Well, thank you. My name is Anthony Decker. I'm the presenter for the medical comorbidities program. The discussion of medical comorbidities for the board review will include several items from the standpoint of what we as addiction specialists need to be aware of in providing care to this population. Currently, I'm the CMO of the division of developmental disabilities for the state of Arizona. I retired after 37 years with federal service. Last station being at the Gallup Indian Medical Center in 2021. I have worked at the, in reverse order, Gallup Indian Medical Center, the Northern Arizona VA Medical System, the Department of Defense at Fort Belvoir, the Phoenix Indian Medical Center, and the US Public Health Service in Chicago South Side. I completed my osteopathic training at Michigan State University in 78, did a family med residency and adolescent young adult medicine fellowship, and have taught at several medical settings. I have no conflicts of interest, no relationships with pharmaceuticals or prohibited donors. I am the past president of the American Osteopathic Academy of Addiction Medicine, which is the sponsor for this course. Although I've been employed in the Public Health Service, Job Corps, Indian Health Service, Department of Defense and the VA, I do not represent any federal or state organization and my opinions are simply my opinions. So our objectives for this program is to understand the short and long-term effects of exposure to substances of abuse, to provide diagnostic evaluations for medical complications of substance use disorders, and to implement interventional strategies for medical complications. First things first, you have to be really good at listening, but you stimulate that process by getting a medical history. So review of the symptoms and or the conditions, review of lab, which includes other objective data sets such as a cardiogram, and when we start looking at post-COVID care, there's a few other things that we worry about in regard to our members who have substance use disorders. The relationships of medical symptoms to substance use disorder and establish the temporal history, the timeline in regard to some of these things, prior diagnoses a person has had, prior treatment, medical and surgical, obstetric and gynecology history, clarify the pregnancy status of the individual. Obviously a pregnant patient with substance use disorder is someone who is more high risk. Dental care, the old rule is if you're not healthy in the mouth, you're not healthy. And patients with substance use disorder, especially the stimulant use disorder have significant dental issues. Medications, past and current, response and side effect, and history of loss, stolen, prior treatments, prior agreements. In the social history, getting the birth and early developmental history is helpful. Sometimes it's not available because the individual is engaged in that. Nonetheless, a person's education is also important. They should be able to give you that. Timeline and completing school, current employment status and prior occupations, marital status, children, close support systems, family setting, their living situation, their legal status, and their current stressors. A family history becomes important because there is a significant genetic component to substance use disorders. So substance use history and family, other psychiatric conditions in family, and other medical disorders in family. We start looking at patterns of substance use. So when we start looking at substances, we want to make sure we cover everything. And that would include tobacco, marijuana, alcohol, your opioids, both prescribed and non-prescribed opioids, hallucinogens, sedative, hypnotic, stimulants, and other substances of abuse, such as inhalants, things like that. Age of first use becomes important because it's a predictor in the trajectory of the person's disease. Determine the patterns of use over time, their frequency, the amount, and the route. This includes prescription medication. If a person says they grind up their Wellbutrin and snort it, that is an abuse disorder. Are they prescribed the Wellbutrin? Yes, but the reality is bupropion snorted has a different effect. Assess recent use over the past several weeks versus current use. Cravings and control, especially over the timeline. You know, when they say, well, things got out of control when I threw my back out again. So they may have an event that caused that. Determine if the patient loses control over use. When we start looking at the substance use history, the effects and consequences become part of how we tailor the intervention strategy. So understand the words, tolerance. You need to have more and more to have the same effect. Intoxication, you are psychically and perceptively different. And withdrawal, if you don't get whatever substance that you're trying to get, you have an effect. Explain what is meant by tolerance. Determine the patient's