Tobacco Use Disorder

With the DSM-V, there is no longer a separate diagnosis of Opioid Dependence and Opioid Addiction. The two are combined into Opioid Use Disorder. Opioid Use disorder can be mild, moderate or severe. And all of the addictive substances have the same list. So here is Tobacco Use Disorder.

According to the DSM-5, there are three Criterion with 15 sub features, and four specifiers to diagnose Tobacco Use disorder. Use of tobacco products over one year has resulted in at least two of the following sub features:

A, Larger quantities of tobacco over a longer period then intended are consumed.

1. Unsuccessful efforts to quit or reduce intake of tobacco

2. Inordinate amount of time acquiring or using tobacco products

3. Cravings for tobacco

4. Failure to attend to responsibilities and obligations due to tobacco use

5. Continued use despite adverse social or interpersonal consequences

6, Forfeiture of social, occupational or recreational activities in favor of tobacco use

7. Tobacco use in hazardous situations

8. Continued use despite awareness of physical or psychological problems directly attributed to tobacco use

B. Tolerance for nicotine, as indicated by:

9. Need for increasingly larger doses of nicotine in order to obtain the desired effect

A noticeably diminished effect from using the same amounts of nicotine

C. Withdrawal symptoms upon cessation of use as indicated by

10. The onset of typical nicotine associated withdrawal symptoms is present

11. More nicotine or a substituted drug is taken to alleviate withdrawal symptoms

Additional specifiers indicate the level of severity of Tobacco use disorder

1. 305.1 (Z72.0) Mild: two or three symptoms are present.

2. 305.1 (F17.200) Moderate: four or five symptoms are present.

3. 305.1 (F17.200) Severe: Six or more Symptoms are present

(American Psychiatric Association, 2013).

from: https://www.theravive.com/therapedia/tobacco-use-disorder-dsm–5-305.1-(z72.0)-(f17.200)

We have much more stigma attached to Opioid Use Disorder, but list for Tobacco Use Disorder is the same. Most chronic pain patients on long term opioids qualify for at least mild Opioid Use Disorder. UW Telepain says that if they only have withdrawal and tolerance, then it is questionable if they qualify. They also have said that “we don’t know what to do with patients with mild opioid use disorder”.

I find our culture peculiar. People get accolades for saying “I am quitting smoking.” or “I am a recovering alcoholic.” But it’s not ok to say “I am a recovering opioid addict.” People will shun you. Demonize. Gossip. It’s all addiction, so we should stop the demonization and stigmatization and help people and each other.

The photograph is not a brain. I took this about a month ago: it’s a brain size mushroom that was in the church lawn…

Heart and brain and alcohol, 2018

For the Daily Prompt: infect. Maybe heart and brain health could be an infectious idea…..

Heart disease is the number one cause of death in the US, around 24% of deaths every year. Strokes are fifth most common cause of death at 5%, dementia sixth most common at 3.6%, data here from 2014. Accidents have beaten strokes out for fourth place because of “unintentional overdose” deaths.

I did a physical on a man recently, who said what was the best thing he could do for his health?

“Reduce or better yet quit alcohol.” is my reply. Even though he’s within “current guidelines”. I showed him the first of these studies.

Two recent studies get my attention for the relationship between the heart and the brain and alcohol.

In this study: http://www.onlinejacc.org/content/64/3/281, 79,019 Swedish men and women were followed after completing a questionnaire about alcohol consumption.

They were followed from 1998 to 2009 and 7,245 cases of atrial fibrillation were identified. The relative risk for atrial fibrillation was alcohol dose dependent: that is, the people who did not drink had a relative risk of atrial fibrillation set at 1.0. At 1-6 drinks per week the risk was 1.07, at 7-14 per week the risk was 1.07, at 14-21 drinks per week 1.14 and at >21 drinks per week 1.39. They also break it down by number of drinks per day. So why do we care about atrial fibrillation? “Atrial fibrillation (AF)/atrial flutter (AFL), the most common cardiac arrhythmia, is accompanied with a 4- to 5-fold increased risk for stroke, tripling of the risk for heart failure, doubling of the risk for dementia, and 40% to 90% increase in the risk for all-cause mortality.”

Atrial fibrillation, stroke, congestive heart failure, dementia and 40-90% increase in all-cause mortality. Want to protect your brain and live longer? Quit alcohol.

Well, that instantly decreased my enthusiasm for alcohol, now down to one drink per week if that.

