Monitoring Abstinence Martin H. Plawecki MD, PhD Indiana University School of Medicine Department of...

Monitoring Abstinence

Martin H. Plawecki MD, PhD

Indiana University School of MedicineDepartment of Psychiatry

Alcohol Medical Scholars Program

Introduction• Many diseases: chronic, relapsing, remitting

• Controlled, not cured

• Examples

• Type I diabetes: 30-50% relapse rate

• High blood pressure: 50-70% relapse rate

• Substance use disorders (SUDs): 40-60% relapse rate

© Alcohol Medical Scholars Program 2

Goals of SUD Treatment

• Harm reduction

• Abstinence

• Abstinence monitoring has a role in both


This Lecture Covers

• Definition/course of Substance Use Disorders (SUDs)

• Goals of monitoring abstinence and detection

• Abstinence monitoring substance examples

• Efficacy of monitored abstinence


This Lecture Covers

• Definition/course of Substance Use Disorders (SUDs)Definition/course of Substance Use Disorders (SUDs)





Substance Use DisorderIn Same Year, ≥2 of:

• Tolerance• Withdrawal• Use longer/more• Unable to ↓• Lots time use• ↓ Activities• Use despite probs• Craving


• Failed roles• Hazardous use• Social problems

Substance Use Disorder II


This Lecture Covers


• Goals of monitoring abstinence and detectionGoals of monitoring abstinence and detection




Goals of Monitoring Abstinence• Improve treatment outcomes by:

• Improving treatment compliance

• Verifying prescribed substance usage

• Detecting problematic usage

• Safety

• Objective is NOT punitive


Detection• When and how are dependent on what

• Both are determined by drug

• Absorption – how and how much drug enters

• Distribution – where drug goes in body

• Metabolism – what body does to drug

• Elimination – how drug is eliminated


Detection II• Strategies• Detect chemical itself• Detect metabolites• Detect secondary effects

• Detection can be chemical or electrical within• Blood• Breath• Sweat• Hair• Urine


This Lecture Covers



• Abstinence monitoring substance examplesAbstinence monitoring substance examples



Monitoring Abstinence - Breath• Advantages

• Easy, non-invasive

• Cost – reusable device

• Disadvantages

• Must be done properly

• Possibly non-specific


Draeger Alcotest

Monitoring Breath - Alcohol• Alcohol is water soluble & appears in breath

• Electrochemical detection (burns alcohol)

• Deep breath is proportional to blood level

• Detects low [alcohol] (1 drink in past hour)


Monitoring Breath - Nicotine• CO from burning tobacco in breath

• Electrochemical detection (burns CO)

• Detected up to 2 dys; “smoker” sensitivity < 10 hrs


Monitoring Abstinence - Urine• Advantages• Easy to obtain/non-invasive

• Detection via specific antibodies

• Common and inexpensive

• Disadvantages• Positive test → expensive replication

• Replication takes weeks to get results

• Specific drugs detected for different time lengths

• Cheating


Monitoring Abstinence – Urine II• Urine drug screen• Specific antibody screening for substances/byproducts• Many substances can be screened in a single test


Times for Useful Urine Monitoring

• Opioids – 1-3 days

• Cannabinoids

• Single use – 3 days

• Daily – 10-15 days

• Heavy – >30 days

• Amphetamines – 2 days

Detection Times

• Cocaine – 2-4 days

• PCP – 8 days

• Alcohol – ¼ - ½ day

• Sedatives

• Short-acting – 3 days

• Long-acting – 30 days


A Problem With Urine Monitoring• Cheating• Adulterants - substances added to urine sample• Dilution - intentional fluid over-ingestion• Substitution - use of another’s, old, or synthetic urine• False attribution - claimed use of one to hide another


Monitoring Abstinence - Blood• Advantages

• Highly specific → confirm other tests

• Difficult to cheat, low false positives

• Direct and indirect measurements possible

• Disadvantages

• Invasive – requires a blood draw

• Expensive – includes testing and procedure fees


Monitoring Blood - Alcohol• Alcohol: Blood Alcohol Concentration

• Direct detection of alcohol

• Limited to recent consumption only

• Alcohol: Carbohydrate deficient transferrin (CDT)

