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M.D. NEWS Southern Nevada
By Beth Leibson
cer story
The current economic condition can be hazardous to your health, even in Southern Nevada.
For years, Las Vegas was seen as recession proof, according to Newsweek magazine. While the recession seems to have hit Las Vegas later than much of the rest of the country, according to UNLV’s Center for Business and Economic Research, conditions have deteriorated markedly over the past year, notes the center. Job levels are down and unemployment rates are up. Taxing sales and gaming revenue, notes the center, are performing poorly.
Reading the headlines, perusing bank statements and hearing reports of pink slips is stressful. And stress, according to the Washington, DC-based National Institute on Drug Abuse, is the No. I cause of relapse to substance abuse, including drugs, alcohol and tobacco. Studies have also found that high stress can lead to continued drug use. In short, while formal studies are not yet available, informal observation and precedent suggest that substance dependence or abuse will be one of the many fallouts of the Wall Street debacle.
CHANGING THE LANGUAGE
The medical community no longer uses the term “addiction,” explains Michael S. Levy, D.O., founder and Medical Director of the Center for Addiction Medicine. “Addiction has been applied to so many behaviors, such as compulsive overeating, video games, computer addiction, etc., that aren’t necessarily substance or chemical addiction based,” says Dr. Levy, who is a Fellow of the American Society of Addiction Medicine — one of three in the state. Because the term “addiction” has been overused, physicians now follow the lead of the Diagnostic and Statistical Manual of Mental Disorders and refer to the issue as “substance dependence or abuse.” But while the terminology has changed, the problem remains the same.
Alcoholism and drug dependence are known as substance use disorders, according to the Substance Abuse and Mental Health Services Administration (SAMHSA) in Rockville, MD. Once thought to involve character defect or moral weakness, most physicians and scientists now consider dependence on alcohol or drugs to be a long-term illness that cannot be cured but is treatable, similar to asthma, hypertension or diabetes. Most people can drink a little wine or take a few painkillers without problems, but some people develop a substance use disorder that is compulsive or dangerous, notes SAMHSA.
“Substance dependence is a brain disease,” explains Mel Pohl, M.D., Medical Director of Las Vegas Recovery Center. Dr. Pohl is also a Fellow of the American Society of Addiction Medicine. “Substance dependence is a dysfunction in the way chemicals interact with receptor sites in the biophysiological part of the brain where rewards are experienced. When some people drink or take an opioid, they feel happy or intoxicated or out of physical or emotional pain. But for other people, it fits like a key in a lock; instead of feeling good, they feel excellent,” explains Dr. Pohl. These people are “wired differently” and the drug normalizes their brain, providing a strong incentive to use it again and eventually build up a tolerance to the alcohol or drug. “It is caused by an abnormal brain, which is genetically influenced and environmentally affected,” says Dr. Pohi.
Stress does not lead to substance abuse, says Dr. Pohl; rather, it relates to the makeup of the brain. But it can precipitate a relapse. If a system is under stress — from something such as a job loss or financial difficulties — it will look to destress. “Drugs are the logical solution,” explains Dr. Pohl. “The brain of the addict looks for immediate relief,” he says, “even if in the long run, it won’t be healthy.”
FREQUENCY OF SUBSTANCE ABUSE
An estimated 22.4 million Americans over the age of 12 were diagnosed in 2007 with substance dependence or abuse, according to SAMHSA. This group includes 3.2 million people dependent on both alcoholand illicit drugs, 3.7 million dependent only on illicit drugs and 15.5 million dependent only on alcohol. These figures represent no change since 2006. And the rates are roughly twice as high for men as women (12.5% versus 5.7%). These statistics were released this past September.
What is perhaps even more disturbing is the number of people requiring treatment who do not receive it. According to SAMHSA, 23.3 million Americans over age 12 needed treatment for substance dependence or abuse. But only 2.4 million people received such help at specialized facilities. Thus, 8.4% of Americans over age 12 needed help for a substance abuse problem, but did not get it.
MAKING THE DIAGNOSIS
Some patients walk into their doctors’ offices, say that they want to stop smoking or drinking and ask the doctor to help. Then, the physician can refer the patient to an addiction specialist. But it is rarely that easy, say both Dr. Levy and Dr. Pohl.
Often, the physician must be observant to spot a possible substance abuse problem, notes Dr. Levy. A patient who walks into the office drunk or stoned clearly needs help, even if no request is articulated. But screening only people who fall down or look disheveled only catches the tip of the iceberg, points out Dr. Pohl.
THE ANNUAL PHYSICAL
Annual physicals offer physicians the opportunity to ask about issues such as substance abuse. While it may feel awkward to ask such personal questions, “the approach is reasonable and recommended,” says Dr. Pohl.
Probably the most common approach is the brief intervention, a 10-question survey developed by the World Health Organization. While the brief intervention was designed specifically to identify people addicted to alcohol, it works just as well for use of illegal or prescription drugs, notes Dr. Pohi. The 10 questions are:
• How often do you have a drink containing alcohol?
• How many drinks containing alcohol do you have on a typical day?
• How often do you have six or more drinks on one occasion?
• How often during the last year have you found that you were not able to stop drinking once you had started?
• How often during the last year have you failed to do what was normally expected from you because of your drinking?
• How often during the last year have you needed a first drink in the morning to get yourself going after a night of heavy drinking?
• How often during the last year have you had a feeling of guilt or remorse after drinking?
• How often during the last year have you been unable to remember what happened the night before because you had been drinking?
• Have you or someone else been injured because of your drinking?
• Has a relative, friend, doctor ~r another health professional expressed concern about your drinking or suggested you cut down?
