Youth Pill and Pot Abuse and SBIRT

SBIRT for youth - pills and pot

Primary care approaches to Screening, Brief Intervention and Referral to Treatment

Dr. Sharon Cirone MD CCFP(EM) ASAM (Cert)

Presentation given at Canadian Society of Addiction Medicine 2013 - Vancouver

This was a superb presentation that was very useful from a clinical perspective.  It was challenging and encouraged more active consideration of use of tools and organized thinking in the office.  Well researched, extremely well presented, and very informative and obviously coming from a lot of thought and experience. These are my rough notes which I hope will give some idea of the depth and breadth of material.

Youth Alcohol and Substance Abuse

greater than 50% past year

greater 30 % use illicit drugs

-22% marijuana

Harms of Youth Alcohol and Substance Abuse

-Impact on

-academic achievement

Sexuality, family, mental health

Alot of Concurrent Mental Health Disorder

Teen Age Brain Development and Vulnerability to Drug Use

-the later the youth puts off substance abuse the less likely the child will go onto to develop addiction in adult hood

-teen age brain more developped in ‘risk taking’ than ‘consequence consideration’ given the evolutionary development - to move out of home and into wild

The Harm of Youth Cannabis Use

-increasing presentations of cannabis induced psychosis

-exploring the link

-increased access with new legislation

“I’m a consultant to a hospital youth unit and at least once a month see cannabis induced psychosis”

Access to Prescription Opioids

-nomedical use of opiods by youth

• youth start by accessing opioids in home cabinets

SBIRT -Calling All Youth - Raise the Subject!  Develop a specific approach! Support a youth friendly environment!

Primary Care

ASK

-while you are here, can I ask you few questions?

-how is school/work going

-how are things at home

-have you ever had alcohol to drink

-have you ever smoked marijuana or hash

-have you ever used pills or other drugs to get high

-have you ever driven in the car of a driver who had used alcohol or drugs?

What next?  SBIRT

Universal Screening

Brief Intervention

Referral to Treatment

This is for all 12 and up youth - ask all , no matter what they present with

Primary care offers a “teachable moment in a confidential setting”

Collaborative interventions are congruent with adolescent development 

-motivational interviewing is - collaborative - youth have skills to build on 

Brief Interventions with Youth Work

Decrease alcohol and substance us - Breslin research

www.youtube.com SBIRT in Pediatrics

www.mcpap.com/pdf/CRAFFT

Screening CRAFFT

Have you ever ridden in a CAR drivine by someone ‘high’ or 

Do you ever use alcohol to RELAX

etc

Making Screening Easier

-Pre printed questioniones in the waiting room or handed out

-put CRAFT on your desktop to ask

PRAISE and EDUCATION

-if adolescent says they’ve not used - praise and say how good they’re doing - hope you keep it up!

-if low risk -ask more questions -advise of brain development effects -  some praise with ‘lets talk about low risk drinking guidelines 

CASE PRESENTATION of low risk 15 year old brought in by mother for stealing money from her wallet for once a week marijuana use ‘he’s on drugs’ 

“if you tell me you’re dealing drugs I’m not going to report this however is you are using your seven year old sister with you to deal crack I’m going to have to disclose - set limits of confidentiality”

Affirm - I appreciate you have really considered this and are making some smart decisions regarding marijuana (eg not carrying it to school, not driving with it, etc, whatever positive you’ve heard)

Advice “As a physician, for your health sake, I strongly advise you against use of marijuana”

Open Ended Questions - we both know that only you can decide about how often and how much you smoke marijuana - what do you thihnk is best. 

