and this deters someone from continuing to use alcohol and connotes a lower risk for the development of an alcohol use disorder. Age of onset can also reflect a risk factor. So, 9 out of 10 individuals with an addiction started using substances before they turned 18, and 97 individuals with an addiction started use before the age of 21. In general, 1 in 4 Americans who began using any substance before the age of 18 develops a substance use disorder. Developmental factors. Early developmental factors like temperament, attachment, parenting, warmth, and stability, can reflect protective factors for an individual in terms of the development of substance use disorder. In middle school, a range of behaviors like the ability to express self-control, the presence of aggression, permissive parenting, low parental aspirations for a child, or parental attitudes towards use, peers and their use, or school failure, can all reflect risk factors for the development of a substance use and risk factors for early onset of use during early or late adolescence. In adolescence, things like academic mastery, school engagement, parental supervision, and then positive peer role models who are also maintaining abstinence from substances and/or engaged in other positive activities, these reflect protective factors that lead to individuals being less likely to start substance use during adolescence. And in young adulthood, the ability to progress through all of these stages of development into young adulthood, leaving home, going to college. And again, we come back to the impact of peers. This can be a period of risk for individuals given the culture for young adults and particularly, in college settings and permissive culture amongst peers related to substance use. But, how someone is able to transition through those periods into young adulthood is a critical time in terms of the consideration for the development of a substance use disorder. Psychological factors that can lead to increased risk of the substance use disorder include various psychiatric diagnoses like depression, anxiety, psychotic disorders, conduct disorders, and youth and adolescence, and ADHD. The spectrum of stress and trauma related disorders including PTSD. Risk-taking or impulsive personality traits, or low self-esteem, these can be risk factors that can lead to use. Or expectancies, the expectations that an individual has of themselves or others in a positive sense, which can be a protective factor against early onset of substance use. Environmental factors. So, access to addictive substances, whether it's the liquor cabinet at home, various sales outlets, access to prescription cannabis or opiates. Substance use in the family, so parental use versus parental anti-use messages and expectations, where parents are setting boundaries around substance use and clearly communicate expectations to their children. Peer influence, so the use and approval of use by peers. The community tolerance of that use amongst adolescents as a rite of passage. A lax in enforcement, so from the standpoint of setting boundaries. The glamorous advertising of use through the media or even the direct-to-consumer advertisement for prescription drugs. Other environmental factors include high levels of parent-child conflict, poor communication, and weak family bonds. Briefly, we want to talk about COVID-19 as a unique psychosocial factor impacting substance use, and it includes a variety of environmental, and psychological, and psychosocial factors. Social isolation, unemployment and economic stress, higher rates of depression, and what we have seen are the highest recorded rates of overdose deaths in decades. So, from 3,442 deaths in 1999 to over 107,000 deaths in 2021. After some years of... At least a couple of years of curbing the rates of overdose deaths in 2017 and in 2018, in 2019, what we've seen through 2020 and 2021 is a dramatic increase with correlation to this unique psychosocial factor of the COVID-19 pandemic. So again, we come back to addiction as a chronic disease. We can compare it to other chronic conditions like depression, Type 2 diabetes, hypertension, and asthma. All of these conditions may be caused in part by genetic factors, but they also have environmental factors and influences that contribute to the development and course of illness. The contributions of voluntary behavior, and also the challenges related to behavior change in these chronic conditions. Addiction similar to these conditions has similar treatment and adherence rates as well as recurrence rates. Addiction like these chronic conditions responds to ongoing treatment. And there are some who will have to engage in lifelong management of the condition. Individuals with more severe substance use disorder have a course of illness and it may take time to achieve stability in their recovery. So, from the time that there's the onset of addiction, there may be four to five years before an individual engages in help-seeking behaviors. Over the course of time, there can be multiple attempts at engaging in treatment or mutual help. 12-13 years into someone's substance use disorder, they may sustain one year of abstinence. And then, there is continuing care and ongoing support to assist an individual in maintaining that abstinence. After five years, the recurrence risk drops below 15%. So, 50% of individuals with addiction will achieve full sustained remission. So, it's important to note that this full sustained remission is possible, but there can be a long treatment course that is required for an individual to achieve this outcome. We'd also like to just state that brain function can recover. And so, what we see in these images are the dopamine transporters in an individual in partial recovery from methamphetamine use disorder, and then in someone with a protracted period of abstinence. And what we can see is