POST-MODULE QUIZ LINK: https://forms.gle/SUZShpY2fegELFVY8

This is a mandatory quiz to be completed upon reviewing this week’s materials.

It is only graded for completion, so take the quiz for your learning!

Module 4: Substance Use

Dependence vs Addiction

Dependence usually refers to a physical dependence on a substance, characterized by increases in tolerance with increased use and by withdrawal symptoms when use ceases. While it is possible to have a physical dependence without being addicted, addiction is often right around the corner.

Addiction is marked by a change in behavior caused by the biochemical changes in the brain after continued substance use. Substance use becomes the main priority of the person, regardless of the harm they may cause to themselves or others. An addiction can cause people to act irrationally when they don’t have the substance they are addicted to in their system. 

Addiction as a Disease

This week, we hope you can hear from Michael Boticelli, prior director of the White House Office of National Drug Control (ONDCP) under President Obama and current Executive Director of the Grayken Center for Addiction Medicine at the Boston Medical Center.

Tobacco

CAGE Questionnaire for Alcohol Use

You will notice that we have an assessment form on REDCap for addiction screening. Several of the questions are based off a quick validated tool called the CAGE questionnaire. Here is a graphic highlighting its key points:

Image Source: https://www.cdc.gov/tobacco/data_statistics/fact_sheets/health_effects/effects_cig_smoking/index.htm

Per the Centers for Disease Control (CDC), smoking cigarettes is the number 1 preventable cause of death in the United States, causing over 480,000 deaths per year. For context, deaths related to smoking are greater than the combined number of deaths by illicit drug use, alcohol use, car accidents, firearms, and HIV.

Smoking causes damage to all systems in the body.

Benefits of quitting smoking

Even if a patient has a long smoking history, the evidence suggest smoking cessation reduces the risk of diseases including cancer, stroke, and heart attack. For example, the CDC reports that after quitting smoking the risk of mouth, throat, esophageal, and bladder cancer are reduced by 50% in 5 years.

5 A’s Approach to Quitting Smoking

1.   Ask about tobacco use

2.   Advise smoking cessation. You can reference the health effects of continuing to smoke and health benefits of quitting (described above).

3.   Assess readiness to quit. One way to conceptualize this is the Stages of Change Model, which describes 5 stages:

Image source: https://mdquit.org/fax-to-assist/module-3

4.   Assist the client with smoking cessation, if the patient is in the contemplative stage or beyond.

a.   Good first step is START acronym

                                     S = set a quit date

                                     T = tell family, friends about your plan to quit

                                     A = anticipate or plan ahead for the touch times you’ll face while quitting

                                     R = remove cigarettes and tobacco products from your house, car, and work

                                     T = talk to your doctor about getting help

b.   Provide referrals for treatment, which can include

                                       i.    Behavioral counseling

                                       ii.    Medications

                                      iii.    Nicotine replacement

                                      iv.    Acupuncture

c.    Quick Resource

                     i.    Mass Smokers Helpline: 1-800-QUIT-NOW (English/Spanish)

5.   Arrange a follow-up. Ask the patient about how it is going next time they are on the Van.

 Alcohol

The national institute of alcohol and alcohol abuse and alcoholism (NIAAA) defines low-risk drinking differently in women and men.

• Women: No more than 3 drinks on a single day. No more than 7 drinks/week.

• Men: No more than 4 drinks on a single day.  No more than 14 drinks/week.

In the short-term, excessive drinking can impair judgment, increase chances of risky behaviors such as drunk driving, and interfere with social and occupational functioning. In people who drink heavily, withdrawing from alcohol can be life-threatening. Over time, heavy alcohol use can also lead to many health problems including but not limited to:

• Brain: Depression, anxiety, disturbed sleep

• Heart: Irregular heartbeats, heart failure, stroke, high blood pressure

• Liver: Inflammation or fibrosis of the liver

• Pancreas: Inflammation of the pancreas

• Cancer: Increased risk of many types of cancer including esophageal, breast, liver, and colorectal.

Treatment of Alcohol Use Disorder

There are multiple options, including medications and support groups. Encourage clients to discuss these options with their doctor. Many people join mutual help groups such as Alcoholics Anonymous (AA). Self-Management and Recovery Training (SMART) is an alternative option for people who feel uncomfortable with AA’s emphasis on submitting to a higher power. To learn more and find local meetings you can look at the following websites:

Alcoholics Anonymous: https://www.aa.org/

SMART: https://www.smartrecovery.org/

Opioids

Opioids include a range of prescription pain medications (e.g., oxycodone) and illicit drugs (e.g., heroin). There are many adverse health consequences associated with opioids including overdose and life-threatening infections (HIV, hepatitis B/C, heart infection) especially among people who inject opioids. Additionally, the consequences of addiction to opioids can have destructive effects on mental health and functioning at work and in relationships.

Deaths related to opioid overdose have increased significantly across the United States, including in Massachusetts, over the past 2 decades. In 2000, there were 375 opioid overdose deaths in Massachusetts compared to 2,032 in 2018 (see graph below).

Image source: https://www.mass.gov/files/documents/2019/08/21/Opioid-related-Overdose-Deaths-among-MA-Residents-August-2019_0.pdf

Potential Opportunities for Counseling Related to Opioid Use

1. Narcan: It can be helpful to counsel patients on the medication Narcan, also known as naloxone. Narcan is a safe, effective medication that acts to reverse opioid overdose. Narcan is available as an easy to administer nasal spray. Counseling about Narcan is important not only for clients who use opioids but also clients who have family/friends who use opioids. Having Narcan on hand can truly save lives.

-  How to recognize Opioid overdose:

Image source: https://www.princeedwardisland.ca/en/information/health-and-wellness/preventing-opioid-related-overdoses

-      What to do if you think someone is overdosing?

• Call 9-11 immediately. Administer Narcan if available.

-      How can clients get Narcan?

• MassHealth and a number of other insurance plans cover the cost of Narcan. You can either visit a local pharmacy and talk to a pharmacist, who can dispense Narcan directly without a prescription, or ask your doctor for a prescription.

• Instructions on how to get Narcan: Click Here

2. Needle hygiene: For people who inject drugs, some of the risks (e.g., HIV, hepatitis C, skin/bone/heart infections) can be reduced by taking precautions with injection equipment.

-      Some key points

• Only use a needle once. Do not assume a needle you find is clean, because it looks clean.

  • List of needle exchange programs in Massachusetts: Click Here

• Never share any of your equipment including spoon, cotton, needle, or syringe.

• If possible, use sterile water (buy at pharmacy) to dissolve drugs. If this is not possible, boiling water is less ideal but a better option than many other alternatives people use (e.g., using toilet water, using water from puddle on street).

3. Treatment: Opioid use disorder is a treatable medical condition. Encourage clients to discuss their opioid use with their doctors who can manage their opioid use disorder with multiple different medication and behavioral options.

4. Offer HIV testing while on the van, if our testers are working that day.

MORE INFORMATION:

• Find below more specific information on specific substance use disorders, by topic:

  • Tobacco: Click Here

  • Alcohol: Click Here

  • Opioid: Click Here

  • Marijuana: Click Here

• Common slang terms for recreational drugs: link

• Substance use in Massachusetts: link

• New England Journal of Medicine article on addiction and the brain: link

• NIH video on Opioid Overdose and Narcan: link