What if things are more complicated? Moderate or High Risk Use

Moderate Risk - brief Motivational Intervention -and/or referral

High risk - Refer

Use with Risk - Assess

-can you tell me more  about your use

how often

has it caused any problems

have you ever tried to cut down or quit

Do you think you wnat to change anything

Assess

Affirm - give positive feedback on healthy decisions

Risk/Confidence assessment

On scale of 1 to 10 how interested are you in changing

On scale of 1 to 10 how confident are you in your ability to risk

Advice - abstience challenge, discuss harm reduction, provide psychoeducation

Assist - Motivational Interviewing, Weigh Pros and Cons, Discuss and write down action plan

Arrange - provide hand out , web based resources, discuss/make referrals

Video used to show brief interventions for a primary care clinician to use with a high risk youth who has reported high risk in context of presenting premenstrual pain and admitting using percocets for the pain

-primary care physician and actor

Decisional Balance Tool

-Worksheet

1. Things I like about....
2. Things I don’t like about

c)

d)

Send patient home with homework

Referral to Treatment

-further assessment - youth community alcohol and substance use counselling services

-addiction medicine specialists

-mental health providers

Outpatient counselling

Day Treatment

Residential Treatment

Inpatient medical treatment

Take home message

Physicians need to ask

Future direction - we need alot more research and implementation of more SBIRT models

Physicians need to especially ask adolescents about marijuana

I care about you

I am concerned about you

I will be here for you

-Dr. Knight

Choosing Opiate Agonist Treatment

Choosing opioid agonist treatment

Dr. Meldon Kahan

Dr. Maya Nader

Dr. Anita Srivastava

Excellent presentation by three clinicians at the Canadian Society of Addiction Medicine annual meeting in Vancouver, 2013

These are my rough notes which hopefully give an idea of what was a very well presented, researched and clinically useful talk

Learning objections

initiation of opioid agonist treatment

 recent evidence regarding efficacy and side effects of buprenophine versus methadone

Opioid Agonist Treatment - OAT

-bruprenorphine USA 1980

-approved in Canada 2008

History of methadone

synthesized in germany in 1941

first methadone maitenance program in the world founded in Vancouver in 1967

Potential considerations

efficacy, safety, weight gain, mental clouding, sedation, sexual function, pain, withdrawal

Methadone more likely to retain patients than buprenorphine

With fixed medium dosing - buprenorphine less likely to suppress heroin desire

questions raised by cochrane review

-retention - was induction to buprenorphine too slow, etc

Stepped care approach

-Kakko 2007

Only 46% who started buprenorphine stayed and rest switched to MMT 

-treatment retention and urine screens and problems good with this group

Safety concerns

 buprenorphine considered safe

Bell 2009 , australia

QT intervals - evidence for prolonged QT - at higher dosages 200 to 300

Safety - Benzos

risk of overdose increased with any opiates

when benzo used with methadone or buprenorphine - methadone did poorer on benzo - Lintzeris et al 2007

Age

Opioids are a risk factor for fractures in the elderly and it’s dose related

Diversion - patients who use methadone nonmedically have higher hospitalizations rates, greater icu, poorer outcomes

Patient preference

-Summit Trial , Pinto et al 2010

patients preferred methadone 2:1

-subset wouldn’t go on methadone

main reason for choosing buprenorphine

-ease of detoxification

• more clear headed

Withdrawal severity may be less intense with buprenorphine - gowling et al, cochrane review 2009

At end of day similar relapse rates during withdrawal whether patient was on buprenorphine or methadone

PAIN

-Neuman, 2013 - equally reduced in methadone and buprenorphine

-suggested alot of pain related to addiction

Adolescent Heroin Users

-better treatment retention with methadone than buprenorphine

-better treatment retention with long term buprenorphine treatemnt versus detox or abstinence (bell, 2006;woody208,)

Weight Gain

-perception of greater weight gain with MMT

-non dose related increase in first 2 years - but when compared to general populations methadone patients less

-no different in weight gain between methadone and buprenorphine

review of patient blogs - mixed response

Mental Alertness/sedation

-both methadone and buprenorphine appear to affect mental alertness and sedation 

-up to 100 mg no difference - but greater than 100 mg more with methadone-winstock 2009

Driving

Increased risk of traffic accidents in both patients on MMT and BMT

Bup pts performed somewhat better on psychomotor tasks than methadone

No on road testing done 

Mood

-double blind controlled trial (n=150)  - showed improvement in mood on beck in all with no improvement of one over the other drug

Quality of Life

Beneficial effects for both

Early onset of benefits with Methadone versus Buprenorphine but both good

Sexual Function

MMT patients have more erectile dysfunction and lower testosterone levels than buprenorphine

