The Growing
Problem of
Substance Abuse
in the U.S.
By Laura Perches-Roberts, MD, and Bertram W. Roberts, MD, DrPH, MHA
In America, here are an estimated 18 million alcoholics
and five million illicit drug abusers who need treatment,
but these numbers seem to be increasing. The total economic
burden is $450 billion including incarceration,
crime, treatment of the problems and complications.
However, there are only 11,000 providers (counselors,
doctors, therapists) to treat 1,000,000 heroin and multidrug
users daily. About 1.6 million drug and alcohol users
enter programs each year, 83 percent as outpatients in a
counseling setting. According to the DEA at a recent USA
Opiate Treatment Program meeting in San Antonio, the
extent of illicit prescription drug abuse is unknown and
there is no plan on how to stop the increase. Hydrocodone
ranks in the top 10 causes of ER visits and deaths in the US.
The risk for youth to become drug abusers is high and
increases from primary schools (5 percent) to middle
school (10 percent) to high schools (20 percent) depending
on area and socioeconomic conditions.
In some communities such as San Antonio, many young
people start their addiction in their early teen years due to
the availability of prescribed addictive drugs in their home
taken by their parents. “Pharm parties” introduce them to
more drugs and they use uppers, downers and alcohol regularly
without their parents’ knowledge or consent. Available
on the street and in schools are all the illicit and prescribed
agents, so it becomes a matter of acquisition. “Cheese”
heroin which is colored and mixed with ephedrine is now
popular for distribution in primary schools to get kids started
early and fast.
Because HIV and Hepatitis C are complications of IV
drug use (and not pills or snorted heroin) teen users think
they can handle these drugs and still do sports, schoolwork
and be productive — and they often can for a while until
they fail, drop out, become pregnant or are arrested. The
fact that they are less than 18 years of age complicates their
therapy since they cannot be treated in standard substance
abuse clinics and must seek other outpatient facilities which
limit client number and may be costly.
Just like in adults, the use of methamphetamine, marijuana,
cocaine and other designer drugs make management
extremely difficult since they are often cheap and available
everywhere.
Fortunately, medical treatment for opiate abuse and
dependence for those 18 years or over has proven very successful
with the recent development of buprenorphine
agents (Suboxone), and these drugs have the potential for
opening a new era for long-term management by primary
care doctors in their offices.
More than four million addicts are in “jurisdiction of the
criminal justice system” (under observation by the court)
and two million addicts are incarcerated in the US every
year! More than one-half of criminal offenses committed in
the U.S. are drug related.
Studies find positive urine drug screens in 2/3 (66 percent)
of arrestees. If untreated, 9 of 10 (90 percent) return
to drugs and crime. Average jail “time” for drugs is 75.6
months, compared to 63 months for violent felonies. A
lot of college tuitions could be paid with the costs of
incarceration of drug users!
EVALUATION OF PATIENTS FOR SUBSTANCE ABUSE:
A CASE HISTORY (an example of the problem facing the practitioner):
Carole, 42 years of age, a divorced
RN with two children, admits to taking
10-15 opiate analgesic tablets (Oxycontin)
each week for migraine headaches
from GYN and recurring back and pelvic
pain she says is due to endometriosis.
As her primary doctor, she is requesting
from you a refill since she could
not sleep last night and had to take an
aprazolam tablet that she had been
prescribed several years before. She
declines to discuss her current personal
relationships because of “legal issues.”
She has a history of drug use since
early in high school, but denies ever
having shot up heroin in the past. She
currently denies using cocaine, amphetamines
or crystal meth, but says she
has asthma for which she takes over the
counter medication and she thinks that
this contains “ephedrine.” She denies
alcohol use except as a “social drinker.”
She is employed as an office manager
at a private physician’s office. There is
no personal history of HTN.
PE: BP-170/115, P-95 regular, Wt: 120
lbs, Ht: 5’6”, T-98.6, R-24
HEENT- negative except for slightly
dilated pupils bilaterally. Thyroid is
not enlarged, no jugular venous distention
or thyroid enlargement, with
clear lungs sounds and RR heart without
rubs or gallops. Abdomen is soft
and bowel sounds are active. Liver
and spleen are not enlarged but pain
is present in the Right Lower Quadrant.
She has no tract evident on her
upper or lower extremities.
Lab including CBC, U/A and Chem
20 are negative except slightly elevated
liver enzymes. Pt says she has never
used IV drugs, and she says she has
been tested recently for Hepatitis A, B,
C and HIV about one year ago and
these were all negative.
True or False
1. Doing a urine drug screen will
not help since she admits to taking
an opiate medication.
False: A drug screen will identify recent
opiates and can distinguish which type,
and most identify methadone which is
now also a common street drug. More
testing can distinguish ephedrine from
amphetamine, check for occult cocaine
abuse as well as marijuana and benzodiazepines.