tolerance and withdrawal history and ask about complications associated with intoxication or withdrawal. DUIs, injuries, loss of job, those types of things. Consequences of use, so current and past levels of functioning, aberrant behaviors, including sedation, deterioration in function, sleep disturbance, changes in intimate relationships. And identify the consequences, not only medical, but also family, employment, legal, psychiatric, and other complications of their substance use as perceived by the patient. When we start looking at screening and assessment, we want to identify the risk individuals patients have with the act of substance use or other substances and those who require additional evaluation. Diagnose problems that meet substance use disorder criteria. Know the DSM-5 TR. Develop recommendations and plan for treatment. Assess biopsychosocial needs. Validated screening and assessment instruments. So the DAST-10, Drug Abuse Screening Test. The COWS, the Clinical Opioid Withdrawal Scale. The Audit Alcohol Use Disorders Identification Test. The Public Health Questionnaire-9 is a good screen for behavioral health issues. And because suicide is an event that occurs too frequently in the field of addiction medicine, the Columbia Suicide Severity Rating Scale is recommended. On physical examination side, you're going to go through history and then physical exam. On the physical exam side, skin is first. So you're looking, and you can't do this with a person fully clothed. So I typically say, have them in their underwear, with a gown, with a chaperone, on that first visit for sure. And then look at the skin, look for signs of scars, of active infections, cellulitis, any evidence of injections. Look for jaundice. And each of us have a differing range of capacity to see this. So remember, males have more rods. We see shade, but we don't see color as well. So if your female staff says, he looks a little yellow. Again, keep that in mind. So picking marks, remember that the stimulants can make a person feel that the itch becomes uncontrollable. So picking scabs and things like that becomes another area to watch for. On the ENT side and the EENT, looking at their pupils, remember that the opioids will cause, active use of an opioid will cause a pinpoint pupil with one exception, and that is Demerol. The yellow sclera, again, tipping off for possible jaundice, any type of conjunctivitis. Evidence of ENT problems, such as trauma, ruptured tympanic membranes, recurrent discharge from the ears, rhinorrhea, rhinitis, perforations in the septum. We don't see those as often, but I remember when that was a very common experience earlier in my career. Mouth examination, look for the dentition, look for periodontal disease, gingival diseases, any types of findings that would be consistent with an infectious disease process or a dental disorder. Cardiovascular, you're looking for arrhythmias, any type of murmurs. People with a history of injection drug use can have issues of endocarditis and things like that, but arrhythmias are common in stimulant use disorders. They're also common in regard to some of the opioid use disorders and people on treatment, methadone and buprenorphine, extend the QT interval significantly. All opioids extend the QT interval, but methadone and buprenorphine extend it even more. Respiratory changes, common in people who are tobacco users, marijuana users, hookah users, and now vape users, but people with reversible airway disease, shortness of breath, rawls, chronic cough, and obviously, if you feel that there's a risk of this person having a cancer diagnosis, you'll wanna pursue that. Musculoskeletal issues, many people have chronic pain syndrome. You're going to be looking for evidence of renal problems with edema, history of broken bones, traumatic injuries, motor vehicle injuries, any amputations, burns, scars from old cellulitis. Keep in mind that people, when they run out of veins, will inject them in the area, so looking at the buttocks, commonplace for skin popping, and you can examine that area with a chaperone in the room. Keep in mind that many people with substance use disorders have a prior history of sexual traumas, so you don't wanna open up that door without having appropriate supervision. Genital urinary, gastrointestinal disorders, hepatomegaly, hernias, people also inject in their abdominal wall, and then from a genital urinary standpoint, looking for STDs, common occurrence, and currently in the US, chlamydia rates are higher now than ever before. So baseline labs for your female patients, make sure you identify a possible pregnancy. Toxicology becomes an important step for us. Remember that we don't terminate therapy because of a positive urine drug screen. We actually enhance their therapies. A complete blood count with a differential on a platelet count are important. Typically, I get a CHEM24, but serum electrolytes. Hep C HIV testing is important. Liver function