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…

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/

Make America sick again: diabetes

The trend in diabetes treatment is clear: keep Americans sick.

The guidelines say that as soon as we diagnose type II diabetes, we should start a medicine. Usually metformin.

A recent study says that teaching patients to use a glucometer and to check home blood sugars is useless. The key word here is teach, because when I get a diabetic transferring into my clinic, the vast majority have not been taught much of anything.

What is the goal for your blood sugar? They don’t know.

What is normal fasting? What is normal after you eat? What is the difference between checking in the morning and when should you check it after a meal? What is a carbohydrate? What is basic carbohydrate counting?

I think that the real problem is that the US medical system assumes that patients are stupid and doesn’t even attempt to teach them. And patients just give up.

New patient recently, diabetes diagnosed four years ago, on metformin for two years, and has no idea what the normal ranges of fasting and postprandial (after eating) are. Has never had a glucometer.

When I have a new type II diabetic, I call them. I schedule a visit.

At the visit I draw a diagram. Normal fasting glucose is 70-100. Borderline 110 to 125. Two measurements fasting over 125 means diabetes.

After eating: normal is 70-140. Borderline 140-200. Over 200 means diabetes.

Some researchers are calling Alzheimer’s “Type IV diabetes”. The evidence is saying that a glucose over 155 causes damage: to eyes, brain, kidneys, small vessels and peripheral nerves.

Ok, so: what is the goal? To have blood sugars mostly under 155. That isn’t rocket science. People understand that.

Next I talk about carbohydrates. Carbohydrates are any food that isn’t fat or protein. Carbohydrates range from simple sugars: glucose and fructose, to long chain complicated sugars. Whole fruits and vegetables have longer chain carbohydrates, are absorbed slowly, the body breaks them down slowly and the blood sugar rises more slowly. Eat green, yellow, orange vegetables. A big apple is 30 grams of carbohydrate, a small one is 15, more or less. A tablespoon of sugar is 15 grams too. A coke has 30 grams and a Starbuck’s 12 ounce mocha has 62. DO NOT DRINK SWEETENED DRINKS THEY ARE EVIL AND TOOLS OF THE DEVIL. The evidence is saying that the fake sugars cause diabetes too.

Meals: half the small plate should be green, yellow or orange vegetables. A deck of card size “white” food: grains, potatoes, pasta, whole wheat bread, a roll, whatever. A deck of card size protein. Beans and rice, yes, but not too much rice.

For most diabetics, they get 3 meals and 3 snacks a day. A meal can have up to 30 grams of carbohydrate and the snacks, 15 grams.

Next I tell them to get a glucometer. Check with their pharmacy first. The expensive part is the testing strips, so find the cheapest brand. We have a pharmacy that will give the person a glucometer and the strips for it are around 4 for a dollar. Many machines have strips that cost over a dollar each.

I set the patient up with the diabetic educator. The insurance will usually cover classes with the educator and the nutritionist but only in the first year after diagnosis. So don’t put it off.

For type II diabetes, the insurance will usually only cover once a day glucose testing. So alternate. Test 3 days fasting. Test 1-2 hours after a meal on the other days. Test after a meal that you think is “good”. Also after a meal that you think is “bad”. I have had long term diabetics come in and say gleefully “I found a dessert that I can eat!” The numbers are not always what people expect. And there are sneaky sources of carbohydrate. Coffeemate and the coffee flavorings, oooo, those are REALLY BAD.

For most of my patients, the motivated ones, they have played with the glucometer for at least a week by the time they see the diabetic educator. I have had a person whose glucose was at 350 in the glucose testing. The diabetic educator called and scolded me for not starting metformin yet. The diabetic educator called me again a week later. “The patient brought their blood sugars down!” she said. “She’s under 200 after eating now! Maybe she doesn’t need the metformin, not yet!” Ah, that is my thought. If we don’t give people information and a tool to track themselves, then why would they bother? They eat the dessert and figure that the medicine will fix it or they can always get more medicine.

Type I diabetes has to have insulin. If a type II diabetic is out of control, high sugars, for long enough, they too will need insulin. The cells in the pancreas that make insulin are killed by prolonged high blood sugars.

I went to a lunch conference, paid for by a pharmaceutical company, at the AAFP conference in September. The drug company said start people on metformin at diagnosis and if they are not in control in 3 months, start a second medicine, the drug company’s new and improved and better and beastly expensive medicine!!!

Yeah, I don’t think so. All of my patients are smart and they all can figure it out. Some get discouraged and some are already on insulin, but they are still all smart.

Fight back against the moronization of US citizens. Keep America healthy, wealthy and wise.