Side Effects

-Summit Trial

greater proportion of MMT complained of sweating, seadation and constipation than buprenorphine

Programmatic differences

-contigency management differences

-patient randomized to buprenorphine in one post jail study - more flexible environment for buprenorphine versus MMT - resulted in better retention and follow up

Soft Factors

-factors other than intrinsic pharmacological 

-family/work obligations -strict MMT requirements associated with treatment to protect against overdose 

-lack of mobility 

-comorbities - tying care to family doctor - a diabetic have buprenorphine in office versus going to clinic

-patient receiving high oral opioid doses from one doctor only

-socially unstable, doesn’t follow up with appointments - methadone might have better retention rate

In states and france - buprenorphine can be prescribed by a family doctor in office versus the clinic based methadone

Buprenorphine has been used in patients who were iatrogenically addicted to opiates for pain management and they are more willing to take buprenorphine

Pregnancy

Methadone approved in pregnancy

buprenorphine/naloxone is not

-consider methadone for women at high-risk or planning a pregnancy

Funding 

-cost - buprenorphine more expensive than methadone

Q&A

Opiates can reduce testosterone and testosterone replacement and viagra can help

Paitents who are on heroin usually have poor sexual function and the majority have improvement with methadone maintenance

A Call for Evidence Based Treatment (in Addiction)

A Call for Evidence Based Treatment

Dr. Bohdan Nosyk  bnosyk@sfu.ca

-health economist with a research focus on substance abuse and infectious disease

Presented at the Canadian Society of Addiction Medicine Annual Meeting, Vancouver, BC 2013. These are my rough notes which only give a jist of the wealth of information presented. Dr. Nosyk has contributed to many papers and his slides were excellent often taking graphs from the research he’d published elsewhere. I hope that these notes though will direct someone to where they might find information they are looking for as well as give some idea of the depth and breadth and controversies in this area.

key recommendations

eliminate financial barriers

increase acces to office based

reduce reliance on detox treatment

evaluate integrate new technologies

increase surveillance, evaluation of quality of care

Background Epidemiology

US 2.3 million with opioid dependence 

75-125,000 injection drugs users; 200,000 people with prescription opioid dependence

Opioid overdose second leading cause of accidental death in US - surpassed only by MVA

In ontario deaths related to PO doubled

Treatment Options

Methadone

Buprenorphine

Methadone still more effective and less costly than buprenorphine

Nosyk et al, Am J of Epidemiology 2009

Primary finding was that patients with multiple treatment tended over time to stay in treatment and morbidity and mortality

Tends to be a pattern of increasing length of time in treatment

Abstinence durations were longer folllowing sustatined treatemn versu incarceration.  Paitents with multiple abstience episodes tend to go onto abstinence

OST has been deemed highly cost effective if not cost saving

often the cost of tratemnt are more than offset by recuction in acquisitive crime and use of health resourcs realted to transmission of HIV or Hep C

Diacetylmorphine - NAOMI  - trial 

Nosyk et al, CMAJ 2012 

all the benefits were derived from the longer retentions and 85% , when they relapsed the crime went up and health went down

DAM cohorts - NAOMI cost-effectiveness

Nosyk et al CMAJ 2012

If you have ‘retention benefit’ to treatment you will be cost effective

Eliminating financial barriers to treatment

Canada - universal health care - medications covered to varying degrees - relaxing constraints on the availability, length of take-home doses could reduce costs to clients who pay for their own pharmacy services

Other benefits - increase access to clients in rural areas, allow patients who have demonstrated stability greater freedom to participate in family life and employment

Regulations in place to prevent diversion is the primary argument - ‘the argument is moot if it is only provided under direct observation in a pharmacy or clinic”

-given pharmacological properties, methadone is less subject to abuse and less desirable to other readily available opiates

Mortality due to methadone overdoses cited as another barrier - increases in overdose are largely from methadone prescriptions for pain,

