SUBSTANCE ABUSE AND WOMEN – THERE’S A LOT YOU CAN DO



 

SUBSTANCE ABUSE AND WOMEN – THERE’S A LOT YOU CAN DO

 

Our expert is Samuel A. Ball, PhD, professor of psychiatry at the Yale University School of Medicine where he is the scientific director of the Psychotherapy Development Research Center and the Women’s Health and Addictive Behavior Faculty Scholars Program. Dr. Ball is also president and chief executive officer of The National Center on Addiction and Substance Abuse at Columbia University (CASAColumbia).

 

Be sure to register for Women’s Health 2015:  The 23rd Annual Congress, April 16-19, 2015 in Washington, DC.

 

Very best,

Mitzi Perdue

mperdue@liebert.com

 

 

 

SUBSTANCE ABUSE IS LIKELY TO AFFECT MANY OF YOUR PATIENTS

 

At any given time in the U.S.,  about 15% of the population has a diagnosable substance use disorder. The lifetime rates are nearly 30%. At some point over the course of 4 years of college, nearly half of students may have a diagnosable disorder. In view of these statistics, be alert to the fact that many of your patients may have a substance abuse problem, whether it’s prescription medications, street drugs, alcohol, or nicotine.

 

 

WOMEN HAVE SPECIFIC VULNERABILITIES RELATING TO SUBSTANCE ABUSE

 

Substance abuse greatly increases the odds of a woman’s being a victim of sexual violence and/or domestic abuse.  In the case of women as mothers, substance abuse impacts their pregnancies and their ability to function in their maternal role.  Also, the same amount of a drug or alcohol taken by a woman is likely to cause more physical damage than it would to a man. In addition, the time it takes from the onset of use to actual physical impairment is generally faster for women than for men.

 

 

YOUR PATIENT MAY TRY TO HIDE HER ADDICTION

 

She may feel stigmatized by her addiction and be unwilling to bring it up. If you see medical symptoms that are related to substance abuse such as liver, coronary, or breathing problems, use these as an entryway to a discussion of alcohol, drugs, or smoking.  Make your evaluation nonjudgmental, like any other medical condition. Try to let her know that you’re not casting blame and that she’s safe talking about it with you.  Let her know that you view this as a medical disorder that impacts her life and needs treatment.

 

 

EVEN TEN MINUTES OF DISCUSSION CAN HAVE A BIG IMPACT

 

For an individual who is not severely addicted but is over-using, there’s strong evidence that a physician’s simply spending five or ten minutes recommending that she cut down or stop can really help. A follow-up conversation within a month makes this intervention even more effective.   On the other hand, if the addiction is severe, refer your patient to a specialist.  Check her insurance plan to find out who are the providers for mental health and addiction issues.

 

 

ATTITUDES TOWARDS PRESCRIBING OPIOIDS HAVE CHANGED

 

Ten years ago, the attitude was that we should be aggressive about treating pain. In some cases, patients were told that taking a painkiller was similar to taking blood pressure medication, and it was simply something to take from now on.

 

The problem with this approach is too many people became addicted. Individuals may find that they require higher and higher doses to achieve the same degree of relief. There’s also some evidence that long-term opioid use actually makes individuals more sensitive to pain.

 

An additional problem is accidental overdosing, as can happen when a patient experiences severe pain and doubles or triples the dose. Maybe she also took a drink to relax, or she was taking some other medication as well.  She falls asleep and never wakes up.

 

Health care providers need to be cautious about prescribing opioids. There are appropriate uses, for example, immediately following surgery, or in cases such as severe cancer-related pain.  However, when possible we suggest other approaches to pain management. For example, with chronic back pain, some combination of the following may be helpful: relaxation and coping skills training; rest; physical exercise; physical therapy; and non-narcotic anti-inflammatory medications. Antidepressant medications may also sometimes be helpful.

 

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HPV Risk and Cervical Cancer



HPV Risk and Cervical Cancer

 

Our expert is Mona Saraiya, MD, MPH. She joined the Centers for Disease Control and Prevention as an Epidemic Intelligence Service officer in the Division of Reproductive Health in 1995, and is currently a medical officer and Associate Director in the Division of Cancer Prevention & Control’s Office of International Cancer Control.