tests are important. In the era of COVID, anyone who has symptomatology should be screened and asking questions. If they have had COVID, if they've been immunized, have they had the bivalent immunization, and do they have any symptoms that are different post-COVID than they had pre-COVID, looking at long COVID possibilities? We look at infectious disease, HIV testing, and continued prevention becomes an important part of our monitoring and care. If you are familiar with HIV treatment, to me, it's a specialty treatment for people who are symptomatic, but it's chronic primary care treatment for people who are in status of infection, but essentially no evidence of infection because they're on heart therapies. Tuberculosis skin testing, imaging, and intervention services for those people who are positive. Many people who have a history of substance use disorder, by the time they receive intervention services, have had a time in the homeless setting, and the very high rates of tuberculosis are occurring in that population. Sexually transmitted infections, including syphilis, and chlamydia, syphilis, and gonorrhea are very high rates in the U.S. right now, but get the troponin test, either an RPR or VDRL, MHA. If they're falsely positive, and that can occur sometimes, you want to pursue, and I said already, chlamydia and gonorrhea are high rates. COVID-19 associated with higher risk for people with substance use disorders, including those who are actively using inhaled substances, tobacco, marijuana, fentanyl, all the amphetamines, and cocaine. And again, we've talked about long COVID symptomatology. Lung cancer screening, either with a low-dose CT, for people 55 to 80, with a 30-pack year history, is a standard. Biennial mammography for women 50 to 74, and now dropping down to 45 to 74, if they agree with the screening evaluation. For people who refuse mammography, breast ultrasounds can be offered. Cervical cancer screening, for those with a smoking history, alcohol history also increases the history of lip, oral, pharyngeal, larynx, esophageal, stomach, and breast cancers. Liver, intrahepatic, bile, ducts, and prostate and colon cancers, that also could benefit from screening services. Abdominal aortic aneurysm screening, for men 65 to 75, with a history of smoking. Prostate cancer is no longer recommended for screening with a PSA, but if the patients are symptomatic with prostate enlargement, digital examination and pursuit can be appropriate. Colorectal cancer screening could be done annually with a fecal occult blood test, a FlexSig every five years, and colonoscopy every 10 years. Remember that colon cancer is occurring at a younger and younger age population, as is metastatic breast cancer. And no real identification as to why that is happening. Thyroid screen, hearing screen, and vision screens, all expected by US Public Health Service. The systemic and local infections from injection drug use, endocarditis and sepsis. What about naloxone and nutritional education? People with opioid use disorder, especially those who are prescribed, or especially those who have prescribed opioids and or have a history of street derived or non-prescribed derived opioids, should be given a intranasal naloxone sprayer. Now, most states have now passed resolution or passed a law that allows people to simply go into the pharmacy and say, I would like to have naloxone spray. They can show their insurance card, most insurances will cover it. It is $45 in most pharmacies for the price for two box or two unit naloxone spray. But anyone with a history of continued use of opioids should have that. All AEDs in Arizona now carry a box of two sprayers of naloxone, and most states are also doing that. Basic Life Support CPR through the American Heart Association incorporates naloxone spray as part of their educational program. Folate and vitamin deficiency is common in all alcohol use disorders, so it should be monitored and treated. Osteoporosis is higher in people who have a history, a long history of alcohol use disorder. Thiamin, vitamin D, paradoxine, niacin, riboflavin, zinc, and folic acid deficiencies have been reported with alcohol use disorders. From a cardiovascular standpoint, there's a higher rate of CV disease and end-stage liver disease and alcoholic gastritis. Withdrawal and overdose management. Dr. Wyatt is giving the alcohol talk, and opioids are done by Dr. Kimmick, and both of those presentations cover that area. You want to treat withdrawal. That is the most serious first. So alcohol and benzodiazepine and barbiturate withdrawal is more life-threatening than opiate withdrawal. Monitor for cardiac status, especially those that may have ischemic heart disease, and that can be even in young people who have a history of stimulant use and cocaine use, or a history of endocarditis. Naloxone use, be ready in your office with that in case patients come in and become uptunded. The old rule was you're not dead until