2. Types of Addiction
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Note: There are a lot of acronyms in the Addiction section. Try to both get a general understanding of the concepts presented and know the acronyms.
Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use or other behaviors.
"ABCDE" of addiction: Addiction is characterized by inability to consistently Abstain, impaired Behavioral control, Craving, Diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional Emotional response. (reference)
Another way that addiction is often summarized is with the "4 C's" method: Loss of Control; Use despite negative Consequences; Compulsion or Craving to use.
Addictions represent an interaction between personal tendencies of the individual and the social context in which they are living. Your management of a patient with an addiction needs to recognize the many layers of influence. For example, the social conditions range from underlying determinants, such as international relations that affect the global trade in drugs, up to local factors that affect access to drugs on the streets of Ottawa.
It is important to view addiction as a disease. The initial decision to try drugs is usually voluntary, but addiction hijacks the brain. Whatever its source, pleasure has a distinct neurotransmitter signature in the brain: dopamine is released in the nucleus accumbens. This reward circuit connects to motivation and memory processes within the limbic system. Substance use floods the brain with dopamine, giving an intense feeling of pleasure that encourages further use. But drugs produce such a strong artificial dopamine surge that this gradually alters brain function: the brain reacts by closing off dopamine receptors and reducing its natural dopamine production. As a result, the person must take more of the drug to achieve the same effect: the development of tolerance. The pleasure declines but its memory persists, leading to a craving for it: the transition from liking something to being addicted to it.
Tolerance: After repeated administration, a given dose produces a decreased effect. This can be a natural characteristic of the drug - for example, prescription opioids may have this effect.
Withdrawal: a substance-specific and unpleasant syndrome resulting from reducing or stopping consumption of the substance
Dependence: repeated use of a drug, without which you have withdrawal symptoms
Abuse: use in a manner that deviates from approved social or medical patterns
Substance Use Disorders: repeated and increased use of a substance (or behavior); deprivation produces symptoms of distress and an irresistible urge to use again
- Impaired Control (DSM lists 4 criteria): substance is taken in larger amounts or over a longer period than intended; the person becomes unable to control its use; time is devoted to trying to control it; craving.
- Social Impairment (3 criteria): use impairs role obligations; use continues despite this; activities are given up because of substance use.
- Risky Use (2 criteria): recurrent substance use in hazardous situations (driving, etc); continued use despite knowing the harm it is causing
- Pharmacological (2 criteria): tolerance, as shown by diminished effect and need to increase quantity taken; withdrawal syndrome.
The disorders often involve cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.
Public health measures aim, first, to reduce general use of an addictive substance to prevent addictions, via fiscal control, legislation, social pressure, advertising, etc. Secondary measures include harm reduction.
Treatment addresses the problems associated with substance abuse, then helps the person reduce risk of harm by managing exposure to risky situations, and then addresses issues beyond substance abuse.
Addictions may be triggered by a range of events but the key theme is that there is a cyclical renewal of the triggers that serves to maintain the addiction (an example in the left-hand diagram below). This cycle can interact with broader socio-economic circumstances (illustrated on the right).
A range of Admission and Discharge Criteria and Assessment Tools ("ADAT") are described by the Centre for Addiction and Mental Health (CAMH).
The SOCRATES scales assess readiness to change; there are alcohol and drug versions ("Stages Of Change Readiness And Treatment Eagerness Scale"). (E.g. I really want to make changes…I am looking for ways to keep from slipping back...) (link)
Treatment Entry Questionnaire records the patient's reasons for seeking help (e.g., I was interested in getting help; because others will get angry with me if I don't; I was pressured to come...). You need to get permission from the CAMH to use this.
Drug Taking Confidence Questionnaire - DTCQ. This explores the person's confidence in their ability not to use in various high risk situations such as being with friends who are using.
Perceived Social Support questionnaire - how much will family and friends help them?
Part of the role of the physician is to counsel patients on drinking behaviour and intervene when there is worry about substance abuse and addiction.
Low Risk Drinking is drinking within the recommended guidelines:
- For men, no more than 3 or 4 standard drinks per sitting, and no more than 14 per week. Evidently, the 3 or 4 drink limit precludes binge drinking.
- For women, no more than 2 or 3 drinks per sitting, and no more than 10 drinks per week.
- Elderly people should reduce the above amounts.
- Drink slowly and take alcohol with food and non-alcoholic beverages.
- No alcohol use in risky situations (e.g., driving car or boat, using machinery).
- No drinking during pregnancy
- If the patient does not drink, do not suggest they begin taking a glass of wine to protect against heart disease; suggest exercise, weight loss (where indicated) or dietary improvements instead.
A standard drink is approximately 10 grams of pure alcohol.
At-Risk And Problem Drinking
‘At-risk drinking’ is drinking more than the recommended amount in a sitting or in a week.
The term ‘problem drinker’ refers to those individuals who are having difficulties in their life as a result of their alcohol intake. Such people may not fit the criteria for alcohol use disorder, but are at risk for accidents and problems resulting from drinking to excess. A significant proportion of patients seen in emergency departments or trauma centers for intentional and unintentional injuries are problem drinkers. Problem drinkers may be moderate drinkers, heavy drinkers, or binge drinkers.
