Monitored Abstinence
Martin H. Plawecki MD, PhD
Indiana University School of MedicineDepartment of Psychiatry
Alcohol Medical Scholars Program
Introduction• Many diseases are chronic, relapsing and 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
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Goals of SUD Treatment
• Harm reduction
• Abstinence
• Abstinence monitoring has a role in both
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This Lecture Covers
• Definition/course of Substance Use Disorders (SUDs)
• Treatments, including with monitored abstinence
• Methods of monitoring abstinence
• Efficacy of monitored abstinence
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This Lecture Covers
• Definition/course of Substance Use Disorders (SUDsDefinition/course of Substance Use Disorders (SUDs)
• Treatments, including with monitored abstinence
• Methods of monitoring abstinence
• Efficacy of monitored abstinence
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Substance Use DisorderIn Same Year, ≥2 of:
• Tolerance• Withdrawal• Use longer/more• Unable to ↓• Lots time use• ↓ Activities• Use despite probs• Craving
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• Failed roles• Hazardous use• Social problems
Remission and Relapse
• Remission
• Early: no symptoms ≥ 3 months but < 1 year
• Sustained: no symptoms ≥ 1 year
• Relapse: back to problematic substance use
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Substance Use Disorder
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Post Recovery
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>26 % 7 %
Within 3 years
This Lecture Covers
• Definition/course of Substance Use Disorders (SUDs)
• Treatments, including with monitored abstinence
• Methods of monitoring abstinence
• Efficacy of monitored abstinence
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Treatment• General treatments
• 12-step programs: Alcoholics Anonymous (“AA”)• Cognitive behavioral treatment (CBT)
• Alcohol Rx meds examples• Naltrexone• Acamprosate
• Opioid Rx meds examples• Naltrexone• Buprenorphine• Methadone (to be discussed below)
• Many treatments include abstinence monitoring
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12 step programs (e.g., Alcoholics Anonymous)
• Goal: commonly abstinence
• Self-help recovery group
• Very common: ~50 meetings/day in Indianapolis
• Difficult to study given program nature
• AA keeps people in and accepting of intervention
• Limited-unequivocal evidence for ↑abstinence
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Cognitive Behavioral Therapy: (The Core of Rehab Rx)• ↓ Dysfunctional thinking
• Substitute rational thoughts
• Relapse prevention
• Anticipate triggers
• Learn to cope w/triggers
• Change behaviors
• Evidence for ↓drinking/use, ↑abstinence© Alcohol Medical Scholars Program 13
Alcohol Rx - Naltrexone• Goal: reduce drinking
• Thought to reduce enjoyment of alcohol
• Daily and long-acting injectable forms
• Reduces drinking
• Return to heavy drinking ↓17%
• Return to any drinking ↓4% → ↑abstinence
• Drinking days ↓4%
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Alcohol Rx - Acamprosate• Goal: reduce drinking
• Thought to reduce withdrawal
• Oral only (3x/Day)
• Reduces drinking
• Return to heavy drinking ↓1%
• Return to any drinking ↓14% → ↑abstinence
• Abstinence duration ↑11%
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Opioid Rx - Naltrexone• Goal: commonly abstinence
• Blocks all opioid highs
• Daily and long-acting injectable (LAI) forms
• Not well accepted by patients → high drop out
• May be especially useful for docs, nurses, etc
• Daily – some evidence for ↑abstinence, ↑ Rx
• LAI - emerging Data for ↓ heroin, ↑abstinence, ↑ Rx
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Opioid Rx – Buprenorphine Maintenance• Goal: abstinence (harm reduction)
• Long-acting opioid replaces short-acting heroin
• Daily medication
• Increases treatment acceptance - ↑50%
• Decreases heroin and morphine usage• ↓17% vs placebo, ↓11% vs methadone
• Dose dependent effect (↑dose → ↑results)
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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 bx, ↓crimes
• Highly structured and federally regulated• Administer methadone daily, usually at clinic
• Monitor for abstinence – urine drug screens
• Requires counselling
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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 19
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
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Chronic Pain Management• Goal: control pain, minimize substance misuse• Adherence monitoring and risk minimization• Explicit behavior agreements
• Estimate risk
• Use difficult-to-abuse medications
• Rx drug monitoring programs• Urine drug screens
• Success → continue in program
• Failure → lose access to prescription opioids
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This Lecture Covers• Definition/course of Substance Use Disorders (SUDs)
• Treatments, including with monitored abstinence
• Methods of monitoring abstinenceMethods of monitoring abstinence
• Efficacy of monitored abstinence
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Monitoring Abstinence - Breath• Advantages
• Easy, non-invasive
• Cost – reusable device
• Disadvantages
• Must be done properly
• Possibly non-specific
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Monitoring Breath Alcohol & Nicotine• Breath alcohol concentration• Alcohol is water soluble -> appears in the breath
• Electrochemical detection (burns alcohol)
• Deep breath is proportional to blood level
• Detects low alcohol concentration (1 drink in last hour)
• Nicotine• Carbon monoxide (CO) from burning tobacco in breath
• Electrochemical detection (burns CO)
• Detected up to 2 days; “smoker” sensitivity < 10 hours
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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
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Monitoring Abstinence - Urine• Urine drug screen• Specific antibody screening for substances/byproducts• Many substances can be screened in a single test
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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
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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
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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
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Monitoring Blood Alcohol and Cannabis
• 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
• Cannabis• Direct detection of cannabinoids• Acute use: peaks in minutes, ↓ <1 hr but > 0 for 1 day• Chronic: detectable up to 30 days
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Monitoring Abstinence - Electronic• Advantages
• Continuous monitoring
• Data can be monitored remotely
• Disadvantages
• Intrusive and highly visible
• Expensive
• Optimized for forensics
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Electronic Monitoring - Scram
• Alcohol → sweat
• Samples every 30 minutes
• Automatic alerts
• Tamper Resistant
• Cost
• Lease: $6-8/day lease
• Purchase: $1,400-1,800 + $5/day
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This Lecture Covers
• Definition/course of Substance Use Disorders (SUDs)
• Treatments, including with monitored abstinence
• Methods of monitoring abstinence
• Efficacy of monitored abstinenceEfficacy of monitored abstinence
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Efficacy of Monitored Abstinence• Methadone clinic
• 3x ↑ Remain in Rx vs no opiate replacement
• 2/3x ↓ Positive opioid hair/urine samples
• 2 ½x ↓ Crime involvement
• Chronic Pain Management
• Urine drug testing → ↓ illicit drug usage
• ↑ Urine drug tests → ↑ prescription adherence
• ↑ Urine drug tests → ↓ non-prescribed medications
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Efficacy of Monitored Abstinence• Court mandated Rx• 12% ↓ Criminal relapse
• No clear effect on SUD outcomes• Difficult to quantify
• Highly variable population
• Different Rx approaches/referral networks
• Physicians health programs• Only ~20% w/ positive UDS at any time during 5 yrs
• 70-80% Physicians still licensed/employed at 5 yrs
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Summary
• SUDs are chronic relapsing/remitting conditions
• Interventions can include abstinence monitoring
• Monitoring - chemical and electronic forms
• Monitored abstinence → better outcomes
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Questions
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