 

To hear more from Dr. Saraiya, be sure to attend Women’s Health 2015:  The 23rd Annual Congress, April 16-19, 2015 in Washington, DC. She’ll be one of the many outstanding presenters.

 

Very best,

Mitzi Perdue

mperdue@liebert.com

 

 

MANY WOMEN ARE MISSING THE BENEFITS OF SCREENING AND VACCINATION FOR CERVICAL CANCER

 

In spite of the fact that cervical cancer screening is one of the greatest achievements in cancer prevention, too many women still die from the disease. Eight million women in the United States between the ages of 21 and 55 were not screened in the period between 2007 and 2012, and almost half of this group have never been screened. This amounts to 11.4% of the population. In the case of women with no health insurance, the figure rises to 23%, and for those with no regular health care provider, it is 25%. The proportion of inadequately screened women is higher among older women, Asians, Pacific Islanders, American Indians, and Alaska Natives.

 

Further, only one in three girls age 11-12 are getting the human papillomavirus (HPV) vaccination, and only one in seven boys in that age group have received the vaccination. HPV vaccination and cervical cancer screening combined could prevent nearly 93% of new cervical cancer cases.

 

 

BE CAREFUL TO SCREEN AT THE APPROPRIATE AGES AND TIMES, SO AS NOT TO OVERSCREEN

 

While many women do not receive the screening they need, there are also women who are overscreened. In 2012, for the first time three major organizations involved with cancer prevention (the American Cancer Society, U.S Preventive Services Task Force [USPSTF], and the American Gynecological and Obstetrical Society) have come together on recommendations for screening. They recommend a Pap smear every three years for women ages 21-65 years. Or, in the case of women ages 30- 65 years who want to lengthen the screening interval, they recommend screening with a combination of a Pap smear and HPV testing, and this combination can be done every 5 years. The USPSTF gives these approaches an A rating, that is, “There is high certainty that the net benefit is substantial.”  In contrast, according to the USPTSF, screening more frequently or screening with younger or older women in the absence of other risk factors carries a “moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.”  In spite of this knowledge, some women are screened more frequently than is desirable, and some are screened when they are outside the range of the ages at which they’ll benefit from the tests.

 

 

VACCINATION PLAYS A MAJOR ROLE IN DECREASING THE BURDEN OF CERVICAL CANCER

 

Persistent HPV infection is responsible for the majority of cervical cancers. Like the common cold, HPV can spread easily, although unlike colds, HPV is spread through sexual contact. It is important to note that it does not require penetration to spread, given that one can get HPV through skin-to-skin contact. The good news is that most women who get the virus will clear it within two years. The bad news is that they may become re-infected many times, or if they have a weakened immune system, they may be unable to clear it. Under the wrong circumstances, the virus may cause abnormal cell changes or lesions that if untreated can progress to cancer.  There are several stages during which this chain of events can be interrupted: vaccination prevents HPV infection from occurring; screening allows detection of the virus and/or cell changes; and follow-up of abnormal results can also prevent the disease from progressing.

 

 

MAKE SURE TO STAY ON TOP OF ABNORMAL HPV AND PAP RESULTS

 

Once a woman has an abnormal diagnosis, education on appropriate follow-up and treatment is essential. This is especially true for African-American women. While Hispanic women have the highest rate of new cases, African-American women are the most likely to die. The problem is follow-up, and the cause of this can be an access, cultural, or insurance issue. No woman should die of this preventable disease, so take special care that each of your patients gets the necessary follow-up.

 

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DIABETES IN WOMEN: IMPROVING OUTCOMES



DIABETES IN WOMEN: IMPROVING OUTCOMES

 

 

Our expert is Kirsten Gill Hairston, MD, Associate Professor, Endocrinology & Metabolism, Maya Angelou Center for Health Equity, Center for Diabetes Research, Wake Forest Baptist Medical Center. Her clinical interests include diabetes management, pituitary gland disorders, obesity treatment, and thyroid disease

 

To learn more from Dr. Hairston, be sure to attend Women’s Health 2015:  The 23rd Annual Congress, April 16-19, 2015 in Washington, DC. She’ll be one of the many outstanding presenters.

 

If there is a medical topic you would like to see explored here, please let me know!