you're warm and dead, unless your potassium is greater than 12. The benzodiazepine overdose treatment is supportive. Fumazanil, which is a benzodiazepine receptor antagonist, is not recommended in my book, mostly because of seizure events and because of the very negative experience the patient has after getting that. If the patient is stable enough to be supported, that's the key. It may be useful in acute short-term acting overdose reversal, but that needs to be watched in the ER or the post-op state. Should not be used for opioid, or should not be used for benzodiazepine dependence because of the cardiac and seizure possibilities. From a cardiovascular standpoint, hypertension from withdrawal of sedative hypnotics and intoxication of stimulants should be monitored. Alcoholic cardiomyopathy and congestive heart failure. Arrhythmias, especially SVT from alcohol use called holiday heart can be treated with benzodiazepine and beta blockers and treated abstinence. Remember, if you have a person who's going through alcohol withdrawal, you want to treat that aggressively. Don't get behind, I mean, that alcohol talk by Dr. Wyatt, but don't get behind in treating alcohol withdrawal. Cocaine and stimulant ischemic disorders are common, even in young people. Cocaine use is higher now than any time in the past in the US. Endocarditis and sepsis from IDU, injection drug use, post-COVID inflammatory cardiitis has been reported. Let's move on to gastrointestinal and liver diseases. So alcoholic hepatitis, AST is higher than the ALT. If the ALT is higher, there's a concomitant etiology such as hepatitis C. Steatohepatitis is best diagnosed with a liver biopsy, but diagnosis is often if B and hep C are negative. Classic alcoholic hepatitis has fewer leukocytosis, right upper quadrant pain, and AST much higher than ALT. These are things that may pop up on the boards. Treatment is abstinence, electrolyte balance, vitamin K, monitor volume, and mental status. Cirrhosis and hypoalbuminemia, myelopathy and hyperbillionemia, hepatitis C, alcoholic hepatitis, encephalopathology, encephalopathy, variceal bleeding, ascites, spontaneous bacterial peritonitis are all complications of cirrhosis. Primary hepatocellular carcinoma with hep C is a significant endpoint that we're trying to avoid. Recurrent alcoholic hepatitis and or from chronic use of alcohol greater than three drinks daily. End stage liver disease can lead to a liver transplant. Keep in mind that hepatitis C is a treatable and treatment should be offered disorder. However, it is not preventable if the person continues to be re-inoculated with other viral types of hep C. Gastritis, Mallory-Weiss tears, stomatitis, esophagitis, pancreatitis, esophageal and gastric cancers are all complications highly associated with chronic alcohol use disorder. Amylase is often elevated and chronic carotiditis. Renal and metabolic disorders. So hepatic disease can lead to renal complications with nephrotic syndrome and glomerulonephritis from hep C. Keep in mind that one of the other talks I give is a pain talk and interstitial nephritis secondary to non-steroidal anti-inflammatory use with dehydration because of the prostaglandin inhibition is an issue and patients who have a history of chronic alcohol use are typically dehydrated on a regular basis and if they have a coagulopathy or if they have a varicea, the likelihood of bleeding in the presence of dehydration and NSAID use is actually quite high. Acute renal failure from rhabdomyolytis secondary to alcohol seizures or just being uptunded and laying on the floor. Dehydration from emesis and volume depletion. Electrolyte abnormalities need volume expansion or replacement and correlation of acidosis or alkalosis needs to be identified. Hyperglycemia and hypoglycemia in alcohol users is common because of pancreatic insufficiency or end-stage cirrhosis. Hepatorenal syndrome is from chronic alcohol use that occurs when fulminant liver failure or cirrhosis develops, profound renal vasoconstriction and splanchnic vasodilation occurs and this is usually in the presence of severe liver impairment. Portal hypertension which causes the esophageal varices, anasites, anasarca. Hepatorenal syndrome is a diagnosis of exclusion, elevated creatinine and oliguria with low urinary sodium but malnutrition and loss of muscle mass may cause a normal creatinine. So if the person is in a depleted state and they're losing their creatinine from their loss of muscle, their creatinine may normalize. So look at the whole picture, not just one or two labs. Nephrotic syndrome, HIV, nephropathy, HIV-AN focal from a standpoint of the nephritic type disorders and also segmental glomerulosclerosis. Toxic alcohols, methanol, ethylene glycol, isopropyl alcohol can be ingested as a substitute for ethanol. This causes all kinds of problems. So metabolic products of these alcohols via the alcohol dehydrogenase are severely toxic. Elevations in the osmol gap is