Here is a second study: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30134-X/fulltext?code=lancet-site

“Findings:
In the 599 912 current drinkers included in the analysis, we recorded 40 310 deaths and 39 018 incident cardiovascular disease events during 5·4 million person-years of follow-up. For all-cause mortality, we recorded a positive and curvilinear association with the level of alcohol consumption, with the minimum mortality risk around or below 100 g per week. Alcohol consumption was roughly linearly associated with a higher risk of stroke (HR per 100 g per week higher consumption 1·14, 95% CI, 1·10–1·17), coronary disease excluding myocardial infarction (1·06, 1·00–1·11), heart failure (1·09, 1·03–1·15), fatal hypertensive disease (1·24, 1·15–1·33); and fatal aortic aneurysm (1·15, 1·03–1·28). By contrast, increased alcohol consumption was log-linearly associated with a lower risk of myocardial infarction (HR 0·94, 0·91–0·97). In comparison to those who reported drinking >0–≤100 g per week, those who reported drinking >100–≤200 g per week, >200–≤350 g per week, or >350 g per week had lower life expectancy at age 40 years of approximately 6 months, 1–2 years, or 4–5 years, respectively.”

Ok, over half a million people followed, 40K+ deaths, 39K+ heart events (heart attack, atrial fibrillation, new congestive heart failure, etc), that’s a pretty impressive study.

A 5% 12 ounce beer is 14 grams of alcohol. Here: https://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/what-standard-drink. Our local brewery and pourhouse usually serve pints, 16 oz, and the range is from 5% to over 9% alcohol. Two 9% pints is how many standard drinks? You do the math. Currently the recommendations in the US are no more than seven drinks per week for women (98 grams) and fourteen for men (196 grams) per week, no saving it up for the weekend, no bingeing. The UK stops at 98 grams for both men and women. The rest of Europe goes higher.

Heart and brain, how I love you! I like my brain and don’t want to pickle it. I think I’ll choose heart and brain over alcohol, long term over short term, health over escapism.

Have a great week!

More:
https://www.sciencedaily.com/releases/2018/02/180220183954.htm


https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(18)30022-7/fulltext

http://www.acc.org/latest-in-cardiology/articles/2016/08/26/16/48/consumer-news-stroke-esc-2016

I took the photograph. It reminds me of neurons in the brain.

Resources on opioid addiction

This is a list of resources on opioid addiction that I am putting together for a talk to a community advocate group this Thursday.

The big picture:

CDC Grand Rounds: Prescription Drug Overdoses — a U.S. Epidemic, January 2012: https://www.cdc.gov/mmwr/preview/mmwrhtml/mm6101a3.htm

CDC 2018 (It’s not getting better yet.) https://www.cdc.gov/media/releases/2018/p0329-drug-overdose-deaths.html


Snohomish County:

Snohomish County:

http://mynorthwest.com/878895/snohomish-co-opioid-crisis/

https://drkottaway.com/2018/03/03/reducing-recidivism-snohomish-county-sheriffs-office-and-human-services-program/

http://www.heraldnet.com/news/state-house-backs-snohomish-county-opioid-help-center/

http://knkx.org/post/snohomish-county-jail-now-offering-medically-assisted-detox-inmates

Washington State Pain Law

https://www.doh.wa.gov/ForPublicHealthandHealthcareProviders/HealthcareProfessionsandFacilities/OpioidPrescribing

https://www.doh.wa.gov/YouandYourFamily/PoisoningandDrugOverdose/OpioidMisuseandOverdosePrevention


Is it genes that make people addicts?
(The short answer is genes are a minimal contribution. It is society and patterns learned in childhood and adulthood.)

Adverse Childhood Experiences (put people at way higher risk for addiction):
https://www.cdc.gov/violenceprevention/acestudy/index.html


Books that helped me understand addiction
(in my teens):

It will never happen to me by Claudia Black (about the patterns children take in addiction households to survive and cope with childhood)

Manchild in the Promised Land by Claude Brown (a black male writes about his childhood in Harlem when heroin hit the community. He was in a gang at age 6.)

Big D, little d, what begins with D?

Happy things starting with D:

Discrimination, death, delight.

I am happy that slowly, slowly, it feels as if there is change in the world and a decrease in discrimination. It is NOT gone by any means, but I think it is slowly being eroded.

My parents had a party when I was two and they were both in college. The party was raided in Knoxville, Tennessee in 1963 and my father was taken to jail. My mother and I were left alone and she was afraid we would be lynched by the neighbors. The next morning the paper wrote about a MIXED RACE COLLEGE STUDENT PARTY possibly with orgies. My parents were both suspended from the University of Tennessee.

