Substance Use disorders and GI - SCSGNA · In alcoholism, related to increased gastric pressure ... people and has been related to cyclic vomiting ... Substance Use disorders and

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SUBSTANCE USE DISORDERS

and the GASTROINTESTINAL TRACTMario San Bartolome, MD, MBA, MRO, FASAM

Mario San Bartolomé, MD, MBA, MRO, FASAM

Medical DirectorSubstance Use DisordersMolina Healthcare, Inc.

Diplomate, American Board of Addiction MedicineDiplomate, American Board of Family MedicineCertified, Medical Review Officer

FINANCIAL DISCLOSURES

■ NONE

LEARNING OBJECTIVES

■ Understand the disease model of addiction

■ Understand the neurobiological association between behaviors in addiction and the brain’s reward center.

■ Understand the in the impact that drugs of abuse have on the GI system.

Simple Road to Understanding Addiction

“…a disease is a cluster of symptoms and /or signs with a

more or less predictable course.

Symptoms are what the patients tell you.

Signs are what you see.

The cluster may be associated with physical abnormality or may not.

[Page x, Psychiatric Diagnosis, 1st Ed, 1994, Woodruff, Goodwin, Guze]

DISEASE

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Volkow ND, Kim SW, Wang GJ, et al. Acute alcohol intoxication decreases glucose metabolism but increases acetate uptake in the brain. Neuroimage 2013;64:277-283

DEFINITIONS

Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors.

DEFINITIONS

Addiction is characterized by inability to consistently abstain, impairment in behavioral control, craving, diminished recognition of significant problems with one’s behaviors and interpersonal relationships, and a dysfunctional emotional response. Like other chronic diseases, addiction often involves cycles of relapse and remission. Without treatment or engagement in recovery activities, addiction is progressive and can result in disability or premature death.

Quick Stats about Addiction

COST OF ADDICTION

Over $700 Billion

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THE GREAT HIGHJACKING

Levels of dopamine increase in the reward center when animals do those behaviors which ensure survival

Food / Water—“Eating/Drinking”

=DOPAMINE RELEASE

DON’T MESS WITH MAMMA

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Addiction is a complex but

treatable disease that affects brain

function and behavior

BUT WHAT ABOUT GI STUFF ?

ESOPHAGUS

■ GERD– Dysfunction in lower esophageal sphincter– Dysfunction in esophageal peristalsis– Abnormal gastric acid secretion

■ Direct damage to esophageal and gastric mucosa– Possible effects from acetaldehyde generated from

ethanol degradation (known toxin and carcinogen)

ETHANOL METABOLISM

The Effect of Inflammatory Cytokines in Alcoholic Liver Disease - Scientific Figure on ResearchGate. Available from: https://www.researchgate.net/259567098_fig3_The-pathway-of-ethanol-metabolism-Ethanol-is-metabolized-into-acetaldehyde-by-alcohol

MALLORY-WEIS SYNDROME

■ Massive bleeding cased by tears in the mucosa at the cardioesophageal junction after vomiting.

■ 5-15% of all cases of upper GI bleeding

■ In alcoholism, related to increased gastric pressure from repeated retching and vomiting following excessive acute alcohol consumption

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STOMACH

ALCOHOLIC GASTRITIS

■ Exposure of gastric mucosa to 20% alcohol induces gastric mucosal injury

■ Gastritis in alcohol dependent people highly related to H. pylori infection

■ Available evidence not conclusive on whether alcoholic beverage consumption causes chronic chemical gastropathy

■ Other causes confound gastritis-like symptoms

ALCOHOLIC GASTRITIS

PANCREATITIS

Figure 76-1. Intracellular events giving rise to alcoholic pancreatitis. Adapted from “ASAM Principles of Addiction Medicine,” by RK Reis et al, 2014, 5th Edition, p. 1147. Copyright 2014 ASAM

SMALL INTESTINE

■ Diarrhea– Altered

motility– Permeability– Nutritional

disorders

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COLON

■ Portal HTN related Hemorrhoids & Colonic varices

■ Chemical colitis (alcohol enemas)

■ Reduced incidence of ulcerative colitis

■ Cancer

OPIATES & OPIOIDS

Opioid induced Bowel Dysfunction (OBD)■ Blockade of propulsive peristalsis

■ Inhibition of the secretion of intestinal fluids

■ Increased intestinal fluid absorption

■ Prolonged GI transit time

■ Exacerbation by concurrent use of often constipating medications, dehydration, advancing age, metabolic abnormalities, and chemotherapy.

■ Can result in fecal impaction and stercoral perforation

“OBD” vs “NARCOTIC BOWEL SYNDROME”

■ Opioid bowel dysfunction (OBD)-Constipation, nausea, vomiting, bloating, ileus, and sometimes pain.

■ Narcotic Bowel Syndrome (NBS)– Abdominal pain is the predominant symptom– Progressive and paradoxical increase in pain despite

continued or escalating dosages of narcotics prescribed to relieve the pain

Laxative Misuse

■ No euphoria associated with laxative use

■ May be associated with bulimia nervosa

■ Can be a form of Munchausen syndrome

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ANTICHOLINERGIC MEDICATIONS

■ Amitriptyline

■ Clonidine

■ Doxepin

■ Antihistamines

■ Medications for Overactive Bladder and Parkinson’s Disease

Dizziness, dry mouth, delirium and abdominal pain

TOBACCO SMOKING

■ Linked to cancers of the upper aerodigestive tract and pancreas

■ Increases risk of Crohn’s disease and decreases Ulcerative Colitis

■ Combination of Alcohol with Tobacco smoking is additive

HEY, WHAT ABOUT THE LIVER?

Happy Liver Sad Liver

LIVER■ Cirrhosis of the liver is the 12th

most common cause of death in America (38,170 in 2014)

■ 1.5% of total deaths

■ Alcohol-related Liver Disease (ALD) 2nd most common indication for liver transplantation

■ Alcohol induced and Viral Hepatitis associated.

SIGNALING MECHANISM

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The disparity between the typical cirrhosis of chronic viral hepatitis (small liver, big nodules) and alcoholic liver diseases (big liver, small nodules) is particularly evident here. Ironically, these patients were both autopsied the same day (photograph courtesy of T.H.Kent, M.D.)

METHAMPHETAMINE

■ Bowel Ischemia possibly by splanchnic vasoconstriction or necrotizing angiitis

■ Paralytic ileus

■ Viral Hepatitis / HIV from IV use

CANNABIS

■ Cannabinoid receptors widely expressed in upper and lower GI tract

■ Antiemetic effects related to the expression of CB1 receptors in the dorsal vagal nucleus.

■ Inhibit gastric emptying and gastric acid secretion

■ May also paradoxically cause hyperemesis in some people and has been related to cyclic vomiting illness. Not well understood.

Body Packing

Case courtesy of A.Prof Frank Gaillard, Radiopaedia.org, rID: 19527

“It sort of makes you stop and think, doesn’t it?”“It sort of makes you stop and think, doesn’t it?”

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