greater than 15, probably from the toxic alcohols. Ethylene glycol ingestion elevates the calcium oxalate crystals. I do remember that on a board exam. So, fulmeprazole IV competitively inhibits the alcohol dehydrogenase more than ethanol and is safer than ethanol infusion. So ethanol infusion is the old intervention but we now have antizole for people who have exposure to the toxic alcohols. If renal function is maintained, the alcohol will be removed by renal extraction or excretion. If the patient is severely intoxicated with toxic alcohols, hemodialysis can effectively remove the alcohols and the toxic products, especially in the presence of a metabolic acidosis. Failure to recognize these alcohol intoxications can lead to multiple organ system failure, including brain, liver, kidney, and in the case of methanol, because of its toxic metabolite, blindness. Pulmonary complications. Tobacco is the leading cause of preventable illness and premature death. It's the leading cause of COPD and bronchogenic carcinomas. It also causes pulmonary hypertension, interstitial lung disease, in other words, damage to the parenchyma and pneumothorax. Tobacco is also related to cancers of the oropharynx, larynx, esophagus, bladder, kidney, pancreas, stomach, and cervix. Now, that being said, vape has become very popular in our youth and our young adult population. We are just starting to see the chronic effects of vaping. I think we're gonna see similar problems in the pulmonary tree because of chronic vape use. In the case of tobacco use, cessation results in decreased risks very promptly. Within months, there's a decreased risk. So the lung has a resiliency that's commendable, but after multiple years of exposures, typically 30 years of exposure, it's gonna be difficult. We don't have 30 years of vape exposure yet, and I think we're gonna start to see more and more problems occur as time goes on. Alcohol intoxication can lead to respiratory depression and aspiration, aspiration pneumonia, obviously, with major complications. So it can be both infectious and or chemical. Injection drug use leads to pulmonary and hepatic granulomatosis from injected particles that can be both infectious and non-infectious. Pulmonary hypertension from these granulomas, in addition to vasoconstrictive effects of the injected drugs, especially the stimulants, cocaine, methamphetamine, and other amphetamine metabolites can lead to pneumothorax, hemothorax, pulmonary emboli, sepsis, and post-COVID complications. Now, keep in mind that phlebitic disorders from injection drug use are common, and thrombotic events occur frequently with that scenario. People who are hypercoagulable, so factor V Leiden deficiencies, factor S and C, all become cofactors in the hypercoagulability complications. Inhaled drugs, depending on the size of the particles and the heat, can also have significant effect. Remember that fentanyl is frequently smoked. In other words, it's put on a piece of tinfoil, bit lighters underneath it, and they inhale the white smoke. Heroin, typically black tar heroin, would cause a purple tail, and that would be called chasing the dragon's tail when they would smoke it again by burning it on a tinfoil wrap. Barrel trauma can also be an issue that could result in pneumothorax. Many times people will have a significant inhalation off of a marijuana cigarette, blunt, or hookah, and hold that product inside their lung to maximize absorption. Same thing is seen with vaping. People take a large inhalation, hold it as long as possible to drive the condition to a point where they can drive the chemical into the alveolar system and then into the bloodstream. But if a person has a blub or with that type of behavior over the course of time, damage, pneumothorax may be a possibility. Burns to the face and the pulmonary tree are common in heated inhalants, including vaping, and obviously the hookah goes through air, so that should cool it down. But some of the delivery systems, especially if you're inhaling literally the flame that comes off of the lighter underneath the tinfoil, that can cause just a thermal injury. Neurologic complications. Well, first off, trauma with head trauma, secondary to falls and motor vehicle events are quite common. Subdural hematomas can be confused with alcohol intoxication. Higher rates of ischemic and hemorrhagic strokes in alcoholics. Alcohol lowers seizure thresholds, especially alcohol withdrawal, but alcohol intoxication too. Alcohol is a very interesting substance. It's a sedative hypnotic when the doses are below, you know, 50 to 75 grams of ethanol, which would be somewhere in the area of three to five drinks. But after five drinks, alcohol can become a vasoconstrictor and has toxic effects. And so a person could have a seizure from withdrawal or they could have a seizure from the toxic effects of significant intoxication. Thymine deficiency is related to the Warnke-Korsakoff syndrome and confusion and