DSM V Criteria For Alcohol Use Disorder
In the DSM V, a minimum of 2-3 of the following criteria are required for a mild alcohol use disorder diagnosis, while 4-5 is moderate, and 6-7 is severe (APA, 2013).
- Taking alcohol in larger amounts and for longer than intended
- Wanting to cut down or quit but not being able to do it
- Spending a lot of time obtaining alcohol
- Craving or a strong desire to use alcohol
- Repeatedly unable to carry out major obligations at work, school, or home due to alcohol use
- Continued use despite persistent or recurring social or interpersonal problems caused or made worse by alcohol use
- Stopping or reducing important social, occupational, or recreational activities due to alcohol use
- Recurrent use of alcohol in physically hazardous situations
- Consistent use of alcohol despite acknowledgment of persistent or recurrent physical or psychological difficulties from using alcohol
- Tolerance as defined by either a need for markedly increased amounts to achieve intoxication or desired effect or markedly diminished effect with continued use of the same amount. (Does not apply for diminished effect when used appropriately under medical supervision)
- Withdrawal manifesting as either characteristic syndrome or alcohol is used to avoid withdrawal (Does not apply when used appropriately under medical supervision)
What can a family doctor do to help a patient who drinks a lot? Screen and intervene!
There are numerous screening methods for alcohol abuse and dependency (the Screening section coming up will look at more of them).
The CAGE test was developed to indicate the likelihood that a person has a problem with controlling alcohol intake. It is not diagnostic, and sensitivity & specificity are not perfect. The original version has been modified to cover drug use as well, forming the CAGE–AID (for "adapted to include drugs"). The AID additions are shown in italics below.
You could begin by asking "Do you drink alcohol? Have you ever experimented with drugs?"
C: "Have you ever felt you should cut down on your drinking or drug use?"
A: "Have people annoyed you by criticizing your drinking or drug use?"
G: "Have you ever felt bad or guilty about your drinking or drug use?"
E: "Have you ever had a drink or used drugs first thing in the morning to steady your nerves or get rid of a hangover?" (an eye-opener)
You may also consider your patient's behavioural and physical symptoms and lab markers when assessing their alcohol dependency.
· drinking leads to problems with personal or family relationships
· difficulty in completing their work
· legal or financial problems related to alcohol
· accidents in which alcohol is involved
· concern about drinking
· intellectual impairment
· hand tremor
· anxiety or depression
· insomnia, nightmares
· mild hypertension
· multiple cuts or bruises
· morning nausea or vomiting
· recurrent diarrhea
· palmar erythema
1. Liver enzymes
- Elevated GGT (gamma-glutamyltransferase). GGT is a glycoprotein enzyme situated on the cell membrane in several tissues, notably the liver. Low sensitivity for alcohol consumption: only 30-50% of excessive drinkers show elevated levels in the general population. Also, GGT is not specific to alcohol: it can respond to a variety of enzyme-inducing drugs (specificity 50% to 75%). Has only a moderate correlation with overall alcohol consumption (r = 0.3 to 0.4 in men; less in women). Variable between people, depending on their drinking history: GGT works best for detecting sustained excess drinking, and is often the first test to respond to alcohol-induced liver damage. Hence a positive result can have clinical significance. It does not respond to a single dose of alcohol unless the person is a habitual drinker. Takes a few weeks to return to normal during abstinence. There is a wide range of reference values, and GGT values rise with age and with BMI, even in non-drinkers. (See Conigrave KM et al. Addiction 2003; 98(Suppl 2): 31-43)
- Elevated Alanine aminotransferase (ALT) - aka SGPT, serum glutamic pyruvic transaminase. Hepatocellular enzyme found in the cytosol. Mainly found in the liver. Like GGT, not elevated by a single episode of excess drinking. Less sensitive than GGT, but alcohol is the most common cause of a raised ALT. Like GGT, not only a marker of alcohol consumption, but of liver damage. Because it records cumulative damage, relatively insensitive in people younger than 30 years.
- Elevated Aspartate aminotransferase (AST) - previously known as SGOT, serum glutamic oxaloacetic transaminase. Hepatocellular enzyme found in the mitochondria. Not specific to alcohol use. Like GGT, not elevated by a single episode of excess drinking. Correlation with alcohol consumption only around 0.24 to 0.34. Like GGT, not only a marker of alcohol consumption, but of liver damage. Because it records cumulative damage, relatively insensitive in people younger than 30 years. (See Conigrave KM et al. Addiction 2003; 98(Suppl 2):31-43)
2. Blood Markers
- Elevated MCV (mean corpuscular volume): Sustained and regular excessive drinking is required to raise MCV levels in the absence of folate deficiency, liver disease or bleeding. MCV does not accurately record irregular drinking. Returns to normal in about 4 months. As a screening test, MCV has a sensitivity below 50%, but it is often more specific than GGT (sometimes 90%). Sensitivity especially poor in those aged below 30, but may be more sensitive in women than men. (See Conigrave KM et al. Addiction 2003; 98(Suppl 2): 31-43)
- Blood Alcohol concentration (BAC) >17 m mol/L at scheduled appointment, or > 30 m mol/L with no apparent intoxication. Elevated for a brief period following drinking. Note the legal driving limit in Ontario is 8m mol/L; this translates into roughly 3 beers (at 5% alcohol content) for a 200-pound man. Most such people will consider themselves sober. Driving in this condition is a criminal offense with a 10-year criminal record, automatic license suspension for 3 or more months and a fine of at least $600.