Undue restrictions on prescribind medications counter production

Weekend training and methadone certification programs for GPs

Lower mainland, greater toronto - vast increases in access, indications of satisfied demand

but elsewhere - waiting lists from 2 weeks to 12 months , St. John 12 month, Montreal, 6 to 12 months, Manitoba 6-12 months, BC waitlists problems outside lower mainland

Availability of buprenorphine BP-NX and their inclusion in drug formularies - several provinces have allowed coverage under special authority

-good idea to allow as secondary option to Methadone

Opioid Detoxification

• most people relapse after detoxification
• alot of tapering and desire to taper
• longer tapers have higher odds of success - 12 to 52 weeks versus 12 weeks)
• 4x more likely to succeed
• tapers taking more than a year 7x more likely

5% for week for tapering is clinical guideline

Best to decrease by stepped every 2 to 4 weeks

Extended vers Short term Buprenorphine - Naloxone for treatment of Opioid Addicted Youth

• treatment was far better than taper

Mortality among regular or dependent users of heroin and other opioidsL a systematic review 

• people are more likely to die outside of treatment by 2.8 factor
• Degenhard - Drug Alcohol Dependence 2009- 
• Mortality among clients of a state wide opioid pharmacotherapy program over 20 years  and lives saved

Analysis of OST outcomes in publicly funded clinicisn in Calirofornia 1991 to 2011

-total unique individuals 200,000 plus

-every time they reentered detox - likelihood of success decreased

-every contact with methadone maintenance program - tended to stay longer

Current emphasis on detoxification needs to be addressed

-clients desire unlikely to change

-practitioners should obtain and sign release showing they ahve been advised of risk

New developments

 Injectable morphine

injectable heroin

Buprenorphine Implants for Treatment of Opiod dependence

• Rosenthal et AL, ADDICTION, 2013
• - promising 

Naltrexone - was done in russia where methadone illegal

-high proportion of confirmed abstinence

-long acting antagonist - what do you do if your client in car accident with legitimate need for opiate

Need for data collection to improve quality of care

BC Pharmanet, Popdata BC - gold standard

6 patterns of dosing noted in research

Q&A

-difficulty of giving buprenorphine and methadone in aboriginal communities

What the Future Holds for Addiction Medicine in Canada

What the future holds for addiction medicine in Canada

Sept. 28 ,2013

Meldon Kahan, MD

University of Toronto

Lecture given at the Canadian Society of Addiction Medicine annual meeting, Vancouver, BC 2013. These are my rough notes which I hope will be of some benefit indicating the depth and breadth of material. Excellent presentation by a very experienced clinician and superb communicator.  Cutting edge genius!

Why should physicians treat addiction?

• broader addiction community - sees role of physicians as limitted for detox and medications

Why should physicians treat addicton

-Most addicted patients can’t attend formal treatment programs

-Patients often prefer to see their physicians

• addiction programs often have long waiting lists, complex intake procedures
• addiction programs don’t have the capacity to meet demand
• MD’s have long term relationship with their paitent - quality of provider-patient relationship more important than actual techniques use - greater predictor of success
• addiction is chronic relapsing illness
• physicians can be involved in all phases, screening, treatment, relapse prevention
• controlled trials have demonstrated that physician counselling is effective for addiction

Addiction counselling is not difficult for physicians and is similar for counsellingfor other chronic illness

-focus on immediate concrete behavioural change

genetic and physiological factors play a central role in precipitating and maintaining addiction, euphoric effects of drugs, tolerance, withdrawal

-medications for alcohol and opioid have been show to improving drinking and subtance use outcomes, decrease health care utilization, improve mobidity

-health care system has greater contact with addicted patient than the ‘addiction system’

addiction system can’t handle the large numbers

Treatment of Acute Withdrawal

-sympton triggered benzo for rx for alcohol withdrawa

-buprenorphine for opioid withdrawal

protocols prevent unnecessary hospital admission

Pharmacotherapy

-naltrexone, acaprosate, disulfiram, gabapentin, topramate, baclofen

have benefits in drinking

Opioid and other addictions

-great crisis of age is opiate addiction - primary role- reducing risk talking to colleagues about better patient selection and reducing risk of od