 

Very best,

 

 

Mitzi Perdue

mperdue@liebert.com

 

 

BE AGGRESSIVE WITH PREVENTION

 

When you screen, be aggressive in responding to what the numbers show. If a woman’s fasting glucose is a little on the high side, say between 100 and 125, have a conversation with her, explaining that there’s cause for concern and we need to do more than just “watch it.”   Tell her that the numbers mean she could be on her way to having diabetes, but it doesn’t have to be that way.  Tell her, “I want to work with you on your diet and exercise so your condition doesn’t progress to actual diabetes.” Let her know that losing just 10% of her body weight and changing her diet may help prevent the disease from progressing.

 

 

GESTATIONAL DIABETES IS A WARNING SIGN FOR POSSIBLE FUTURE DIABETES

 

Since pregnancy is an insulin-resistant state, it can reveal that the woman has issues with glucose regulation. After the baby is born, your patient may revert to her former state of having no evidence of elevated blood sugar.  However, she is at higher risk for developing diabetes, so   it is worth being aggressive in managing her weight and diet.  Action at this point can prevent future problems.

 

 

ENCOURAGE POSTMENOPASUAL WOMEN TO EXERCISE

 

Postmenopausal women are apt to experience a decrease in lean muscle mass. This is unfortunate because muscle mass is critical in glucose regulation.   Added to this, changes in estrogen mean postmenopausal women have a tendency to develop abdominal fat, which in turn is linked with increased risk for insulin resistance and type 2 diabetes.  Diabetes then creates increased risk for cardiovascular disease; if a woman has diabetes, it is the equivalent of already having had one heart attack.  A good exercise program can help counteract all of these risk factors.

 

 

FOCUS ON WHAT IS DOABLE

 

We often find that because of her caretaker role, a woman allows her own health to slip.  Given that she has multiple demands on her time and energy, it’s important to have a realistic conversation with her about what she actually will be able and willing to do.  With a particular individual, you may not get perfect adherence, but there are probably at least some areas where she can improve.  Maybe she cannot eliminate the stressors in her life, but with the help of a counselor, she may be better able to cope with them. Maybe she is not up for cooking different meals for herself and her husband, but perhaps she can change the menu to include lean protein as opposed to fatty proteins.  Maybe she will follow her medication regime if instead of having to keep track of her blood glucose five times a day, you reduce it to twice a day. Look for improvements that can be made.

 

 

WITH WEIGHT CONTROL, REMIND YOUR PATIENTS ABOUT “THE WHOLE PACKAGE”

 

She probably knows that to lose weight, she needs to get rid of more calories than she is taking in.  However, it often happens that she does not take into account “the whole package.”  She’ll run and maybe burn 800 calories, or spend an hour vigorously participating in a Zumba class, but then she stops by a fast food restaurant and blows it all in a few minutes.  I tell people that in order to burn the calories from two slices of regular bread, they will need to walk for an hour. And by the way, I don’t mean a casual stroll, I mean walking at a good clip.

 

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ANXIETY DISORDERS: COMMON AND VERY TREATABLE



 

ANXIETY DISORDERS: COMMON AND VERY TREATABLE

 

 

Our expert is Heidi L. Combs, MD, Associate Professor, Department of Psychiatry, University of Washington, Harborview Medical Center.  Dr. Combs is a graduate of the University of Washington, where she also completed her Psychiatry Residency.

 

If there is a medical topic you would like to see explored here, please let me know!

 

Very best,

Mitzi Perdue

mperdue@liebert.com

 

 

ANXIETY DISORDERS ARE COMMON, UNDER-DIAGNOSED, AND DEBILITATING

 

Anxiety disorders are the most common psychiatric diagnosis in the U.S.  In primary care clinics, 11% of the patients seen will have generalized anxiety disorder, and there’s a two-to-one female predominance.  Other anxiety disorders include: panic disorder, social anxiety disorder, obsessive-compulsive disorder(OCD), and post-traumatic stress disorder (PTSD).  Many of the individuals will present complaining about pain, sleep disturbance, fatigue, or distress, not realizing their symptoms may stem from an underlying anxiety disorder. If the healthcare provider is not looking for anxiety disorders, he or she may end up focusing on the symptoms and not the cause.  Chasing symptoms that don’t get better can mean years of unnecessary suffering for the patient and frustration for the provider. It is important to realize that anxiety disorders are similar to major depression when it comes to functional impairment and decreased quality of life, yet we are far more likely to miss the diagnosis.