3. Urine concentrations
- Elevated serum uric acid: Elevated mainly during drinking; marker of acute intake
One intervention model is the 4 A's model of intervention: ASK, ASSESS, ADVISE & ASSIST.
Depending on what form of substance use issue your patient is having, your role is different:
- “Controlled Use”
- Trial of Abstinence
- Detoxification Unit
- Outpatient Treatment
- Inpatient Treatment
- 12-Step Programs (Alcoholics Anonymous / Narcotics Anonymous)
The decision to choose inpatient care based on:
- Need for detoxification
- Medical complications
- Unstable psychiatric condition
- Multiple drugs of abuse
- Poor social conditions
- Unstable home environment
- Failed out-patient attempt(s)
- Patient or family’s preference
"Alcoholics Anonymous (A.A.) is a fellowship of men and women who share their experience, strength and hope with each other so that they may solve their common problem and help others to recover from alcoholism. The only requirement for membership is a desire to stop drinking. There are no dues or fees for A.A. membership; we are self-supporting through our own contributions. A.A. is not allied with any sect, denomination, politics, organization or institution; does not wish to engage in any controversy, neither endorses nor opposes any causes. Our primary purpose is to stay sober and help other alcoholics to achieve sobriety." (A.A. Grapevine, Inc.)
Some key elements of A.A.:
- It is non-professional, self-supporting and there are no age or education requirements
- It was started in 1935 by a New York stockbroker and an Ohio surgeon; there are over 100,000 groups in 150 countries.
- It is a program of total abstinence. Sobriety is maintained through mutual support, sharing experiences, strength and hope.
- It focuses on a single purpose. People with addictions other than alcohol can attend open meetings, but only those with a drinking problem can attend closed meetings (see below).
- It is 'anonymous' to emphasize governance by principles rather than personalities. Anonymity is the guarantee that members will never be identified.
- What does A.A. do? Members share their experience with anyone seeking help with a drinking problem. The program, described in the 12 steps listed below, offers the alcoholic a way to develop a satisfying life without alcohol
- What does A.A. NOT do? A.A. does not motivate alcoholics to seek to change, solicit members, undertake research, keep case records, try to control its members, engage in education about alcohol, offer opinions on issues or support causes, accept money for its services or contributions from non-A.A. sources (it is entirely self-supporting and donations from any member are limited to $2000 per year), provide letters of reference for its members.
Types of meeting
• Open speaker meetings: members tell their stories and outsiders (especially doctors, clergy, etc.) are invited.
• Open discussion meetings: one member describes his experience, followed by discussion on any topic raised by others.
• Closed discussion meetings: the same, but for alcoholics or prospective members of A.A. only.
• Step meetings: closed discussions of the 12 steps.
The Twelve Steps
- We admitted we were powerless over alcohol -- that our lives had become unmanageable.
- Came to believe that a Power greater than ourselves could restore us to sanity.
- Made a decision to turn our will and our lives over to the care of God as we understood Him.
- Made a searching and fearless moral inventory of ourselves.
- Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.
- Were entirely ready to have God remove all these defects of character.
- Humbly asked Him to remove our shortcomings.
- Made a list of all persons we had harmed, and became willing to make amends to them all.
- Made direct amends to such people wherever possible, except when to do so would injure them or others.
- Continued to take personal inventory and when we were wrong promptly admitted it.
- Sought through prayer and meditation to improve our conscious contact with God as we understand Him, praying only for knowledge of His will for us and the power to carry that out.
- Having had a spiritual awakening as the result of these Steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs.
Alcoholics Anonymous Links
Consumption of most types of alcohol rose in Canada between the early 1960s and 1980, then fell, largely due to reduced consumption of spirits. But as wine became more popular in the 1990s, consumption rose again.
For men and women, drinking becomes rapidly more prevalent from ages 14 to 20, so that at ages 20-24, 68% of people are current drinkers. On average, drinking peaks by age 25 and then declines slowly with advancing age (a bell shaped curve). At ages 55-64 about 50% of the population are regular drinkers; at age 75+ the rate is 30% (41% of males, 23% of females).
Heavy drinking is not very common in Canada: of current drinkers, 15% of adult men consume 14 or more drinks per week, compared to 4% of women. As you may have noticed, heavy drinking is most common among 20-24 year olds.
There is a positive association between drinking alcohol and income adequacy. 68% of people in the highest income group drink regularly (and only 9% are abstainers), compared to 40% of those in the lowest income group (18% abstain). However, heavy drinking is probably more common among lower SES groups: 11% of those with less than high school education consume 14+ drinks per week, compared to 7% of university graduates.
Over time, there has been a decline in alcohol-related morbidity and mortality:
There has also been a decline in maternal alcohol consumption during pregnancy in Canada. In 1994-95, 17.4% of children under the age of two had a mother who reported drinking alcohol during pregnancy compared with 14.6% in 1998-99. This percentage includes all mothers who reported drinking, regardless of amount. The rate of mothers who reported drinking alcohol during pregnancy was 12.2% in 2000-2001, 12.4% in 2003 and 10.5% in 2005. This percentage includes all mothers who reported drinking, regardless of amount and frequency (reference).