• Indirect marker - ↑ alcohol > 2 wks → ↑ CDT

• Timing: abstinence → ↓ CDT in 2-5 weeks


Monitoring Blood - Cannabis• Direct detection of cannabinoids

• Acute use: peaks in min, ↓ <1 hr but > 0 for 1 day

• Chronic: detectable up to 30 days


Monitoring Abstinence - Sweat• Advantages

• Largely non-invasive

• Relatively tamper resistant

• Can be done chemically and electronically

• Wide variety of substances can be detected

• Disadvantages• Positive test → expensive replication

• Difficult to quantify

• Unclear effects of exercise → ↑sweat


Monitoring Sweat - Chemical• Swab collection

• Primarily to verify intoxication

• Detects recent usage only (<24 hours)

• Patch collection

• Detection over longer time window (1-2 wks)

• May provide a cumulative measure of the interval

• Possible for drugs to be re-absorbed


PharmaChem Patch

Monitoring Sweat - Electronic• Advantages

• Continuous monitoring

• Data can be monitored remotely

• Disadvantages

• Intrusive and highly visible

• Expensive

• Optimized for forensics


Sweat Monitoring - Alcohol

• Alcohol → sweat

• Samples every 30 minutes

• Automatic alerts

• Tamper Resistant

• Cost

• Lease: $6-8/day lease

• Purchase: $1,400-1,800 + $5/day


Monitoring Abstinence - Other Hair• Advantages• Chemical detection• Long-term use patterns• Non-invasive• Limited cheating

• Disadvantages• Limited substances• No acute intoxication• 1 week until detection• + → $$$ confirmation

Saliva• Advantages• Chemical detection• Acute intoxication• Non-invasive• Limited Cheating• Sensitive

• Disadvantages• Short detection time• + → $$$ confirmation


Monitoring Other - ExamplesHair

• Drug → follicles → hair• ~100 hairs cut by scalp• Detects• Cocaine• Amphetamines• Opiates• PCP• THC• Ecstacy

Saliva

• Drug → blood → saliva• Pad placed in cheek• Detects• Cocaine• Amphetamines• Opiates• PCP• THC• Sedatives


This Lecture Covers




• Efficacy of monitored abstinenceEfficacy of monitored abstinence


Methadone Maintenance• Goal: ↓ health risk, ↓ crime, ↑ family/job

• Replacement: methadone vs heroin• Lasts >24hours → 1x/day dosing

• Allows work; avoids withdrawal and prevent “high”

• Cheaper & from clinic → ↓ risky acts, ↓crimes

• Highly structured and federally regulated• Administer methadone daily, usually at clinic

• Monitor for abstinence – urine drug screens

• Requires counselling


Methadone Maintenance Efficacy• 3x ↑ Remain in Rx vs no opiate replacement

• 2/3x ↓ Positive opioid hair/urine samples

• 2 ½x ↓ Crime involvement


Chronic Pain Management• Goal: control pain, minimize substance misuse• Adherence monitoring and risk minimization• Explicit behavior agreements

• Estimate risk

• Use difficult-to-misuse medications

• Rx drug monitoring programs• Urine drug screens

• Success → continue in program

• Failure → lose access to prescription opioids


Chronic Pain Management Efficacy

• Urine drug testing → ↓ illicit drug usage

• ↑ Urine drug tests → ↑ prescription adherence

↓ non-Rx medications


Court Mandated Rx• Goal: ↓ drug use → ↓ crime

• Links highly structured Rx to legal system• Residential and outpatient treatment

• Random urine drug screens

• Routine judicial interaction and progress monitoring

• Success → avoid jail

• Failure→

• ↑ Monitoring frequency/intensity

• ↑ Punishment up to jail© Alcohol Medical Scholars Program 34

Court Mandated Rx Efficacy• 12% ↓ Criminal relapse

• No clear effect on SUD outcomes

• Difficult to quantify

• Highly variable population

• Different Rx approaches/referral networks


Physician Health Programs• Goal: ↓ patient harm• Links highly structured Rx to medical license• Residential and outpatient treatment• Random urine drug screens• +/- Random office visit• ≥5 Yr follow-up • Success → practice medicine, keep job• Failure →• Treatment, ↑monitoring frequency/intensity• Referral to medical licensing board


Soberlink Blue Device System


Physicians Health Programs Efficacy

• Only ~20% w/ +UDS at any time during 5 yrs

• 70-80% Physicians still licensed/employed at 5 yrs


Summary

• SUDs are chronic relapsing/remitting conditions

• Abstinence monitoring is therapeutic

• Monitoring can be chemical and electronic

• Monitored abstinence → better outcomes


Questions


Monitoring Abstinence Martin H. Plawecki MD, PhD Indiana University School of Medicine Department of...

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