that the individual with a protracted period of abstinence of 14 months looks more like the normal control with the return to those darkened red areas in their dopamine transporters. Association of addiction with other conditions. There are many medical and psychiatric conditions associated with addiction. Cardiopulmonary conditions like asthma, COPD, and hypertension. Pain conditions like arthritis, headache, and low back pain. GI conditions like hepatitis C, cirrhosis, pancreatic disease, and gastritis. And a variety of psychiatric disorders including depression, dysthymia, bipolar disorder, anxiety disorders, psychosis, and personality disorders. The harmful effects of substances can occur through a variety of mechanisms. There are the direct harms caused by desired effects like intoxication, then also withdrawal and intentional overdose. There are the direct harmful effects due to undesired effects, and this is, in large part, due to the presence of contaminants in nicotine use, this can lead to lung cancer, talc lung. Again, unintentional overdose as we see in the contamination of the drug supply with fentanyl, and cirrhosis due to harmful effects from alcohol use. There are indirect harmful effects due to the method of administration. This can include endocarditis, pneumothorax, and also various additional infectious complications like HIV and HCV. And there are indirect harmful effects due to associated behaviors, sexually transmitted diseases, assault and injury, intimate partner violence, or a motor vehicle crash. We speak about these mechanisms of harmful effects because they can lead to other medical and psychiatric conditions associated with addiction. In terms of the harmful effects of injection, they include collapsed veins, skin endocarditis, and septic phlebitis, hepatitis A, B, C, and delta, HIV and other STDs, cellulitis, septic arthritis, pneumonia, osteomyelitis, epidural abscesses, skin abscesses, mycotic aneurysms, malaria, tetanus, pulmonary hypertension, talc granulomatosis, septic emboli, pulmonary embolism related to injection use, pneumothorax, and hepatic granulomatosis. Additionally, kidney failure and amyloidosis. All of these are harmful effects leading to other associated conditions related to injection drug use. HCV and HIV among persons who inject drugs. One-third of individuals who inject drugs aged 18-30, have positive serology reflecting infection with HCV. This rate is much higher in older and former individuals who inject drugs, at 70-90%. The prevalence of HIV among individuals who inject drugs is 11%, with a 9% attributable risk among individuals who inject drugs. Keeping in mind the multitude of harmful effects of various routes of administration. We'll spend some time discussing harm reduction. Harm reduction is a spectrum of practical strategies aimed at mitigating the medical consequences and social stigmas of substance use. It ranges from abstinence to managed use and really focuses on person-centered care. Recommendations from a harm reduction perspective include changing the route of administration. Oral administration being the least harmful and existing on a spectrum with injection as the route of administration associated with greatest risk and the highest rates of additional harmful consequences. Individuals are encouraged not to use alone. To avoid mixing drugs. To stagger their use. This can include using over a longer period of time at lower amounts, rather than using higher amounts within a short period of time. We also encourage patients then, to plan not to drive or take on a large task following their use as their coordination and their decision making is likely to be impaired. Harm reduction services fall under a variety of categories. There's safer injection or infection prevention services, which includes free syringe service programs, sterile injection or smoking equipment, and teaching individuals a sterile technique when they are utilizing substances. These methods have been demonstrated to prevent 43% of the new incidents of HCV by eliminating nonsterile injection techniques. PrEP, or pre-exposure prophylaxis is another tool in infection prevention. Overdose prevention. This includes naloxone kits and training. Training individuals in the utilization of naloxone to reverse an overdose. The use of fentanyl test strips so that individuals can test their drug supply for the presence of fentanyl. And the development of overdose prevention centers where individuals are observed using in an environment that would allow them to have any symptoms of an overdose monitored and reversed if needed. Medications for addiction treatment. These have been associated with decreased rates of HIV and HCV as well as a decreased risk of overdose, specifically in the treatment of opioid use disorder, medication for addiction treatment, decrease the risk of of overdose by 50-80%. Integration of addiction treatment. Only 10% of all patients with addiction receive any treatment, whether it's the management of withdrawal or detox, inpatient or outpatient services. Only 50% of patients who receive withdrawal management or detox then go on to further treatment. Of those who go on to further treatment, inpatient or outpatient, only 50% complete. So, how can we increase access and utilization of addiction treatment? Many models suggest that integration into general medical and psychiatric care is critical in increasing the engagement of patients in addiction treatment. In the Choosing Healthier Drinking Options in Primary Care Trial, patients with high risk unhealthy use or an alcohol use disorder received nurse care management for one year. The results of this study showed that there was higher utilization of medications to treat alcohol use disorder, 32% of those who received this intensive nurse care management versus 8% of individuals in the general primary care population. There