Maternal alcohol consumption can lead to fetal alcohol spectrum disorder (FASD). This refers to a range of birth defects and neurodevelopmental disorders, behavioral and cognitive abnormalities that persist into adulthood. A diagnosis of fetal alcohol syndrome (FAS) is based on a history of exposure to alcohol during pregnancy, prenatal and postnatal growth retardation, facial dysmorphology and CNS damage.
Addiction: Cigarette Smoking
Nicotine is the principal addictive component of tobacco smoke; it has many of the rewarding and reinforcing properties typical of an addictive drug; these are mediated, in part, by its effects on mesolimbic dopamine neurons. However, this does not seem to explain adequately the powerful addiction to tobacco smoke experienced by many habitual smokers. Balfour proposed that sensory stimuli and other pharmacologically active components in tobacco smoke also play a role in the addiction to nicotine inhaled in tobacco smoke. This greater complexity may explain why nicotine replacement therapy is not an aid in smoking cessation (Balfour DJK. The psychobiology of nicotine dependence. European Respiratory Review 2008; 17: 172-181).
Over the past 50 years, the proportion of Canadians who smoke cigarettes regularly has declined steadily: a public health success story! Rates fell from from 50% overall in 1965 to 14.6% in 2013. There has also been a decline in the numbers of cigarettes smoked daily by smokers, and 64% of Canadians who have ever been smokers have now quit (link).
The decline in smoking reflects the successful use of multiple strategies to combat a public health problem. No single strategy is adequate, and all run the risk of a backlash. Presumably the decline has been due to a combination of shifting public attitudes, price rises due to taxation, campaigns by the anti-smoking lobby and the ensuing legislation against smoking in public places. At the same time, methods such as the nicotine patch to help people stop smoking have allowed physicians to play a more effective role.
The Ontario story of imposing high taxes on tobacco and the resulting smuggling from New York State illustrates how any pricing policy has to consider what is happening in other countries.
Who Currently Smokes Cigarettes?
In 2013, 16% of males and 13.3% of females smoked cigarettes (14.6% overall, or 4.2 million smokers). Smoking prevalence was highest among young adults aged 25-34, at 18.5% in 2013, and 17.9% among those aged 20-24. It appears that smoking rates may be higher in the LGBTQ+ community. The 2007 Toronto Rainbow Tobacco Survey reported smoking rates of 36% compared to 17% of Toronto adults aged 18+ (reference).
Smoking rates are highest in the North: over 55% in Nunavut, 30% in the Yukon and NWT. The Atlantic Provinces have the next highest rates, and BC the lowest, followed by Ontario.
Half of smokers claim to have made an attempt to quit in the past year; this is more common among men (56.5%) than women (41.4%). Roughly 50% of those who quit used stop-smoking medications.
One estimate places cigarette smoking as the most important cause of premature death in Canada, and suggests that smoking is the cause of 17% of all deaths (about 100 per day), but 37% of cancer deaths (link).
A Discussion Point: Lung cancer mortality in women has now overtaken that of breast cancer. What should we be doing about this as individuals and as professionals?
Legislation works proactively, creating a climate that discourages smoking. Tobacco litigation works retroactively, seeking to divert the burden of tobacco use onto the tobacco industry. Litigation has three objectives:
- To recover compensation for economic damages, medical expenses and perhaps pain and suffering, due to the defendant’s wrongdoing;
- Deterrence: to avert future wrongdoing of the defendant, here in terms of producing and marketing harmful products;
- To establish accountability, so that wrongdoers can be held accountable by society.
Litigation and legislation can work together, in that successful litigation can then fund legislated smoking cessation or health promotion programs. Tobacco litigation in the USA has included class action lawsuits, ranging from a group of people to coordinated efforts of several States against tobacco companies. The Engle case, for example, was a class-action begun in 1994 on behalf of all individuals suffering from tobacco-related diseases along with their surviving relatives in Florida. A verdict of US$145 billion was awarded by a jury in punitive damages against tobacco companies, but this was reversed in 2006 by the Florida Supreme Court, although this ruling allowed for individual cases to be brought. The Tobacco Products Liability Project (TPLP) in April of 2010 caused tobacco companies to pay over US$230 million for a smoking cessation program to help thousands of smokers in Louisiana. As of 2010, at least eighty tobacco cases were pending in eleven countries.
Smoking is responsible for about one-third of the potential years of life lost () due to cancer, about one-quarter of PYLL due to diseases of the heart and about one-half of PYLL due to respiratory disease.
Health Canada estimates that tobacco-related diseases cost an excess of $3 billion per year in direct health costs, and $7 billion in indirect costs to the economy.
The benefits of cessation increase with duration of being smoke free, as illustrated by figures relating to lung cancer. The risk of getting lung cancer among continuing male smokers is around 16% by age 75 (rising from 10% for those smoking 5 cigarettes per day to 25% for those smoking 25+ per day). If this 16% figure is used as the baseline and set at 1.0, the relative risk for someone who quit smoking within the last 10 years is 0.66; quit 10-19 years ago RR = 0.44, quit 20-29 years ago = 0.2, and quit 30+ years ago = 0.1. The RR for lifelong non-smoking men is 0.03, which corresponds to an absolute risk of around one-third of one percent. The equivalent RR figures for women are 0.69, 0.21, 0.05 and 0.05 (Source: Peto R et al. BMJ 2000; 321: 323).