Where should Physicians treat Addictions

• many work in methadone clinics and addiction treatment programs
• we’re not reaching those other patients
• medical or psychiatric illness
• unstable living conditions

These patients are frequent attenders in ER and community care, and acute care

-don’t receive addiction care in these settings - remain at risk for addiction related harm

need and offten want tx 

• on site
• integrated

We need to practice where patients are

near hospitals

near teaching centres

provide consultations and follow up for emergency departmnts, hospitals, community clinics

Addiction Physicians as Teachers

Addiction is orphan medical discipline

their teacherss and mentors never role modelled addiction treatment - Sentinel Student Study

-they don’t know how

-never been taught clinical protocols

-when they see an addiction patient

--it’s not my responsibility

--I can’t help them, beyond treating complicatons

addiction MDs need to role modell, supervise practice, didactic treating

What physicians learn in med school/residency determinest their practice patterns

Addiction MDs as advocates and policy makers

-addiction treatment programs

-general hospitals and clinics

-public health

Many abstinence based treatment programs do not offer evidence based treatments

• initiation of opioid agonist treatment

• Case Study - patient was told by inpatient addiction physician that their abstinence based program doesn’t not have a philosophy of accepting buprenorphine patient  - no other medial specialty would accept their treatment being ‘forbidden’

Addiction policy in hospital

-many hospitals don’t have policy

case study of woman want ing to withdraw - given 5 mg diazepam - no evidence of CIWA use - prolonged qt -

Coroner inquest recommended that hospitals use symptom triggered benzodiazepine protocol

-large hospital has only one addiction physician

We have alot to offer

-addiction protocols are rapid, effective and simple

eg

St. Joseph Health Centre - addiction medicine service - implemented hospital wide protocols for 

alcohol withdrawal

opiate management

-elective and selective students 

6 and 12 month clinical fellowship program

initial skepticism but now fully supported

Addiction Physicians and Public Health

The Opioid Crisis

-huge increase in opioid prescribing, in response to a massive marketting campaign

-led to dramatic increase in rates of addiction, overdose death and harms

-most serious medically -caused public health crisis of generation

Pharmaceutical company and his physician lobbyist promoted idea

• opioid addiction rare in pain patients but truth is that it is common, serious and preventable
• prescribing high dose to high risk patients puts them at risk for addiction and overdose
• tapering opioids improves pain, and function and mood

compared to pain physicians , addiction physicians were very quiet

-call to action began with media, public, researchers, then later provincial governments and medical regulatory bodies

Addiction physician response

opioid guidelines

limits on high dose formulations

 defundint oxycontin

Coming Crisis

2014 Health Canada new regulations allow MDS to prescribe dried cannibis

this will harm patients and physicians

no evidence of benefit vs oral cannabinoids

Smoked cannabis not good

Addiction physician as advocate for marginalized patients

Sioux Lookout - 50,000 - prevalence of opioid addiction 50 to 80%

-suicide, overdose, crime, family break up

-attempts to introduce methadone failed

-few family physicians began prescribing buprenorphine

• addiction physicians beng to fly in to prscribe buprenorphine as locums
• provide telemedicine
• provide clinical support through phone and email
• advocate with NIHB, MOH, medical colleges re funding, licensing requirements, protocols

Over 400 people on buprenorphine

support of band leaders and comunity

local treatment programs have developed eg ceremonial, group induction onto buprenorphine

adapted protocols to rural community

aboriginal communities do not have access to safe inexpense and life saving treatments

-in most provinces only methadone mds can prescribe buprenorphine

-this would not be accepted for any other medical conditon

addiction physicains need to advocate with ministry, public, medical colleagues, funding and resources for addiction treatment,do front line work with underservice populations

• we need to model ourselves on HIV doctors of 80s and 90s

Challenges for addiction medicine

-isolation and small numbers

some addiction doctors work alone

-powerless against the harmful policies of the institutions where they work

lack of standards in addction

-others specialties have consensus on how problems are managed and expect members to comply

-culture of passivity

-other groups fill the void

Younger physicians

-evidence based

-fierce, fearless and relentless

assumer responsibility

-patients

-health care colleagues

-the public

Hepatitis C in Addiction

Hepatitis C in Addiction

Sept 28, 2013

Mark Hull MHSc FRCPC

Lecture given at the Canadian Society of Addiction Medicine, Vancouver, 2013

My poor rough notes just give a slice of the wealth of information presented by this cutting edge researcher, clinician and remarkably fine communicator. I trust this will help someone appreciate the depth and breadth of information available and the extraordinary work and advances being made.  

