1. Monitoring Abstinence Martin H. Plawecki MD, PhD Indiana University School of Medicine Department of Psychiatry Alcohol Medical Scholars Program

2. 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 Program2

3. Goals of SUD Treatment Harm reduction Abstinence Abstinence monitoring has a role in both © Alcohol Medical Scholars Program3

4. This Lecture Covers Definition/course of Substance Use Disorders (SUDs) Goals of monitoring abstinence and detection Abstinence monitoring substance examples Efficacy of monitored abstinence © Alcohol Medical Scholars Program4

5. This Lecture Covers Definition/course of Substance Use Disorders (SUDs) Definition/course of Substance Use Disorders (SUDs) Goals of monitoring abstinence and detection Abstinence monitoring substance examples Efficacy of monitored abstinence © Alcohol Medical Scholars Program5

6. Substance Use Disorder In Same Year, ≥2 of: Tolerance Withdrawal Use longer/more Unable to ↓ Lots time use ↓ Activities Use despite probs Craving © Alcohol Medical Scholars Program6 Failed roles Hazardous use Social problems

7. Substance Use Disorder II © Alcohol Medical Scholars Program7 Abstinence Controlled Use Problems

8. This Lecture Covers Definition/course of Substance Use Disorders (SUDs) Goals of monitoring abstinence and detection Goals of monitoring abstinence and detection Abstinence monitoring substance examples Efficacy of monitored abstinence © Alcohol Medical Scholars Program8

9. Goals of Monitoring Abstinence Improve treatment outcomes by: Improving treatment compliance Verifying prescribed substance usage Detecting problematic usage Safety Objective is NOT punitive © Alcohol Medical Scholars Program9

10. 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 © Alcohol Medical Scholars Program10

11. Detection II Strategies Detect chemical itself Detect metabolites Detect secondary effects Detection can be chemical or electrical within Blood Breath Sweat Hair Urine © Alcohol Medical Scholars Program11

12. This Lecture Covers Definition/course of Substance Use Disorders (SUDs) Goals of monitoring abstinence and detection Abstinence monitoring substance examples Abstinence monitoring substance examples Efficacy of monitored abstinence © Alcohol Medical Scholars Program12

13. Monitoring Abstinence - Breath Advantages Easy, non-invasive Cost – reusable device Disadvantages Must be done properly Possibly non-specific © Alcohol Medical Scholars Program13 Draeger Alcotest

14. 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) © Alcohol Medical Scholars Program14

15. Monitoring Breath - Nicotine CO from burning tobacco in breath Electrochemical detection (burns CO) Detected up to 2 dys; “smoker” sensitivity < 10 hrs © Alcohol Medical Scholars Program15

16. 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 © Alcohol Medical Scholars Program16

17. Monitoring Abstinence – Urine II Urine drug screen Specific antibody screening for substances/byproducts Many substances can be screened in a single test © Alcohol Medical Scholars Program17

18. 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 © Alcohol Medical Scholars Program18

19. 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 © Alcohol Medical Scholars Program19

20. 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 © Alcohol Medical Scholars Program20

21. 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 © Alcohol Medical Scholars Program21

22. Monitoring Blood - Cannabis Direct detection of cannabinoids Acute use: peaks in min, ↓ 0 for 1 day Chronic: detectable up to 30 days © Alcohol Medical Scholars Program22

23. 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 © Alcohol Medical Scholars Program23

24. 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 © Alcohol Medical Scholars Program24 PharmaChem Patch

25. Monitoring Sweat - Electronic Advantages Continuous monitoring Data can be monitored remotely Disadvantages Intrusive and highly visible Expensive Optimized for forensics © Alcohol Medical Scholars Program25

26. 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 © Alcohol Medical Scholars Program26

27. 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 © Alcohol Medical Scholars Program27

28. Monitoring Other - Examples Hair 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 © Alcohol Medical Scholars Program28

29. This Lecture Covers Definition/course of Substance Use Disorders (SUDs) Goals of monitoring abstinence and detection Abstinence monitoring substance examples Efficacy of monitored abstinence Efficacy of monitored abstinence © Alcohol Medical Scholars Program29

30. 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 © Alcohol Medical Scholars Program30

31. Methadone Maintenance Efficacy 3x ↑ Remain in Rx vs no opiate replacement 2/3x ↓ Positive opioid hair/urine samples 2 ½x ↓ Crime involvement © Alcohol Medical Scholars Program31

32. 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 © Alcohol Medical Scholars Program32

33. Chronic Pain Management Efficacy Urine drug testing → ↓ illicit drug usage ↑ Urine drug tests → ↑ prescription adherence ↓ non-Rx medications © Alcohol Medical Scholars Program33

34. 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 Program34

35. Court Mandated Rx Efficacy 12% ↓ Criminal relapse No clear effect on SUD outcomes Difficult to quantify Highly variable population Different Rx approaches/referral networks © Alcohol Medical Scholars Program35

36. 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 © Alcohol Medical Scholars Program36

37. Soberlink Blue Device System © Alcohol Medical Scholars Program37

38. Physicians Health Programs Efficacy Only ~20% w/ +UDS at any time during 5 yrs 70-80% Physicians still licensed/employed at 5 yrs © Alcohol Medical Scholars Program38

39. Summary SUDs are chronic relapsing/remitting conditions Abstinence monitoring is therapeutic Monitoring can be chemical and electronic Monitored abstinence → better outcomes © Alcohol Medical Scholars Program39

40. Questions © Alcohol Medical Scholars Program40