Recently, the Bureau of Primary Health Care Behavioral Health Technical Assistance hosted an informational webinar for health care providers about polysubstance misuse in the primary care setting. Presenter Joseph Hyde, MA, LMHC, CAS, has nearly 40 years of experience working with substance use prevention, intervention, and treatment. Substance use and substance use disorder (SUD) are complex, Hyde said, but screening doesn’t have to be.
Despite the growing resurgence of synthetic drugs, the most commonly misused substance is still alcohol, which retains more use-related morbidity and mortality than other substances. Cannabis and opioids are the second and third most popular substances, respectively, though use of methamphetamines continues to rise.
Polysubstance use is not a new trend. The use of more than one substance concurrently was popular when Hyde began working in addictions treatment in 1980. However, many of the drugs involved in polysubstance use today are far more lethal than in years past. Drugs like fentanyl, including new strains which are much more potent, carry high risks of overdose, neurotoxicity, organ damage, and death, Hyde said. “The risks are much higher today than they were then, in terms of mortality.”
Some places call these synthetic drugs names like synthetic THC or synthetic cannabis, but they have nothing to do with marijuana, and their neurotoxicity is “profound,” Hyde said. These lethal chemicals contribute to a large portion of the increase in synthetic use. Fentanyl is another drug whose abuse is on the rise. Fentanyl is a hundred times more potent than heroin — but carfentanyl is 10,000 times more potent than morphine.
“I’m not an alarmist by nature, but the combinations of these things are really scary. I have friends, and friends of friends, who have buried children. It is a very scary time.”
Transition-age youth (TAY), defined as 18 to 25-year-olds, have the highest rates of polysubstance use and comorbid mental health conditions. According to data drawn from validated screens, 29% of teenagers age 13-17, and 39% of transition-age adults, are at risk, meaning their patterns of use put them at greater chance of harm — psychological, physical, or social. At the same time, 12% of youth are experiencing moderate to severe depression, and 9% have suicidal ideation — but that number jumps to 12% among TAY. Anxiety shows similar patterns, wherein the number of people reporting moderate to severe anxiety rises sharply between youth and young adults.
These statistics are changing the way some groups do screening. As opposed to waiting for a child to show a sufficient number of depressive warning signs before screening for self-harm, said Hyde, it may be better to screen without waiting. “There are some kids who may be considering self-harm, but they score too low just in terms of those up-front depressive symptoms.”
One of the groups at highest risk for many problems is transition-age youth who are aging out of child welfare systems, such as foster homes. Of this group, 42% experienced homelessness by the age of 21, more than 25% had been referred for SUD treatment, a third had been incarcerated, about 34% were uninsured, and a quarter had no primary care provider. Especially for the uninsured, “oftentimes the emergency department is their primary care,” said Hyde. “It’s a major fault in the system, how these kids transitioning out of child welfare are being maintained.”
Another at-risk group is persons with chronic pain. Contrary to popular belief, about two-thirds of the people who developed an opioid use disorder experienced a chronic pain condition, often an accident, prior to engaging with opioids rather than afterward. “There’s some bias out there about they’re basically scamming for more narcotics,” said Hyde, but the data shows otherwise. For these patients, an integrated approach is especially important.
“If you have a pain condition and [were] indoors for more than 30 days, and you were on narcotics for more than 30 days, the risks start to elevate in terms of depression and suicidal ideation and suicidality.” Some groups and clinics have undertaken preemptive screening for depression for people who fit this profile, Hyde said.
Hyde described a pattern where many low-income manual laborers, such as mine or construction workers, are injured on the job, are not given enough leave to heal fully, return to work too soon, and reinjure themselves worse, causing them to be on painkillers for a much longer period of time. This extended exposure puts them at higher risk for developing opioid use disorder.
What can providers do?
There are a number of measures available to aid in prevention and detection of early warning signs when prescribing narcotics to patients, says Hyde. “First things first, you’ve got to have a treatment contract.” Built into those include clauses about only obtaining prescriptions for certain types of treatment from one provider. Other measures include routine urine tests, pill counts, and care coordination between the patient and behavioral health. Because of the time frames implicated in chronic pain patient care, care coordination with behavioral health is especially important. “One of the things we know about chronic pain: It’s not going to go away,” Hyde said. “It’s not going to go away.”
Screening is another crucial tool. Hyde recommends screening for depression and alcohol and other substances regularly — even every time providers see the patient. In addition to frequent screening, providers can keep an eye out for certain patterns or behaviors that may be cause for concern, such as illegal activities, “the dog ate my prescription,” non-adherence to monitoring tests such as pill counts or urine tests, resistance to changing medication, excessive sedation, running out early consistently, requesting specific brand names only, asking for dose increases, non-adherence to recommended therapies such as physical therapy, or other signs that the patient’s life is deteriorating. “Any one of these is a cause for concern, but it’s not a cause for ‘the house is on fire,’” said Hyde.
“When you are witnessing a deterioration in the life of this person, the life that sort of makes life worth living, which is relationships, and work, and social connectedness, that’s a cause for concern. It may be because of use of medications, that may be because of a spike in depression, but when you’re seeing that happen, intervene.”
For more information on the presentation and more detailed data, look for Joseph Hyde’s webinar and associated slides to be posted at this link in the coming days.