In the DSM V, a minimum of 2-3 criteria indicates a mild tobacco use disorder diagnosis, while 4-5 is moderate, and 6-7 is severe (APA, 2013).
- Taking tobacco in larger amounts and for longer than intended
- Wanting to cut down or quit but not being able to do it
- Spending a lot of time obtaining tobacco
- Craving or a strong desire to use tobacco
- Repeatedly unable to carry out major obligations at work, school, or home due to tobacco use
- Continued use despite persistent or recurring social or interpersonal problems caused or made worse by tobacco use
- Stopping or reducing important social, occupational, or recreational activities due to tobacco use
- Recurrent use of tobacco in physically hazardous situations
- Consistent use of tobacco despite acknowledgment of persistent or recurrent physical or psychological difficulties from using tobacco
- Tolerance as defined by either a need for markedly increased amounts to achieve intoxication or desired effect or markedly diminished effect with continued use of the same amount. (Does not apply for diminished effect when used appropriately under medical supervision)
- Withdrawal manifesting as either characteristic syndrome or the tobacco is used to avoid withdrawal (Does not apply when used appropriately under medical supervision)
Fagerstrom Test (link)
It takes most people several attempts to quit before they succeed. Dozens of ways to promote cessation have been proposed (check "smoking cessation" on Wikipedia!), but many do not seem to work. Here are some methods that have been shown to be effective and that may help your patients.
Smoking Cessation Products
Nicotine replacement (NR) therapy: OTC products like chewing gum (Nicorette or CigArrest – $2 to $5 per day), longer-lasting patches such as Habitrol or NicoDerm ($5 per day), or short-acting lozenges or mouth spray help reduce cravings by giving small amounts of nicotine. NRT can also be administered via nasal sprays or lozenges or tablets. These deliver nicotine to the body more rapidly than the patch, but slower than a cigarette. The Cochrane Collaboration reviewed 123 trials of NR and reports that it increases the chances of stopping smoking by 50% to 70%. It seems that using a combination of the patch and a faster-acting form enhances quit rates. Also, begin the NR therapy a few days before the intended quit date.
Prescription drugs: Zyban is a prescription antidepressant (bupropion hydrochloride) that appears to reduce cravings and withdrawal symptoms. The Cochrane Collaboration review claims it doubles the odds of quitting, and outlines the side effects. The tricyclic antidepressant nortriptyline also doubles quit rates, but SSRIs do not appear to help smoking cessation.
Varenicline (trade name Champix), like cytisine, acts as a partial agonist of the α4β2 nicotinic acetylcholine receptor in the nucleus accumbens of the brain and acts as an antagonist to nicotine by preventing it from binding. The Cochrane Collaboration reviews 3 trials that suggest that varenicline increases the chances of quitting two-to three-fold after 1 year, compared to placebo.
- Note: is Varenicline associated with an increased risk of suicide? (See, for example, Moore TJ et al. Suicidal behavior and depression in smoking cessation treatments. PLoS One 2011; 6(11): e27016)
Bupropion: originally developed as an antidepressant, acts as a dopamine and norepinephrine reuptake inhibitor at the synapse. Its effectiveness appears to reflect the involvement of dopamine and norepinephrine in nicotine addiction.
Physical replacements: Smokers Edge is a small plastic tube like a cigarette that delivers a mouthful of herbs and oils. Devices such as E-Z Quit help keep the smoker's hands busy.
The 5 A's approach (seen before under Alcohol Abuse) is a simple framework for an approach:
- Ask every patient, at every visit, about their tobacco usage status ("Do you smoke?")
- Advise the smoking patient to quit —"I think it is important for you to quit smoking now and I can help you."
- Assess their willingness to quit (e.g. within the next 30 days)
- Assist them in quitting (set a quit date; involve family & friends; provide aids)
- Arrange for follow-up
(Fiore, M et al. “Treating Tobacco Use and Dependance: 2008 Update)
The Ottawa Heart Institute Model is based on the 5 A's but is slightly different:
- Identification (ask the patient, every time you see them)
- Documentation (note it in the chart)
- Pharmacotherapy, and
- Long-term follow-up.
The Heart Institute also suggests the 4 D’s of Dampening the Desire to smoke: Distraction; Deep breaths; Drink water; Delay. Quitters should also cut back on coffee to avoid the jitters (smokers metabolize caffeine twice as fast).
If the patient is not willing to quit, the “5 R's” can be used to enhance motivation in your discussion:
- personal relevance of quitting
- risks or negative consequences of smoking
- potential rewards of quitting
- roadblocks or barriers he or she has to quitting + treatment that would help address these, and
- repeat this process every time the unwilling patient is seen
The ‘STAR’ acronym can guide you with patients who are prepared to quit :
- Set a definite quit date
- Tell family, friends and coworkers about quitting and request understanding and support
- Anticipate challenges and provide advice to deal with such challenges
- Remove tobacco products and make your home smoke free.
In any city there will be lots of smoking cessation programs to which you can refer patients. In Ottawa, the Tobacco Information line offers information on programs currently available: 613-724-4256. The Heart Institute program is at 1-866-407-7848.
Maternal smoking during pregnancy increases the risk of intrauterine growth restriction, of preterm birth, stillbirth, birth complications and various forms of infant morbidity. The adverse effects increase with the amount smoked. It is important to encourage pregnant women to quit smoking.