They were both reinstated after a hearing, because there were no drugs, no underage drinkers, and it was not illegal to have a mixed race party. My parents never touched marijuana ever and I think it was because of that party. I don’t remember it, but I still feel cautious at parties and in crowds. My mother refused to return to the U. of TN and eventually finished her undergraduate degree at Cornell. My parents were so notorious that we left Knoxville as soon as my father graduated.

I grew up learning protest songs and work songs and joke songs. My mother joked about the party and it was years before I found out how terrifying it was. My mother joked that they sat at the one liberal table at the University of Tennessee. I hate discrimination and I do not understand it.

Death: is death a happy thing? Death is as much a mystery as life, and we cannot have one without the other. How could we value life if it were eternal? And we’d also get awfully crowded. I have the privilege of caring for all ages in clinic, all genders, any race that comes in the door, age newborn to 104, what joy! I get to be present when someone is dying and try to help the person and the family. There is no single idea about death or about how to “do it right” and often families struggle with multiple opinions and ideas and feelings. Death is as intense as birth and I have had the privilege to attend both.

Delight: there are many things that I find difficult and depressing, but I find delight too! The latest morbidity and mortality report from the CDC on overdose deaths, up from 52K in the US in 2015 to 62K in the US in 2016: Overdose deaths involving opioids, cocaine and psychostimulents — United States, 2015-2016. We have to work harder to prevent addiction, why do we choose addictive substances, why do people think it won’t happen to THEM?

And yet, I still find delight, taking photographs of bird, seeing patients that I know well in clinic, we laugh often, finding joy walking outside, my family and friends.

D

The photograph is from Mauna Loa last week. It is not a giant dinosaur nest, it’s a cinder cone. At least, that’s what a geologist claims….

 

Causes of death: which does your doctor treat?

What is the number one cause of death in the United States? The heart. You know that.

You might know the number two: all the cancer deaths put together.

Number three is lower respiratory disease: mostly caused by tobacco.

Number four. Can you guess? Number four is accidents. Unintentional deaths. In 2012 number four was stroke, but unintentional deaths have moved up the list, here: https://www.cdc.gov/nchs/fastats/deaths.htm. The CDC tracks unintentional deaths, here: https://www.cdc.gov/nchs/fastats/accidental-injury.htm. And what is the number one cause of unintentional death right now? It is not gun accidents. It is not car wrecks. It is not falls. It is unintentional overdose: usually opioids, legal or illegal, often combined with other sedating medicines or alcohol. Alcohol, sleep medicines, benzodiazepines, some muscle relaxants. No suicide note. Not on purpose. Or we don’t know if it is on purpose….

And does your physician try to prevent accidental death? Do they talk to you about seatbelts, about wearing bicycle helmets, about smoke alarms, about falls in the elderly, about domestic violence, about locking up guns? About not driving when under the influence? Do they talk about addiction and do they treat addiction?I think that every primary care physician should treat the top ten causes of death. I am a family medicine physician and I try to work with any age, any person. I treat addiction as well as chronic pain. I have always tried to talk about the risk of opiates when I prescribe them. I treat addictions including alcoholism, methamphetamines, cocaine, tobacco and opioids. Legal, illegal and iv opioids, from oxcodone and hydrocodone to heroin. That doesn’t mean I can safely treat every patient outpatient. People with multi drug addiction, or complex mental health with addiction, or severe withdrawal must be treated inpatient. But I have taken the buprenorphine training to get my second DEA number to learn how to safely treat opiate overuse. I took the course in 2011. I was the only physician in my county of 27,000 people who was a prescriber for two years. Now we have more, but still the vast majority of physicians in the United States have not taken the training even when it is offered free.

I don’t understand why more physicians, primary care doctors, are NOT taking the buprenorphine and recognition and treatment of opiate overuse course. Most are not trained. Why not take the training? Even if they are not prescribers, they will be much better informed for the options for patients. People are dying from opioids daily. Physicians have a DEA number to prescribe controlled substances: I think that every physician who prescribes opioids also has a duty and obligation to train to recognized and intervene and be informed about treating opioid overuse.

A large clinic group in Portland, Oregon made the decision last year that every primary care provider was required to train in buprenorphine. One provider disagreed and chose to leave. However, everyone else is now trained.

We as a country and as physicians need to get past fear, past stigma, past discrimination and past our fixed ideas and step up to take care of patients. If a physician treats alcoholism as part of primary care, they should also be knowledgeable and trained in treatment of opiate overuse.

Ask YOUR physician and YOUR local clinics: Do the providers prescribe opiates? Are their providers trained in preventing, recognizing and treating opiate addiction? Do they treat opiate overuse? Do they understand how buprenorphine can save lives and return people to work and to their families? Are they part of the solution?