ataxia and nystagmus can be seen. This is something that should be treated immediately with a hundred milligrams of thymine. Korsakoff syndrome with memory impairment does cause confabulation and the member may be non-confrontive. In other words, they're not denying things, but they'll agree to things. And so that is something that goes along with chronic neurological effects of alcohol use. More common chronic alcohol use has a nonspecific dementia. Cerebellar dysfunction has ataxia and in coordination is often irreversible. Peripheral neuropathy from vitamin deficiency and nerve compression and the direct effect of alcohol toxicity may occur. Some of those are reversible with vitamin replacement. Seizures from sedative withdrawal or stimulant use are commonly reported. Hemorrhagic CVA stroke from methamphetamine, phenylpropylamine, LSD, PCP and ketamine now, a secondary to hypertension, vasculitis have been seen. Cocaine can cause both hemorrhagic and thrombotic events and anabolic steroids can cause hypercoagulability. And keeping in mind that most people who have the inherited hypercoagulable disorders are unaware that they have this. Trauma is also highly associated with alcohol use disorders. 50% of major trauma is related to alcohol use. 22% of minor trauma is related to alcohol use. There's a high rate of physical and sexual injury secondary to substance use disorders. Alcohol impairment changes balance and coordination and judgment, and that can be with one serving. 14 grams of ethanol can change your reaction time. Now, in most states, you're not impaired unless you're at 0.8%. That's intoxication. It typically takes a female four servings of alcohol, a male five servings of alcohol to get to that point, but impairment occurs at 0.2%. Subdural hematomas can mimic alcohol intoxication, as we said before. Cocaine and stimulant use to the relationship in interpersonal communication can result in public safety engagement altercations with others. Phoenix has the highest rate of car pedestrian deaths, and so everyone's heard the term it's dangerous to drink and drive. Well, it's also dangerous to drink and walk in some communities. Screening, brief intervention, and referral for treatment is required at all trauma centers now. So the goal with motivational interviewing is, would it be okay if we talk a little bit about your alcohol use so you get permission to bring that issue up? Could we talk about safe alcohol use? And again, you're encouraging the discussion, and then you get to a point of negotiation. I think your broken leg could be related to intoxication and falling off a curb. And so you can see what's happening is you're going little steps at a time in that process, but you're going to get that presentation in a different lecture. So vaping, electronic cigarettes, delivery systems, 3.5 of all adults, that number for high school students in 2022 is now 40% of US high school students are vaping. Increased rates of trauma and burns are noticed in e-cigarette users. Drownings, falls are higher with all SUDs. Endocrine changes, this is a big area here. So alcohol hypogonadism from direct effects on the testes and secondary changes from liver disease, including gynecomastia. In women, alcohol may delay menopause and may cause menstrual irregularity and decreased fertility. So the change in the menstrual cycle from chronic alcohol use is commonly reported. Alcohol can increase the high density lipoproteins and the serum triglycerides, which contribute to metabolic disorders. Hepatic steatosis and pancreatitis are obviously reported with chronic alcohol use in some individuals. Moderate drinking may decrease heart disease and diabetes, but more than three servings, 14 grams per servings per day, increases the risk in regard to both heart disease and diabetes. Cortisol increases may create a pseudo Cushing's type syndrome, which is reversible with termination of alcohol. Tobacco increases the risk of Graves' disease, hyperthyroidism. It also has subsequent hypothyroidism, insulin resistance, and diabetes. Tobacco decreases estrogen in both sexes and decreases bone density, increasing osteoporosis and fractures. Tobacco decreases sperm counts and motility and motility of sperm. It also increases erectile dysfunction, probably directly related to its vasoconstrictive effects. In women, it can cause low birth weight, increased spontaneous miscarriages or abortions, increased sudden infant death events, and infant delays and neural development are associated with chronic tobacco use in the mothers. Continuation on endocrine systems, cannabinoid receptors affect the hormonal systems. Remember, our cannabinoid receptors are a very primitive receptor in the brain. It also increases the appetite, which people call the munchies. Cannabinoids and the endocannabinoid system contribute to the development of diabetes with insulin release and the impact, the severity of complications on the cardiovascular