In 2007-08, one estimate for Ontario found that 15% of pregnant women were current smokers (http://www.pregnets.org/dl/Lit%20Review%20FINAL.pdf). Based on self-report, this is plausibly an underestimate. A 2009 estimate reported that 23% of Canadian women smoked during pregnancy, but the figure was 59% in the Northern Territories (link).
Younger mothers are more likely to smoke during pregnancy, although because of the differing birth rates, mothers under 20 accounted for less than 10% of all children exposed to tobacco smoke prenatally.
Factors associated with smoking experimentation and onset among youth include low socioeconomic status, older age, male gender, low academic achievement, problem behavior, low self-esteem, low self-efficacy, stress, smoking by parents, siblings and peers, low social support, access to cigarettes and tobacco advertising. More recently recognized factors include weight-related smoking among pre-adolescents, the role of psychological distress, and the possibility of genetic predisposition to nicotine dependence.
Many studies show a relationship between smoking and a desire to control weight. Among girls aged 9-12 years, one study found that those who were overweight and who tried smoking were 3.5 times more likely to continue smoking than normal weight girls who tried smoking. The association for girls between body weight and smoking begins early in life.
There may also be an association between continuing smoking in children and stressful life events. Among adults, smoking is linked to depression, anxiety disorders, bulimia and other psychological disorders. Severe depression can follow smoking cessation, even among young smokers trying to quit.
You get very different pictures of the health care costs due to cigarette smoking if you look at individual costs, comparing the health care consumption of a smoker and a non-smoker at each age, versus calculating the total population cost due to smoking at each age. The left panel shows that health care costs for smokers (red line) are higher at each age. However, overall smokers actually cost the health care system less because they die younger (green & blue lines in right diagram): these figures were from a study of Dutch men (statistics from 1988)
Up to 1/3 of street drugs come from misused prescriptions obtained from doctors; in these scenarios, the doctors become the dealers.
Drug Seeking Individuals
Drug Seeking Individuals (DSI): Individuals who seek and obtain controlled (prescription) drugs in order to sell them on the street or abuse them. Some DSI may be entrepreneurs who seek to sell drugs on the street, others DSI may be family members of a dealer who pass drugs on, and some DSI may use/abuse the drug themselves in addition to selling excess.
Common drugs sought by DSIs:
- Opiates (Codeine, Percocet, Oxycontin, Morphine, Tussionex …)
- Benzodiazepines (Valium, Xanax, Ativan, Serax, …)
- Barbiturates (Fiorinal, Seconal, …)
- Amphetamines (Ritalin, Concerta…)
- Medication for mental disorders or virtually any illness that requires pain management
Common excuses for seeking drugs:
- From “out of town”
- "Own MD is unavailable"
- Sense of urgency; overly flattering
- "Lost my prescription"
- Asks for psychoactive drug by name; uses clinical terminology
- Intolerant of Hx, Px, work up
- Claims to be allergic to codeine, NSAIDs & regular analgesics
- “Could you add some…”
DSI usually target MDs who are new grads, foreign grads, busy, at walk-in clinics, or ones who can be threatened or whose knowledge is out of date. A few MDs who are users themselves.
Rational Prescribing: “The right amount, prescribed to the right patient, at the right duration of therapy, and so that the risks of therapy will be acceptable”
Gather the information you need for rational prescribing:
- Develop a policy on narcotics prescribing & post a notice in the office
- Take a careful history & physical, independent of treatment plan. Confirm the history as much as you can. Ask patients for I.D. at every visit.
- Ask about & document narcotics use in previous 30 days.
- Develop an index of suspicion; know the drugs commonly abused, know the con games played.
- Have clear clinical indication for prescribing any drug.
- Be aware, not intimidated. Learn how to say "No."
- Use therapeutic alternatives.
- Don’t enable: Do not prescribe “on demand"
- Do not prescribe small amounts to get rid of patients
- Write foolproof prescriptions; Secure prescription pads
- Do not give more medication than necessary
- Do not authorize refills on psychoactive drugs over the phone.
- Establish a therapeutic end point
- Set a time-limit for the patient's use of the drug
- Clearly state your policy on refills
- Discontinue by tapering
- Be available for support and follow-up
- Co-operate with Pharmacists, College of Physicians & Surgeons of Ontario, RCMP
In the DSM V, a minimum of 2-3 criteria represent a mild substance use disorder diagnosis, while 4-5 is moderate, and 6-7 is severe (APA, 2013).
- Taking the substance in larger amounts and for longer than intended
- Wanting to cut down or quit but not being able to do it
- Spending a lot of time obtaining the substance
- Craving or a strong desire to use substance
- Repeatedly unable to carry out major obligations at work, school, or home due to substance use
- Continued use despite persistent or recurring social or interpersonal problems caused or made worse by substance use
- Stopping or reducing important social, occupational, or recreational activities due to substance use
- Recurrent use of substance in physically hazardous situations
- Consistent use of substance despite acknowledgment of persistent or recurrent physical or psychological difficulties from using substance
- *Tolerance as defined by either a need for markedly increased amounts to achieve intoxication or desired effect or markedly diminished effect with continued use of the same amount. (Does not apply for diminished effect when used appropriately under medical supervision)
- *Withdrawal manifesting as either characteristic syndrome or the substance is used to avoid withdrawal (Does not apply when used appropriately under medical supervision)
*This criterion is not considered to be met for those individuals taking opioids solely under appropriate medical supervision.