For the Daily Prompt: provoke.

Reducing recidivism: Snohomish County Sheriff’s Office and Human Services Program

The last two days have been at the 20th Annual Fundamentals of Addiction Medicine Conference in Washington State, 15 lectures. Everything from science trying to understand addiction via studying dopamine in ratbrains to the last presentation: Snohomish County started a program two years ago that pairs a social worker with a county sheriff or deputy to work with the homeless.

The county is trying to stop the revolving door of homeless to arrested to jail to homeless. 95% of the county homeless are addicted to heroin and some to methamphetamines. They don’t access services when they are “dope sick”. They describe heroin as being 10x worse than the worst influenza. I think of withdrawal from opioids as having all the pain receptors turned as high as they can go and screaming at once.

The sheriff and social worker go to the camps. They get to know people and offer services. They have helped over 100 people get their identification replaced. When someone is arrested, their homeless encampment is often stolen. No honor among thieves, you say? The rat studies address that: in addiction the brain puts the drug first, in front of food, water, sex. Some rats will access the drug until they die, just like people. I think of it as the person losing their boundaries to the drug. The conference used the phrase “incentive salience” — dopamine is released when the person or rat is cued that the drug is now available and again when the drug arrives. More on that in another write up.

At any rate, the clients do not get to appointments. So the deputy and social work start at the beginning: they make the appointment, go knock on the tent that morning, remind the person to get dressed, take them to get food and coffee and then take them to the appointment. Then they return them to their camp.

After two months, the first sheriff and social worker were so successful that the program was expanded.

They have 206 chemical dependency evaluations.
232 have gone to detox. The detox is 3-5 days. They are taken straight from there to inpatient treatment, 30 day minimum, but ranging from 30-90 days. After treatment, clients are taken straight to sober housing, with a 6 month supported stay and intensive outpatient treatment.
85% get through the detox.
59% graduate from the treatment
50% go on to sober housing and intensive outpatient.
Their first clean and sober client is two years out.

50% of the homeless who agree to the program getting to sober housing is huge. Recidivism and incarceration drop, so it is making a true difference.

The program is expanding. They have a Community Court set up, much like Juvenile Drug Court, modeled after a program in Spokane. If the person agrees to drug treatment, they can do that instead of jail. This is for minor offenders. The sheriff says that once the homeless person is incarcerated, everything is stolen. They then steal food and supplies for a new camp when released and it happens again. If the client completes the program, low level charges may be dropped. They are setting up a service center right by the court where the clients are sent immediately to talk to a chemical dependency person, to get medical treatment, dental emergencies, centralized services because these people do not have transportation.

The social worker is in kevlar and heavy clothes as well and is never to go in the encampments without the law enforcement officers: it’s usually private land so it would be trespassing anyway.

This was an absolutely inspiring presentation. It starts with outreach and intervention, and gives people choices. They will soon be opening a temporary site, up to 15 days with medical support and beds, for when a client is ready but the social worker needs to arrange the detox, the treatment, the housing. Sometimes when a client is finally ready, there are no beds. And they don’t want to send them to detox and then back to the streets. The sheriff says that he was “volutold” for the program, but he, the deputy and the social worker are all clearly inspired by the program and enjoy their work and that it is making a difference.

 

Any write up on addiction fits today’s Daily Prompt: messy.

opioids international

The US is not the only opioid crisis.

Reblogging:

https://www.groundup.org.za/article/woman-battles-escape-whoonga-park/

Living in the hell of Whoonga Park

Murder, rape, crime, homelessness, abuse by police … daily life for whoonga users

Photo of a woman holding a beaded South African flag
Nobuhle Khuzwayo doing bead work during life skills training at the Denis Hurley Centre. Photo: Nomfundo Xolo
By

“Siqalo used to be the most promising child in our house … the last born. He got the best of everything. We took him to better schools than we did his younger sister and brother. He did well for the better half of high school.Then he met up with the wrong friends, and never even got to matric,” Fanele Ngcobo tells GroundUp about his son.

Siqalo is 22. He has been a whoonga user since 2015. By 10am, he has already smoked his second fix. Without the drug he struggles to function. Withdrawal effects – which people refer to as “arosta” – include stomach cramps, vomiting, and extreme anxiety.

Whoonga is a mixture of marijuana and heroin and rumoured to contain anti-retrovirals, detergents and even rat poison. Active addiction has spread in KwaZulu-Natal townships such as KwaMashu and iNanda. Hundreds of people now live in Durban’s ‘Whoonga Park’,

Siqalo was a keen soccer player, says his mother, Sizakele. Now his worn, black soccer shoes peek out from under the bed in his old room at home in iNanda, Durban.