At what age should we talk to our kids about drugs?

I am a rural family physician and my recommendation: before age 9. Before third grade.

WHY? Your eyes are popping out of your head in horror, but my recommendation comes from surveying my patients. For years.

The biggest drug killer is tobacco. However, it takes 30 years to kill people. It is very effective at taking twenty years off someone’s life, destroying their lungs, causing lung cancer, heart disease, mouth cancer, breast cancer, uterine cancer, stomach cancer, emphysema, heart disease….

I ask older smokers what age they started smoking. This is informal. This is not scientific. But most of my male older smokers say that they first tried cigarettes at age 9. I think parents need to be talking to their children about cigarettes by age 9.

And then start talking about alcohol and illegal drugs and the terrible dangers of pills.

“My innocent child would never….” Unfortunately my daughter said that as a senior in high school in our small town, there were 4-5 kids out of the 120+ that were not trying alcohol and marijuana. But there are kids trying far worse substances. We have methamphetamines here, and heroin, and pain pills sold on the street.

The perception that pills are safe is wrong too. Heroin is made from the opium poppy and it’s rather an expensive process, not to mention illegal and has to be imported from dangerous places. But teens take oxycodone and hydrocodone, bought on the street, to get high. And now drug sellers are making FAKE oxycodone and hydrocodone and selling that on the street. It contains fentanyl, which is much much stronger. If the dealer gets the mix wrong, the buyer can overdose and die.

Talk to your children young! NEVER take a pill from a friend, never take someone else’s medicine, never take a pill to party! YOU COULD DIE! And if you have a friend that is not making sense, that you can’t wake up, DON’T LEAVE THEM! Call an ambulance. Your friend may have used something illegal, and may not want you to call an ambulance. But if you think they are too sleepy….. don’t take a chance. People can get so sleepy, so sedated, that they stop breathing.

And parents, you are the ones that have to set a good example. Don’t drink alcohol every night. Don’t use pot every night. Take as few pills as possible. Pills aren’t necessarily safe because they are “supplements” or “natural” — hey, opium and heroin are plant based! Stop using tobacco and if you have a hard time doing it, tell your children you are struggling. It takes an average of eight tries to quit smoking. Get help.

Lastly, we talk about childhood innocence, but we let kids babysit at age 11. That is the Red Cross youngest age. My daughter took a babysitting course at age 11 and babysat. If we think they are responsible enough to do CPR, call 911 and do the heimlich maneuver, shouldn’t we also be talking to them about addictive substances by that age?

Talk to your children about addiction young… so that they can avoid it.

I am submitting this to the Daily Post Prompt: calm. I am not calm about this topic, but the photograph is calm…. and if we can help more children and families…..

Update on marijuana 2016

I attended the Swedish Hospital Update on Chronic Pain in Seattle two weeks ago on the stormy Friday. The power went out and we were without slides from about noon on.

The first two hours and three lectures were about marijuana. Including medical marijuana and one speaker for and one against. So here are some of my notes.

In 1960 and 1970, the marijuana had about 4% THC. Now some strains have 30% THC, so long term there is no data about what 30% THC will do to a person rather than 4%. THC in strains ranges from 0% to 30% and CBD from 0 to 3.5%. However, those two are not the only active ingredients, so to speak. 537 constituents have been identified that work at the cannabinoid receptor…. that is impressive. I think it might take a while to sort out what they do.

At any rate, we don’t know what smoking 30% THC will do, because it’s new. 4% had pretty minimal psychotropic effects. 30% has a lot more. The average now is 12%. Hashish is closer to 66% and hash oil 81% THC. A patient recently told me that she fainted within the last year. She got butter from the fridge at a friend’s and buttered her toast. Turned out it was THC infused butter and she was taken by surprise on a walk 30-60 minutes later. Luckily someone was with her and she was not hurt.

Recent data is showing that there is not much tolerance smoking 12% THC regularly. However, higher doses show tolerance in about 2 weeks in a study of HIV patients with dronabinol, which is 40% THC. Another study of multiple sclerosis patients with 15/15% CBD:THC reduced pain, reduced spasticity and did not show tolerance.

There is anecdotal evidence about seizures, but no study yet. There is some evidence that CBD reduces THC induced paranoia and/or hallucinations. THC side effects from dronabinol include drowsiness, unsteady gait, delusions, hallucinations, mood change and confusion.