and neuropathic systems. So, human reproduction is regulated by the endocannabinoid system. Decreased fertility, decreased pregnancy success has been seen. Sperm counts and motility has decreased with chronic THC exposure. In vitro fertilizations has decreased success for males and females that are chronic cannabinoid users. In animal studies, neural development is delayed, probably related to the lipid solubility of THC to the fetus. Again, this is in animal studies. And THC does seem to increase germ cell tumors. Synthetic cannabinoids, CB1 and CB2 receptor agonists, such as spice and things like that, are now schedule one, and that has been since 2012. They can have psychotic and manic events. Seizure inductions and cardiac arrest, CBAs have been reported. Fortunately, we're not seeing as much of the synthetic cannabinoid products on the street anymore because THC has become very high potency and is currently legal in many states. Acute renal damage is reported from the synthetic cannabinoids. Agonism at the CB1, CB2 receptor agonists or receptors can be higher than 30 times in the synthetics compared to THC. There's currently over 600 types of cannabinoid synthetic products. Cocaine activates the hypothalamic pituitary adrenal axis. So you have increased secretion of epinephrine, corticotropin, releasing hormone, and adrenal corticotropic hormones and cortisol are all observed. Acute cocaine use decreases plasma prolactin concentration, especially in naive individuals, but not in chronic cocaine users, which increase prolactin after dopamine is depleted. So remember what happens is that all the stimulants cause the nucleus accumbens to release dopamine. What happens is that as time goes on, the amount of dopamine available is less. So you have to use more and more. Methamphetamine is especially problematic in this area where people have a rise in the need for methamphetamine to get the same effect. Chronic cocaine use does not alter basal levels of testosterone, cortisol, luteinizing hormone, or thyroid hormones. Acute cocaine use can complicate and precipitate diabetic ketoacidosis secondary to its adrenergic effect. Opioids impair gonadotropin release. This is seen with many people who have changes in their menstrual cycle, but also decreases in their testosterone. Opioids also decrease sperm motility, which may be directly related to the decrease in testosterone, and can also have ovulatory irregularities. Barbiturates create vitamin D deficiencies and osteomalacia from the P450 induction. Anabolic steroids can promote androgen effects in women and lipid metabolism changes in both sexes. Amphetamine suppress appetite and increase corticosteroids. Growth hormone is acutely changed. Ecstasy can cause severe hyponatremia from a syndrome of inappropriate antidiuretic hormone secretion. This has been reported to be fatal in hyperthyroid patients. Caffeine response is dose dependent. Epinephrine release will increase the blood pressure. Ingestion of over 400 milligrams of caffeine, that's 80 milligrams in a cup of coffee, so that'd be five cups of coffee, is associated with decreased insulin sensitivity in tolerant young adults. 500 milligrams of caffeine increases hyperglycemia in type 2 diabetics, and chronic caffeine use decreases type 2 diabetes. Now, all that taken into consideration, keep in mind that coffee is not the primary source for caffeine for our young adult and adolescent population. So the Red Bulls, Monsters, all these stimulant drinks, and sometimes you can get up to 500 milligrams of caffeine in one can of those drinks. Inhalants are related to skeletal fluorosis, infertility, fetal solvent syndrome, renal tubular dysfunction from the solvents, especially the hydrocarbon solvents, and hyperphosphatemia with nephrolithiasis. Refrigerant inhalation, so that's going to be the Freon inhalations in those Freon cans, can create a cardiac arrhythmia that has been reported to be fatal. I've had two patients die in Indiana when I was in practice there, from going to the Napa Auto Parts store and getting the Kluant sprays. LSD increases blood pressure, cortisol, epinephrine, oxytocin, and prolactin. LSD and PCP do not seem to have lasting endocrinologic effects. Musculoskeletal issues, intoxication with individuals in one position for extended periods can lead to compression nerve palsies and rhabdomyolysis and compartment syndromes. This is especially true with people who are using the set of hypnotics or the opioids and then end up laying in a certain position that puts them at risk for these complications. Hyperuricemia and gout are common in alcohol use disorders and any substance use disorder that precipitates dehydration in at-risk individuals. Colchicine treatment in those with renal and or hepatic insufficiency or with indomethacin may precipitate a gastric lesion and renal compromise from interstitial nephritis. Steroids and hydration in the acute state and allopurinol or probenicid