Dr. Levy states, “Physicians can use the opportunity of the annual physical to conduct routine blood work that may reveal information associated with the medical complications of drug abuse. In addition, checking the state of Nevada’s patient prescription monitoring data-bank [Nevada Prescription Drug Monitoring Program] may reveal a pattern of ‘doctor shopping’ for controlled substances.”
“The physician needs to be aware of the indirect presentations of substance abuse — emotional and physical — such as marital stress, mood disorders, gastrointestinal discomfort, burns on the fingers and hands, chronic runny nose, etc. In alcohol dependence, every major body system may be affected,” explains Dr. Levy.
“Physicians should always ask about alcohol and drug use, having an index of suspicion and concern about possible substance dependence,” says Dr. Pohl. It is also important for physicians to follow up on any unusual comments that patients might make. For instance, says Dr. Levy, when a patient mentions vomiting up blood, the physician should ask how much alcohol the patient consumes — and how often. That symptom may be associated with alcohol abuse or dependence.
The key is the patient-physician relationship, notes Dr. Levy. Physicians should be frank with their patients about their concerns. They should point out that they have the patient’s well-being at heart. “I want my patients to know that I believe in them; I know they can be successful at being sober given commitment and the right tools,” Dr. Levy says. “It is important to have the discussion in a way that is nonemotional and nonjudgmental,” says Dr. Pohl.
FOLLOWING UP
If the brief intervention points up a problem, doctors should follow up. “Physicians have tremendous power to influence their patients,” says Dr. Levy. “If a physician mentions the dangers associated with smoking, about 20% of patients will make an effort to stop.” Often, a simple office intervention with regular follow-ups is all it takes, adds Dr. Pohl.
Physicians must engage their patients, says Dr. Pohi. “If they exude judgment, it will backfire. They should take a warm, reflective tone.” Physicians should start by asking the patient about their problem: How often does the patient drink or use drugs? “It helps to set guideposts,” says Dr. Pohl. If, for instance, the patient drinks three times a week, ask
the patient to set a drinking goal to c~ut down to once a week. Then, schedule a check-up appointment for a few weeks. “Then, if the patient says he’s only drinking once a week, but his liver enzymes are up, you know that either the patient is not doing what he says he’s doing, or the problem is bigger than either of you had anticipated.” At this point, the physician can provide additional support or refer the patient to an addiction specialist. “The physician will hopefully know in his or her gut when it is time to refer,” says Dr. PohI.
An addiction specialist can mean a variety of options, says Dr. Pohl. It could be a physician specializing in addiction medicine; a certified addiction specialist, psychologist or nurse practitioner who works in the area; or an Alcoholics Anonymous or Narcotics Anonymous meeting if the patient will attend. Many treatment centers also provide no-cost assessments for the possibility of drug abuse.
Helping patients requires vigilance. “Many of my patients who have alcohol or drug abuse problems also smoke,” says Dr. Levy. “So, I make it a point to mention the dangers of tobacco on every visit.” Sometimes, patients do not listen. “They will say that it’s the only vice they have left or offer some other excuse,” notes the addiction specialists. But often, the physician’s words have an effect. “Mentioning your concerns in a nonthreatening, nonjudgemental way can have a significant impact on the patient,” Dr. Levy says.
TREATING THE ADDICTION PATIENT
Once a patient has been identified as having a substance abuse problem, that problem should be part of the patient’s medical chart, as it affects his or her care forever. “If a patient has a receptor-side abnormality,” says Dr. Pohl, “it is a loss-of-control phenomenon, treatment is abstinence of all mood-altering substances.”
Physicians must be careful not to prescribe anything that is habit forming, including opioid pain pills, carisoprodol (Soma), tranquilizers and sleeping pills. “If a physician were to prescribe something habit forming, he or she could inadvertently participate in the patient’s relapse,” says Dr. Pohl. Before prescribing medication for a patient with a known substance abuse problem, physicians should take the time to check whether the drug can be habit forming.
“But that is difficult,” points out Paul Oesterman, Pharm.D., an assistant professor and introductory pharmacy experience coordinator at the University of Southern Nevada College of Pharmacy, and also Chairperson for the Drug Use Review Board for the Division of Health Care Financing and Policy (Nevada Medicaid).
First of all, there is the time issue; physicians only have so much time to devote to each individual patient. “Beyond that, doctors don’t want to withhold pain relief from patients who really need it,” explains Dr. Oesterman.
Over the past five years, there has been a marked increase in prescription drug abuse, notes SAMHSA. Among adults ages 18 to 25, the nonmedical use of prescription pain relievers has risen 12% over the past five years. Similarly, the rate among people ages 55 to 59 has more than doubled to 4.1% as of 2007, reports SAMHSA.
“At least at first, prescription drugs are cheaper than illegal drugs,” says Dr. Oesterman. “Given the economy, it is not surprising that their use is rising.” Patients sometimes see two or three physicians a week, receive prescriptions from each and fill them all at different pharmacies, says the pharmacist. “The more educated the patient, the more able he is to work the system,” Dr. Oesterman adds.
As a result, physicians should be extremely careful when writing prescriptions for controlled substances, says Dr. Oesterman. Patients have been known to augment the number of pills dispensed or the number of refills available on a written prescription. “Doctors should write those figures with numerals and should also write the amount in words” to thwart any such efforts, says Dr. Oesterman.
These days, physicians must be very alert to the risks associated with substance use and abuse. “It is useful for internists and family practice doctors to take a course in addiction,” says Dr. Pohl. “That is information that patients would be best served if their physicians knew.”
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