The growers are being very creative in names and marketing. This is re recreational pot.
There are hundreds of names and hundreds of varieties and they make interesting claims as to effects. For example:

AK47 with 36.6% THC and 0.3% CBD ….. creative, euphoric and hungry
sage with 27.5% THC and 0.7% CBD ….. attentive
flow with 23.2 % THC and 0.6% CBD ….. happy, relaxed, alert
Super Sour Diesel 22.7 % THC and 0.8% CBD ….. attentive, giggly, hungry
707 Headband with 22.1% THC and 0.7% CBD ….. euphoric, lazy, inspired

How amazing the difference less than a percent of THC makes… oh, wait. There aren’t clinical trials on this, hon, this is MARKETING.

Onset for oral is 30-90 minutes
peak in 2-4 hours
half life 8-12 hours but sometimes 20 hours

sublingual tincture
onset 30-45 minutes
peak 60 minutes
half life 3-5 hours

Smoked onset quicker and I did not get those numbers.

The emergency rooms in Colorado saw lots of people who were “trying it” but if they had only tried smoking marijuana in the 1970s, a strain with a much higher percentage made many people sick or hallucinate or frightened. The gummi bears look just like the ones for kids, so kids got sick. More sick people with edibles, as some eat too much.

People using THC before age 25 who have risk factors for schizophrenia are more likely to develop it. Family history, other hallucinatory drugs, mental health problems. The age 21 limit should be taken very seriously.

In Arizona re medical marijuana, 90% of the prescriptions were from only 24 physicians. In Colorado, 94% of the patients applying for medical marijuana did so for “severe pain”. Two of my friends in their early 20s  got medical marijuana permits in California for “back pain”, um, ok, hooey. Some people DO have severe chronic pain….

The history of medical marijuana is that Eli Lilly produced a medical version from 1850-1940 for pain. It was removed in 1942. In 1970 it became a schedule one, that is, illegal, drug. There are a few randomized clinical trials for pain, the best ones with high CBD/low THC treatments. Marijuana smoke alone has not been proven to cause lung cancer, but combined with tobacco or other smoke, the evidence is that it is synergistic and makes things worse faster. Dependence can occur, an increase in antisocial personality disorders and there is a withdrawal syndrome for dependent folks. For the small number of people I have had working hard to stop, sleep is the most difficult issue. Anxiety as well.

If people state that they use pot a small amount a couple of times a week, their urine sample should clear after a week. If it’s not clear they 1. couldn’t stop and/or 2. were using quite a bit more.

As far as Washington state law, it was described as a mess. Physicians can’t prescribe, they can only “attest” that the person has a problem treatable by medical marijuana. To attest, the physician has to sign a document saying that they are sure that not only has the patient READ the law chapter 69.51A RCW but also “understands the requirements of being a patient”. There are 24 sections. The physician doing this part of the talk said that he would only prescribe to non-driving MS patients in wheelchairs. Because he finds it hard to read the law himself, so the signing that the patient has read and understood it…. well, the driving legality issue is huge. And the provider, including NDs (naturopaths) and ODs (Doctor of Optometry) in Washington can attest. They are then immune in Washington but not at the federal level.

Every marijuana store is legally obliged to have a medical marijuana consultant present at all times that they are open. The medical marijuana consultant has 20 hours of training to get certified. Patients that are certified with an attestation can grow 6 to 15 plants but ONLY after they have been entered into a database which includes the person who signed the attestation and a photo of the patient. If they grow without being entered, they are breaking the law.

Use of THC long term, the risk of addiction is 25-50%. 17% of the addicted folks started during adolescence. Addiction is currently estimated at 9% of people who have tried it overall. About 30% of users have “problem use” and starting before age 18 increases the problem use 4-7 times. The DSM-V has diagnostic criteria for “marijuana overuse syndrome”, including not being able to stop even though the person wants to. Risk factors for addiction and problem use include early use, family history, PTSD (especially sexual abuse), bipolar diagnosis, ADHD, conduct disorder, oppositional defiant disorder. Mediating factors include parental disapproval, parental supervision, academic competence, higher perceived risk and availability.

And am I attesting? No. My MS patients get the attestation from the neurologist if they want it….

Medical marijuana consultant training: http://www.doh.wa.gov/YouandYourFamily/Marijuana/MedicalMarijuana/RulesinProgress/MedicalMarijuanaConsultantCertification
Washington State Medical Marijuana attestation form: http://www.doh.wa.gov/Portals/1/Documents/Pubs/630123.pdf
WA law: http://app.leg.wa.gov/RCW/default.aspx?cite=69.51A
And pain clinics getting closed down: http://www.seattletimes.com/seattle-news/health/pain-patients-scramble-for-care-after-clinic-crackdown/

The tree trunk is a bonsai from the Lan Su Chinese Garden in Portland. I like the thorns…..