were no differences in specialty alcohol treatment or mutual health, and no difference in the percent of heavy drinking days. Also, no difference in the, quote, in the good drinking outcome. However, this trial did demonstrate an increased use of medications. So, how can we take this a step further and develop models for increased integration of addiction treatment in general medical and psychiatric settings? There have been quite a few studies demonstrating a variety of combination of interventions that can be helpful, including a demonstration that CBT and primary care management with naltrexone demonstrated similar outcomes in terms of the treatment of alcohol use disorder. That medication management in primary care versus specialty care actually led to better engagement and less heavy drinking for those with medication management with naltrexone in their general medical setting. And then, integrating care in HIV clinics versus referring individuals out for treatment. When the care for opioid use disorder and other substance use disorders was integrated into the HIV clinic, there was a higher utilization of medications for opioid use disorder, there was less substance use and improved primary care outcomes. The Collaborative Care for Opioid and Alcohol Use Disorders in Primary Care Trial demonstrated the effectiveness of collaborative care training and care coordinators in a primary care setting. Individuals had access to any opioid use disorder or alcohol use disorder treatment, including brief evidence-based therapy and medications for addiction treatment. And they measured abstinence from opioids or alcohol at six months. For individuals who were paired with care coordinators who received this collaborative care training and offered these evidence-based treatments, there was a higher rate of the utilization of those evidence-based treatments and greater rates of abstinence at six months. Another frontier for integration is within the emergency department. D'Onofrio et al. in 2015 demonstrated that buprenorphine induction in the ED demonstrated a higher rate of continuation of SUD treatment compared to individuals who were referred or only received a brief intervention while in the hospital. The days of opioid use decreased. Though they did not show a difference in toxicology screenings, the differences in linkaged care are very important to note. Herring et al. in 2021 also demonstrated the safety of high-dose buprenorphine induction in the ED. Patients given greater than 12 milligrams of buprenorphine demonstrated no respiratory depression or sedation. There was no association of the rate of precipitated withdrawal with the dose received. As we think about integration into general medical and psychiatric settings, it is important to remember that it takes a team, not just the individual prescribing the medication or the individual offering the counseling or therapeutic individual. There are multiple members of our team and everyone's role is critical in addressing substance use disorders. Medical, psychiatric, and addiction specialists are all needed. Prescribers, physicians, advanced practicing nurses, and physicians' assistants. Nursing, pharmacists, counselors and therapists, social work, vocational and psych rehab therapists, as well as peer support specialists. In conclusion, substance use varies. Individuals can have low risk use, risky or hazardous use, or harmful use that meets DSM-5 criteria for substance use disorder. As we describe the range of substance use, the consequences of those use, and the clinical management of that use, accurate language is important. Substances work on many areas of the brain, including the reward and pain pathways and the dopamine systems. There exist many theories behind addiction. Most likely, the etiologies are combined, an abnormal motivational system, neurobiology, and environmental factors. Substance use disorders are associated with a range of mental health and medical conditions. More evidence is needed on the benefits of chronic care management for substance use disorders. Harm reduction principles provide practical strategies to reduce the harms associated with substance use. Integrated care is advantageous as only 10% of individuals with an addiction receive treatment in specialty care settings. And we need every member of our multidisciplinary team if we are going to be successful in our goal of increasing access and utilization of substance use disorder treatment. Here are the references. I would like to make you aware of two resources offered through PCSS that may be of interest to you. First, PCSS Mentor Program is designed to offer mentoring assistance to those in need of more one-on-one interactions with one of our colleagues to address clinical questions. You have the option of requesting a mentor from our Mentor Directory, or we are happy to pair you with one. To find out more information, please visit our website using the web link noted on this slide. Second, PCSS offers a discussion forum which is comprised of our PCSS mentors and other experts in the field who help provide prompt responses to clinical cases and questions. We also have a mentor-on-call each month. This person is available to address any submitted questions through the discussion forum. You can create a new login account by clicking the image on the slide to access the registration page. This slide simply notes the consortium of lead partner organizations that are part of the PCSS project. Finally, please reference this slide for our contact info, website, and Twitter and Facebook handles, to find out more about our resources and educational offerings.

Substance use disorders

Dr. Myra Mathis

Addiction Psychiatrist

Providers Clinical Support System

Opioid use disorders

Chronic disease

Harm reduction

Diagnostic criteria

Neurobiological responses

Access to treatment