for chronic hyperuricemia can be used. Fractures from falls while under the influence are common. Vitamin deficiencies are common, especially with thiamine, pyridoxine, niacin, riboflavin, vitamin D, and zinc. The fat-soluble vitamins from malabsorption from pancreatitis can also occur. Vitamin replacement is safe and should be done. Peri-surgical issues. Tobacco increases post-operative complications of pneumonia, which is just common sense, atelectasis, reactive airway exacerbations, and respiratory failure. Cessation of tobacco for two months prior to major surgery is associated with improved outcomes. Alcohol, benzodiazepines, and I apologize for the misspelling there, and opioid withdrawal should be expected in patients with heavy use. History may not indicate use. The pharmacy monitoring drug program only identifies prescribed medications. Remember, methadone in the opioid treatment programs is not in the pharmacy drug monitoring programs. Buprenorphine can be stopped one day prior to surgical intervention. Some people don't even stop it, but can be continued after most procedures after the full muaginus has been stopped. Vitamin replacement is important, not only for alcohol use disorder, but also for those with cachexia and lack of consistent or adequate nutrition. Coagulopathy does need to be assessed and treated, vitamin K and clotting factors, and monitoring fluid status and mental status. Cocaine and beta blockers can complicate cardiac rhythm. Sleep issues. Despite alcohol being a set of hypnotic high levels, especially above the 100 gram dose, does become toxic and stimulating for some individuals. Hence, that's why some people become physically violent when they become significantly intoxicated. Sleep architecture changes with alcohol, opioids, benzodiazepines, barbiturates, and other drugs of abuse. Obstructive sleep apnea worsens with excessive alcohol and set of hypnotics, including opioids. Sleep hygiene and the use of drugs with low to no risk should be considered, such as strazodone, a quiet place to sleep, bed for rest, and the bed should be for rest and sleep only, or rest and sex only, and avoid stimulants including nicotine and caffeine before sleep times. If you're going to get a sleep history, stop bang, which is snoring, tired, obstruction, pressure, BMI of 28 or more, age of 50, a neck of 17, 16 and a female, gender male, and the Epworth, which is never, one for slight, two for moderate, three for a high chance of dozing, sitting and reading, watching TV, sitting inactive in public or as a passenger in a car, post-meal laying down, sitting talking to someone after lunch and falling asleep, and sleeping in a car stopped in a traffic light, they have zero to 10 as normal, 10 to 12 is borderline, and 12 to 24 is sleepy. So these screening tests, stop bang, and the Epworth are scales that can be used to evaluate people with sleep-related disorders, keeping in mind that concurrent use of alcohol and other set of hypnotics will complicate that significantly. From an osteopathic standpoint, we believe in a holistic evaluation of the biopsychosocial history and presentation. Musculoskeletal history and examination will most likely identify pathology many times before physical complaints arise. Therapeutic touch transmits acceptance. Take appropriate precautions for infectious disease. If you're examining anything that is in the chest or the underpants area, a chaperone is recommended. Monitor verbal and nonverbal cues. Patients communicate nonverbally more than verbally in regard to informed consent and examination permissions and treatments. Dermatologic findings are more visual. Palpatory skills for the subdermal areas are helpful. Person's injection use could be identified with phlebitis that you might not see, but you can definitely feel. Muscle tension and response to verbal stimuli can be detected during examination. And then avoid painful procedures in the musculoskeletal systems in patients that are hypersensitive. Indirect techniques may be more helpful in that regard. So in summary, looking at medical comorbidities, patients with addictions have medical and surgical risks. Unhealthy substance use has a wide variety of organ and system effects. Prevention can be targeted to patient's history and current use. Immunizations are important, especially in the era of COVID. Nutrition, sleep, fall prevention, laboratory evaluation, repeat examinations need to be focused on the risk issues. I have some reference that are listed here, which includes the DSM-5-TR and the Centers for Behavioral Health Statistics. Thank you very much for your interest in becoming certified in addiction medicine. And my name is Anthony Decker. If there's any questions, you're welcome to contact me. Thank you very much.

medical comorbidities

substance abuse

physical health

screening tools

assessment tools

biopsychosocial approach

preventive measures

holistic evaluation

addiction medicine