Screening For Drug Abuse
CAGE-AID (See Alcohol Abuse section)
Drug History Questionnaire - records use over the past year in an interview with a counsellor.
DAST – Drug Abuse Screening Test. 28-item self completed questionnaire, counterpart of the MAST
Marijuana is dried plant matter from the hemp plant, Cannabis sativa. The plant contains delta-9-tetrahydrocannabinol, which can have significant short-term and long-term effects on the brain, mood and perceptions.
Who Is Using Marijuana?
Note: As of 2016 there are few recent statistics and use will probably rise with its legalization & growing availability. The figures we have, therefore, likely form a baseline.
The 2012 Canadian Community Health Survey – Mental Health reported that 12.2% of Canadians (aged 15 years or older) (3.4 million people) used marijuana at least once in the previous year. While this total number had been stable in the last decade (i.e. approximately 12% of Canadians used in 2002 and in 2012), trends have changed by age group. When contrasting 2002 data to 2012 data, it can be seen that significantly fewer 15-17 years olds used marijuana; use remained the same in 18-24 year olds at around one-third and use in older individuals increased slightly.
10% of regular users develop dependency.
Health Impacts Of Marijuana
“A dose-response relationship has been observed between the frequency of marijuana use during adolescence and reduced cognitive functioning, educational attainment, longer-term personal disadvantage, and marijuana dependence.” – CCHS-MH, 2012
Short term metal effects include:
- loss of short-term memory,
- impaired ability to focus and pay attention,
- impaired ability to concentrate and learn,
- loss of motor coordination,
- poor reaction time,
- impaired judgment and ability to think,
- psychotic episodes,
- mild paranoia, anxiety, and fear,
- panic attacks,
- perceptual distortions (visual, auditory),
- severe agitation,
- disorientation, and
While the short-term effects of marijuana may seem innocuous to most (red eyes, increased heart rate, drop in blood pressure, light-headedness), there are also more serious effects like risk of heart attack, stroke and significant short-term mental effects.
Long-term physical effects of marijuana use include lung and breathing problems, heart problems and pregnancy problems. Long-term mental health effects include issues with concentration & memory, harm to the ability to think and make decisions and decreased IQ.
Youth are particularly vulnerable to the health effects of marijuana use as the adolescent years are important in brain development.
Some individuals who use marijuana (especially if used during their youth) may be at increased risk of developing mental health issues like psychosis or schizophrenia.
10% of regular users develop dependency.
For more information on the physical and mental effects of marijuana use, click here. (Government of Canada, Health risks of marijuana use)
Legalization of Marijuana
In October 2015, Prime Minister Justin Trudeau announced that discussions would begin between the federal, provincial and territorial governments to determine the best process to decriminalize & legalize marijuana use for recreational purposes.
What is the difference between decriminalizing and legalizing? Decriminalizing means that possession of small amounts of marijuana would no longer be considered punishable with criminal record or jail sentence; fines on possession or use may still apply. Legalization means that consumers face no penalty and that the supply process is also legal. Legalization additionally allows the government to regulate and tax marijuana use and sales.
Currently, the Canadian government aims to legalize use and remove incidental possession of marijuana from the Criminal Code and create new laws to “more severely punish” individuals who provide the drug to minors or people who drive under the influence of the drug (reference).
Facts about marijuana use in Canada
- Estimated number of marijuana users in Canada: 3.4 million
- Average age of introduction to marijuana: 15.7 years old
- 10% of regular users develop dependency
- Annual number of arrests for all offences concerning illegal drugs: 109,000
- Number of reported marijuana offences (1999): 35,000
- Number of reported marijuana offences in 2001: 73,00 (80% for possession)
- Annual cost of enforcing marijuana laws (police and courts): $500 million
During Portugal’s dictatorship, which ended in 1974, drug use was harshly punished and the country was effectively cut off from the drug culture that had swept Europe. After the dictatorship drug use rose steadily, in part as an expression of new-found freedom. Portugal formed a geographically convenient gateway for drug importation into Europe. Harsh laws were enacted but to no avail. The problem became so acute that by 1999 almost 1% of the population was using heroin. HIV infections from dirty needles were among the highest in Europe.
Desperate for a solution to the crisis, in 2001 the government reversed its approach and decriminalized all illicit drugs for personal use. Drugs are still illegal in Portugal and drug dealers and traffickers are still sent to jail, but users found with less than a 10-day supply no longer receive a criminal charge. Portugal has carefully kept itself within the confines of the UN's drug convention system that guides national drug laws.
Responsibility for drug control was shifted from the Department of Justice to the Ministry of Health; treatment and harm reduction centres were established. Users found with less than a 10-day supply (a gram of heroin, ecstasy, or amphetamine, two grams of cocaine, or 25 grams of cannabis) are given a citation and sent before a 3-person ‘dissuasion panel’ that reviews the case and tries to help them, including referral motivational counseling or opiate substitution therapy. The idea is that where drugs are less stigmatized, problem users are more likely to seek care.