If there is question of this
being someone else’s urine, then an “observed urine” should be obtained
and the urine temperature recorded. If
there is a question of validity, it should
be repeated randomly with a similar
controlled situation. The bottom line is
that the urine drug screen should be
consistent with the story and details are
critical. If equivocal results appear, then
further chemical tests can be done, and
include other tissues.
2. If the urine drug screen is done
and shows amphetamines, benzodiazepines
and opiates (no cocaine
or marijuana) and she has the
medication bottles to prove the
sources, the prescription for oxycontin
can be written.
False: It would be premature since
there should be documentation of the
endometriosis by GYN, the details of
her opiate pill use by her pharmacy,
other MDs, and a review of her licensure
status by the Board of Nursing.
In addition, consideration of the
underlying causes of her abnormal liver
enzymes (gall bladder disease, ethanol,
fatty liver, Tylenol toxicity) should be
planned and discussed. The fact that
she has dilated pupils makes opiate
withdrawal a strong consideration.
Cocaine and amphetamines are negative
on the urine drug screen, so
detailed questioning about the withdrawal
symptoms from opiates is indicated
before a prescription is written.
Common ones are “goose flesh”, yawning,
diarrhea, irritability, decreased
appetite, difficulty sleeping and most
often, dilated pupils.
Finally, the fact that this patient
will not confide details about “legal”
or any historical issues should make
the physician very hesitant to comply
with any patient’s request for opiates.
There is a very low mortality from
opiate withdrawal, although patients
feel like they will die.
Heroin
The increasing purity of imported
heroin has made it easier to use by
non-injection routes such as ‘snorting’
and smoking. Heroin addicts in San
Antonio use from $50 to $300 per day
(average about $100/day) so that their
entire life becomes “looking for the
money to support their habit.”
Bexar County has an estimated
10,000 heroin addicts, with only
about 2,000 currently receiving methadone,
which costs about $10/day and
is not supported by the state. Government
supported methadone clinics
charge only $2.50 per day for an initial
period of time but the number
admitted to these programs are very
limited and depend on funding cycles.
The South Texas VA has no methadone
program!
There are estimated to be at least
1,000,000 heroin addicts in the U.S.,
and only 20 percent are, at any one
time, under treatment on methadone.
In America and in Texas, heroin users
are more likely to be educationally disadvantaged,
male, Hispanic or Black
and young, but the demographics are
shifting to more Caucasian, older and
female users.
One in four heroin abusers has co-morbid depression, anxiety, PTSD or
psychosis. About four years after beginning
use, the psychosocial and physical
consequences of drug use become
manifest. Although the documented
major income source for 30 percent of
drug users is public assistance, it is
seen that many heroin addicts must
steal or prostitute to support their
habit. Interestingly, about 70 percent
of heroin addicts self-refer for methadone
or buprenorphine treatment usually
because they are exhausted or “sick,”
in financial and social ruin, with Hepatitis
C, HIV or other associated health
problems. They have “lost control of
their lives” to the opiates. They said “it
is like arm wrestling with King-Kong!”
PRESCRIPTION OPIATE
ANALGESIC ABUSE
Abuse of prescription opiates
should be suspected when:
a) There is a pattern of early and/or
frequent refills opiate containing
analgesic medications
b) There are inappropriate therapy
or dose escalations of opiate analgesics
c) There are reports of frequent
lost, spilled or stolen medications.
d) The patient is taking large
amounts of analgesic opiate medications
and exhibits behavior
which is consistent with abuse or
dependence criteria. (See Appendix)
Note: Illicit prescription writing is
currently under intense investigation by
the DEA, especially the medication filled
by offshore internet pharmacies.
When you suspect analgesic
opiate abuse
• As part of the history, review all
medications given for pain and contact
other clinics, pharmacies or
physicians as necessary.
• If the patient has hepatitis or HIV,
look for needle tracts.
• Use the criteria for Substance Abuse
and Dependence (Appendix )
• If your patients are on high doses of
opiates and meet the criteria for
abuse or dependence, consider
referral for drug testing, substance
abuse consultation, methadone or
buprenorphine/naloxone maintenance
therapy.
TREATMENT
Methadone Maintenance
Treatment (MMT)
Methadone maintenance therapy
offers major pharmacologic benefits,
such as alleviation of physical withdrawal,
opioid craving and blockade of the
euphoric effects of outside opioids.
MMT Programs are all licensed by the
state and federal government. Not only
is methadone dispensed at the MMT or
Opiate Treatment Programs (OTPs), but
also provide monthly licensed counseling
sessions and regular physician visits.
Psycho-social issues and medical
treatment issues also are discussed and
referrals to agencies and specialists arranged.