Hepatitis C Overview

HCV is a RNA virus

single strang Rna 3000 amino acid

North Amer - 1 a and 1 b dominant straints

Overlapping Global HCV and HIV

• 8 million co infection
• 33 mill HIV
• 170 million Hep C

BC Chronic HCV rates

• gradual decrease since 2002
• increasing number of women
• originally male
• baby boomers with increased elderly

High Prevalance of HCV among PWID Worldwide

Injection drug users in canada make up 60% of HCV

HIV in BC PWID

VIDUS Youth   

CEDAR Youth/youth/young adults

Miller C CAn J. Public Health 2005

Spittal P BMC Public Health 2012

Risk for acquiring HCV rises dramatically after 2 years of IV drugs

Harm Reduction and HCV

-number of syringes - associated with decrease in HCV - free needle programs

Harm Reduction and HCV

effect of opiate subtitution treatment on HCV incident

-80% reduction in risk of HepC with OAT

Turn, K et al Addiction 2011

HCV Surveillance - Corrections Canada

Seroprevalence people entering jail fairly high compared to general population but very flat over years

 -about 30% - higher than community

-jail amplifier - New infections acquired in jail

-new infections with tattooing and Intravenous drug use

HCV prevalence by birth cohort in USA

-prevalence in baby boomer 5x higher than others 

-amstrong , G An. Int Med 2010

-most don’t know - may have got young and may have been victim of poor blood transfusion, or very young , or other ways

HCV Natural History

-75 to 85% patient develop chronic infection

20% develop cirrhosis after 20 years

Estimated reduction in morbity by birth cohort

-recommending routine screening if baby boomer - birth 1945 to 1955

Ontario Burden of Infectious Disease Study 2010

-Hep C the most burdensom infectious disease - loss of life and disability - HIV far less

Mortality in Canadian HIV/HCV Co Infection Cohort Study

-rate of death due to liver disease extremely high

-escallates liver disease

-Klein, M

Baseline Assessment

-All PWID (Persons with Injection Drug Use) should be screened for HCV 

-HCV antibody

-if negative, re screen every 6 months if still at risk

-if HCV Antibody positive

--HCV RNA PCR/genotype

--vacinate for Hepatitis A, B if non-immune

-pneumoccocal vacine

-alcohol cessation treatment

Staging of Liver Disease

-all patients should undergo staging of liver disease - cirrhosis - (clinical, laboratory, radiography)

Use of non invasive techniques - fibroscan (transient elastography 

alternative to Biopsy

Stebbing, J et al, J Clin Gastro 2010

biopsy is still used occasional

Evaluation of HCV treatment

Absolute contraindication to treatment

-pregnancy

Strong contraindication

• active autoimmune
• hepatic decompensation

Relative contraindication

-major depression

-major psychosis

-renal failure

Ideal study - Peg IFN alfa -2a vs Peg IFN alfa-2b 

Serious side effects

 -Neuropsychiatric symptons

20-30 % severe depression

Benefits of successful treatment

• Van der mer, Jama 2012
• all-cause mortality reduce- increases long term survival, regeneration of liver

Pegylated Interferon and ribavirine for genotype 2/3

24 weeks if RVR

48 week

Boceprevir - SPRINT2 overal SVR Rates - doubling of response

Telaprevir - 75% cure rate - revolutionary over last 2 years

These drugs also have this effect with those who have relapsed after previous response

There is a very minor subgroup of non responders that are still a tricky problem but hopefully will respond to new drugs.