Critics argued this approach would encourage rampant drug use and would play into the hands of dealers. Use did seem to rise initially but fell by 2012. Continued drug use was estimated at 45% of the population in 2001, but fell to under 30% by 2012. Drug-related deaths fell precipitately as addictions treatment was made available (80 deaths in 2001; 16 in 2012). HIV infections fell from over 1,000 in 2001 to 56 in 2012. Drug users formed 44% of the prison population in 2001, falling to 24% in 2013.
Reviews of the experiment agree that it has not produced the disastrous results that some foresaw; it did not lead to a rise in drug tourism. It did lead to a reduction in criminal justice overcrowding
The clinician needs to be aware of, and know how to ask about, the main drugs commonly used recreationally. It is also useful to be aware of the terms used by patients in reporting their drug use.
The term “party drug” or “club drug” refers to drugs used at clubs and house parties. As party drugs are often made in illegal laboratories, it can be very difficult to know what chemicals they contain, their strength, what their effects will be and whether they contain poisonous ingredients. Party drugs include MDMA, Rohypnol, Ketamine, GHB, and hallucinogens (e.g. mushrooms with psilocybin, LSD, mescaline, PCP, salvia divinorum and jimson weed).
MDMA: Also known as ecstasy or Molly, MDMA is a synthetic chemical that alters mood and perception. It was introduced into North America in the 1970s as a pschyotherapeutic tool, despite the fact it had not been approved by the U.S. Food and Drug Administration or undergone any formal testing. (reference).
Less than 1% of Canadians use MDMA, but use is concentrated in youth (15-24): 1 in 25 Canadian youth in grades 10-12 reported using MDMA in the last year.
Cocaine is a white powder; ‘crack’ is derived from cocaine and has the appearance of an opaque white crystal. Cocaine is a Schedule I drug under the Canadian Controlled Drug and Substances Act; possession can lead to 7 years imprisonment. Only 1% of the Canadian population reports use of cocaine. Use is concentrated in homeless or street-involved youth and adult drug users. Depending on location, 20-62.5% of homeless or street-involved individuals report having used cocaine in the last year; use is higher in youth than adults.
Cocaine is also used recreationally by adult drug users. Health Canada’s report “Monitoring of Alcohol and Drug Use among High-Risk Populations Study (HRPS)” found that in 2013 cocaine was the second most commonly used illicit substance after cannabis among both street-entrenched and recreational adult drug users.
The Policy Of Harm Reduction
Harm reduction refers to a policy approach to tackling drug-related health problems that focuses on reducing the negative consequences of drug use, rather than trying to eliminate use.
The paradigm of harm reduction argues that we should set up programs to help keep addicted people as safe as possible, while working in the longer term to help them escape from their addictions. Examples of this approach include needle exchange programmes, providing safe alcohol in limited quantities to alcoholics, and supplying free condoms. Harm reduction can be used with most forms of addiction, but came to prominence when applied to injection drug use to reduce risk of spread of HIV infection.
Examples of harm reduction policies:
- bans on smoking in public places to reduce exposure to second-hand smoke
- methadone maintenance for heroin users;
- a needle and syringe exchange programs to reduce the spread of HIV infection among intravenous drug users;
- prescription of drugs to drug users;
- the creation of safe injection sites;
- the provision of safe alcohol to homeless people;
- designated driver programs;
Controversy over Harm Reduction
Not unexpectedly, there is controversy over the idea of harm reduction: it can appear to condone illegal activities.
Instead of seeking to eliminate the problem through 'a war on drugs', harm reduction establishes a hierarchy of goals, beginning with reducing negative consequences of the drug use. "If a person is not willing to give up his or her addiction, then we should assist them in reducing harm to himself or herself and to others." It tries not to stigmatize users, and allows them to address the underlying problem in their own time.
Harm reduction represents a gradualist approach to improving health behaviors. It argues that addictions lie on a continuum, rather than being all-or-nothing, so categorical judgments of good or bad are inappropriate. The philosophy holds that any effort that reduces the damage a person is doing to themselves (and the wider community) is a positive step, even if it involves providing materials that imply condoning illicit behaviours. This runs counter to the views of many fundamentalist thinkers and some law enforcement agencies.
Alternatives to harm reduction include supply reduction (e.g., destroying crops from which illicit drugs are derived, or interrupting the shipment of drugs). This approach has been used for years but is expensive and may not be cost-effective. Furthermore, underlying determinants such as poverty and corruption in the supplying countries, continue to drive the supply side of the equation. Demand reduction therefore focuses on the other side of the equation: discouraging people from wanting illicit drugs. This is usually attempted via education and information, community programs or legal penalties. Research suggests that these approaches may work best for those who need them least (you can review an evaluation of the Drug Abuse Resistance Education 'DARE' program in US schools).
Characteristics of the harm reduction perspective:
Pragmatism: drug use carries both dangers and benefits; humans have used mind-altering substances for millennia and addictions are intractable. From a community perspective, containment may prove more achievable than eliminating the problem.
Humanistic values: No moralistic judgment is made concerning the drug use; the rights of the user are respected.
Focus on Harm: Harm has been broadly defined as "sickness, death, social misery, crime, violence and economic costs to all levels of government." The focus on harm neither denies nor supports the long-term goal of abstinence. Sometimes, but not always, abstinence will be the most effective route to harm reduction.
Hierarchy of Goals: The first priority is reducing harm, followed by a reduction in usage.
Updated February 26, 2018