Quality evaluations of all MMTs
are required by all credentialing agencies
such as CARF or JACHO just like hospitals,
although they receive no funds
from Medicare or Medicaid in Texas.
Research for more than 40 years on
methadone use consistently shows
improvements in family stability,
decreased number of hospital admissions,
more regularity of medical and
dental care among clients, decreased
criminal activity and incarceration; and
increased percentage of clients entering
vocational rehabilitation.
In methadone clinics, patients come
daily for doses averaging about 65 mg
per day, but can receive regular take
home doses up to one week if they
meet certain strict criteria which
include regular urine drug testing that
is clean of use of other drugs.
Methadone is still the treatment of
choice for pregnant opiate dependent
patients.
There are more than 90 methadone
clinics in Texas, and five are in San
Antonio. The newest clinic, located
near the South Texas Medical Center at
3780 NW Loop 410, is STOP-SA, LLC.
Office Buprenorphine Treatment
Now Available
In 2002, the FDA division called
Substance Abuse and Mental Health
Service Agency (SAMHSA) approved
2 sublingual formulations of a new
Schedule III opiate partial agonist
medication Subutex, (buprenorphine)
and Suboxone (buprenorphine/naloxone)
for office-based use by physicians.
The approval of this drug for prescription
use was in part due to the alarming
increase in opioid analgestic abuse,
which has more than doubled in the
last 10 years.
Buprenorphine can be used on an outpatient
basis by physicians who take
a one day course and apply for a special
DEA designation on their BNDD
number.
Suboxone is a partial agonist at the Ì (pain) receptors. As such, it activates
the receptor, but does not produce as
great an effect as does a full agonist,
like methadone, especially as the dose
is increased. Since the therapeutic ceiling
can be reached at moderate doses
it is much safer, yet very effective.
Physicians who use this drug find it
the best treatment for all opiate addiction.
Unfortunately, it is currently
more expensive than methadone for
those without health insurance. Most
insurances, including Medicaid cover
the drug “off-formulary.”
Suboxone is given sublingually, is
combined with naloxone, and if diverted,
cannot be ground up and injected.
Since the naloxone is a full antagonist to
opiates, it will cause a violent withdrawal
if given IV. Physicians who qualify to
prescribe this drug currently are limited
to a maximum of 100 patients under
treatment at any one time.
APPENDIX
Criteria for the Diagnosis of
Substance Abuse/Dependence
A. Abusemaladaptive pattern of substance use
leading to clinically significant impairment
or distress, as manifested by
(one or more in a 12 month period)
of the following:
1) Failure to fulfill a major role at
school, work or home
2) Results in physically hazardous
situations
3) Results in legal problems
4) Results in recurrent interpersonal,
social or legal problems
B. Dependence also is characterized
by a maladaptive pattern of substance
use leading to clinically significant
impairment or distress, but is manifested
by (three or more in a 12
month period) of the following:
1) Tolerance – an increasing
amount of the substance needed to
achieve intoxication or the same
effect or the markedly diminished
effect with continued use of the
same amount.
2) Withdrawal
a) If there are characteristic
withdrawal symptoms for that
substance or,
b) If the same substance is
taken to relieve/avoid the withdrawal
symptoms.
3) The substance is taken in larger
amounts over a longer period than
expected.
4) There are repeated unsuccessful
attempts to cut down or quit.
5) There is much time spent on
activities necessary to obtain the
substance, use the substance or
recover from its effects.
6) There are important social,
occupational or recreational activities
that are given up or reduced
because of substance use.
7) The substance use is continued
despite knowledge of having a persistent
or recurrent physical or psychological
problem that is likely to
have been caused or exacerbated
by the substance.
COMMUNITY OUTREACH AND PREVENTIVE
EDUCATION (COPE)
More than 50 percent of Texas high school students have used one illicit
drug, more than 25 percent have used 2-3, and more than 10 percent have
used more than four! Experts talk about the need to begin drug prevention
education for 8 year olds!
STOP-SA has initiated this non-profit program Community Outreach &
Preventive Education (COPE) Project which has as its goals:
• to teach youth and adults about the negative consequences of drug use
• to help those already using drugs get treatment through timely referrals
• to help those on treatment avoid returning to drugs by establishing mentoring
relationships
• to build a team of community outreach workers
Anyone interested in helping (funds or volunteer time) should contact
STOP-SA, LLC at (210) 736-4405 or (210) 643-3692 or drbroberts@gmail.com.
STOP-SA
3780 NW Loop 410
San Antonio, TX 78257
info@stopsa.com
Laura Perches-Roberts MD, is a boardcertified
psychiatrist and the medical
director of STOP-SA.
Bertram W. Roberts, MD, DrPH, MHA,
is administrator of STOP-SA, LLC, and
an associate professor of medicine at
UTHSCSA.