Now responses to 6 month of treatment excellent

Integrate Models of Care

-Community based multidisciplinary team - grebel, Eur J Gastroenterology Hep

HIV treatment as prevention BC

Patients currently on HAART

HIV engagement in care

HCV Engagement in CAre 

Decreased mortality and morbidity

decrease sero prevalence

Hepatalogy - Martin, n et al 2013 -

Conclusions

PWID have high burden of HCV disease and should be screened routinely 

Treatment uptake is low among PWID

Use of HCV DAA’s have substantially altered treatentn paradigms and success rates will continue to improve

Treatment as PRevention models suggest populations level benefits to improved therapy 

Q&A Periods

1)System failing - British Columbia - restriction on treatment meaning that our patients aren’t being treated.

Reduces morbidity and mortality for individual but also stops spread at population level

Pharmacare is recognising fibroscan - it’s as acceptable as biopsy

Cost effectiveness of dx and treatment to health care system

1. Viremia - clear and negative tests - might have negative test this month but negative 6 months - want 4 negative tests over 3 years q 6 months
2. Fatty liver - first nations - seems almost all my patients have - aboriginal care giver gave - results in poorer response to treatment, mortality worsened, 

some treatment programs in us are treating metabolic syndrome as well as liver

4) lady with seizure disorder, socially unstable, on methadone, continues to inject cocaine and heroin - should I treat hep c early - or should I just continue to work at treatment of her addiction - if you waited a year unstable - and stabilize for this year then treat -

Behavioural addiction - Gambling - in people living with Disabilities

Behavioural Addiction

In people living with disability: disordered  gambling and health functioning

Sept. 28, 2013

Sandra Cortina, RN, MPH, MD candidate

Nady el-Guebaly, MD 

Department of Psychiatry, University of Calgary

Fascinating Study presented by Sandra Cortina at the Canadian Society of Addiction Medicine Annual Conference, Vancouver, BC 2013.  These are my rough notes of this excellent presentation which included many pertinent slides I can’t reproduce here. I trust this helps someone to appreciate the depth and breadth of information available.

Problem Gambling - gambling behaviour that creates negative consequences for the gambler, their social network, or community

-up to 3.8% of Canadians have symptons of moderate risk or problem gambling

Higher rates of pathological gambling found in US among people with disability

Disability

Largest category of Canada Pension Plan disability

-mental illness 22%

-musculoskeletal 21%

-neoplasm 20%

Gambling and Health Function

-direction of association between disability and gambling not known

This association can be especially deterimental to people living with disability who may already suffere from pre existing health deficits related to their disability

Objectives

problem gamling, disability and health function

-measure prevalence in gambling in people with disability in canadian sample

-association between two

Methodology

Gambling Prevalence

-Leisure, Lifestyle and Lifecycle Project (W4)

-prospect study

Demographices 

-disability - 18-59 - Canada/Quebec Pension Plan, Worker’s Compensation or both in last 12 months

Canadian Problem Gambling Index (CPGI ) (non,non problem, low risk, moderate-risk, problem)

-Disordered CPGI greater than or equal to 4

Short-Form 8 Health Survy

-Mental Health Burden - vitality, social, emotional, 

-physical health burden - general, physical, function

Results

Gambling prevalence -

Sample 769 participants from Alberta

39 received disability benefits (PRDB)

Characteristics and Behaviours of PRDB

-pretty similiar groups except

-Older participants 66.7% vs 50.6%

Income -less than $50,000  51.3% versus 23 %

Video terminals/slots last 12 months (63 % versus 42.1 %

PRDB found to have a greater proportion of DIsordered Gamblers

15.8 % versus 3.5% 

  

Gambling and Health Function

Physical burden: Well being

• gambling status was predictive of decreased health function
• as gambling status became more severe increased physical burden

Summary

People receiving disability have higher prevalence of disordered gambling versus sample remainder and general Canadian population

-small sample - accuracy, confounding, generalizability

-disability definitiion - exclusive, indirect, etiology

Couldn’t differentiate mental or physical disability

And we couldn’t exclude the fact that some disability people don’t receive disability

Increased gambling severity found to significantly predict higher burdens on physical health but couldn’t predict direction

Future Research Directions

-need large sample size

-control confounders

-increase estimate precision, and representation of disordered gambling among people living with disability

Prospective design, monitors health function and problem gambling over time