“He always went for practice with his friends at the local playground. But after a while, soccer wasn’t the only thing he and his friends were playing with; he was also experimenting with dangerous drugs,” she says.

Siqalo lives in so-called Whoonga Park, under a bridge next to the Berea railway lines in Durban. The park has become a den for whoonga users. They have bright beach umbrellas to protect them from the heat and black plastic bags for shelter. The activities under the bridge are in plain view. People trade and smoke. In the afternoons and at night, many take to the city streets to hustle for food and the money they need to buy their fix.

“There are no beds here. Even if you can get a blanket or sheet to sleep in, it doesn’t last a week. The police will burn it,” says Siqalo. “So it’s easier just to use cardboard and plastic as it is easy to find in the streets. Although I miss home, I cannot go back home like this. I need to be clean. My family doesn’t trust me around the house and for good reason because I’ve stolen their money and appliances too many times. I tried to be clean when they first fetched me, but arosta is too painful – nobody can understand. But I still want to go home.”

Cooked meals, showers and clean clothes

Nobuhle Khuzwayo from eMpangeni, KwaZulu-Natal, is one of those trying to get off whoonga. She attends the iSiphephelo Centre housed at the Denis Hurley Centre in Durban, where she gets cooked meals and clean clothes three times a week. For a few hours she is free of whoonga.

Co-founder of the centre Sihle Ndima says it is a place of safety for young girls and women living on the streets of Durban. It offers meals, counselling, clean clothes and showers.

“Many of them return back to the streets soon after classes, and the work we do seems like failure, because in the end they go back to using whoonga,” says Ndima. “We work with a rehabilitation centre in Newlands East, Durban, and they offer free help.”

Khuzwayo, who is 30, came to Durban seeking a job in 2014, but after numerous failed attempts, she was left homeless and desperate.

“The shoe factory I was working for closed down after a month. Thereafter it was difficult to get employment. I had been staying at the Dalton hostel with some friends, who later introduced me to smoking. They would tell me it was marijuana, but after becoming a frequent smoker … I would get headaches, pains and stomach cramps when I hadn’t smoked. I just could not cope without it. When I confronted them, they told me it was in fact whoonga. I was already deeply hooked,” says Khuzwayo.

She could no longer live at the hostel. She moved to Whoonga Park. To get money she would have to resort to sex work, crime or selling cigarettes. She found a boyfriend who sold cigarettes at taxi ranks to help get them food and the R30 a day they needed to buy whoonga.

“To survive on the streets, I got myself a boyfriend because you can’t survive a day alone under the bridge as a woman. There are men known as amaBhariya, who claim to own the spots in Whoonga Park. They do not smoke or deal the drug; they do not speak local languages or even English. They are ruthless. They rape and kill women under the bridge and make sure the park functions the way it does. They wear blue workmen’s clothes and hats and use the underground drains to move around. So if you don’t have a man to protect you, they will always take advantage of you,” says Khuzwayo.

Merchants outside the park sell whoonga for R30. “They are usually in the streets or in nearby flats but not many sell whoonga under the bridge,” she says.

Hundreds now live in Whoonga Park beside the railway lines in Berea, Durban. Photo: Nomfundo Xolo

Khuzwayo has now moved to a local shelter, paying R20 a night. Her closest friend had TB and when she died it was a turning point.

“I am tired of this life. I am determined to change. I don’t want to die a senseless death without dignity,” she says.

She is now a part-time cleaner at iSiphephelo. After attending all counselling and life skills classes she will qualify for rehab. “After rehab, I am going to go back home and stay with my sister in eMpangeni. You cannot stay away from whoonga in the city,” says Khuzwayo.

Siqalo and Khuzwayo say whoonga users are known as amaPhara. “Because we look like zombies. We’re dead people walking. We sleep standing. We stab you for your phone and sell it for a fix. Plastic and rubble is our shelter, faeces and rubbish are everywhere, and we run from police who destroy our things and chase us away every week. But we always come back. We can’t survive anywhere else,” says Siqalo.

Khuzwayo says she has seen people high on whoonga killed by trains.

“You can’t save them, because it’s like the railway shocks you, and you’re unable to move … seeing the train come at you but unable to run. I’ve seen some getting crushed in half and some losing their limbs. Even a security guard, who was chasing us one time, got stuck and the train crushed his foot.”

“One way or the other, you’re lucky to survive under the bridge.”

reblogged from: https://www.groundup.org.za/article/woman-battles-escape-whoonga-park/