 

SIMPLE SCREENING QUESTIONS CAN QUICKLY REVEAL ANXIETY DISORDERS

 

With the time pressures that clinicians are under, it feels as if there is never enough time to do a screening.  However, an effective screen can be done in roughly one minute, simply by asking a series of quick questions. This upfront screening can save years spent trying to manage symptoms without treating the cause. The questions I recommend are:

 

*          For generalized anxiety disorder: “Do you consider yourself a worrier?”  If the answer is yes, you might say, “Give me a sense of how much you worry in the course of a day?”  Someone with an anxiety disorder may give an answer like, “Every moment of the day.” You are on the lookout for something that impairs her quality of life.

 

*          For panic disorder: “Do you have panic attacks?”  Often someone who has panic attacks knows it and can tell you. If they are not sure, describe a panic attack as “a wave of nervousness that comes out of the blue and you notice changes in your body, like your heart is racing, it is hard to breathe, you break out in a sweat.”

*          For PTSD: “Has something traumatic that happened to you still haunt you?” We often think of PTSD as combat-related, but in fact, it can come from such experiences as sexual assault, domestic violence, a natural disaster, or a car accident. More women have PTSD than men.

 

*          For OCD, ask, “Do you get thoughts stuck in your head that really bother you, or do you need to do things over and over, like washing your hands?” To distinguish between normal and abnormal, it’s normal to check that you unplugged the iron, and you may even check several times.  However, a woman who has to go back to check that she unplugged the iron over and over again for more than 2 hours has a disorder that impairs her ability to function.

 

*          For social anxiety disorder, ask, “When you’re in a situation where people can observe you, do you feel nervous and worry that they will judge you?”  What you are looking for is not garden-variety slight discomfort, but a level of discomfort that impairs her ability to function.

 

 

ANXIETY DISORDERS ARE HIGHLY TREATABLE

 

Pharmacotherapy and psychotherapy can be highly effective, and for mild to moderate cases, either of these two approaches can be equally effective. However, in severe cases, both may be needed.

 

Psychotherapy alone can be a good choice in mild to moderate cases because often the individual with an anxiety disorder is worried about taking medications. Psychotherapy, particularly cognitive behavioral therapy, has the added advantage that the skills for handling anxiety will be available long-term, while the medications are only effective while the individual is taking them. Anxiety disorders can wax and wane throughout an individual’s lifetime, so having skills available to deal with them is an important advantage.

 

Pharmacotherapy is a good choice for those with moderate to severe symptoms or those who don’t want to do or don’t improve with psychotherapy. The cornerstone of pharmacotherapy in these cases is increasing serotonin. A variety of antidepressants are available for this, and I start my patients off with half a dose.  These medications often have side effects that transiently increase the patient’s anxiety, so I invite the patient to tell me when she is ready to increase the dose. When she feels she has control, she is apt to feel less anxiety about the medication.




MEDICATIONS AND MOOD DISORDERS IN A PRIMARY CARE SETTING



 

MEDICATIONS AND MOOD DISORDERS IN A PRIMARY CARE SETTING

 

Our expert is C. Neill Epperson, MD from the Perelman School of Medicine at the University of Pennsylvania.  She holds dual appointments in the Departments of Psychiatry and Obstetrics/Gynecology and is internationally renowned for her research in women’s mental health, specifically with respect to the pathophysiology and treatment of premenstrual dysphoric disorder and perinatal depression. Dr. Epperson is a frequent lecturer on topics in women’s behavioral health, and will be a featured speaker during Women’s Health 2015:  The 23rd Annual Congress, April 16-19, 2015 in Washington, DC. To register for the Congress, click here.

 

If there is a medical topic you would like to see explored here, please let me know!

 

Very best,

Mitzi Perdue

mperdue@liebert.com

 

 

 

WHEN TREATING BEHAVIORAL HEALTH ISSUES, BE AWARE THAT YOUR PATIENT MAY BE AMBIVALENT ABOUT TAKING MEDICATION

 

Many patients feel ambivalent about taking psychotropic medications, and this has a direct impact on how compliant they are in taking them. We health care providers expect that when we prescribe medications–for example, an antibiotic for pneumonia—the patient will take what we prescribe, because she wants to feel better. However, in the case of antidepressants, the patient may perceive a stigma attached to taking a psychiatric medication. She may not like thinking of herself as someone who needs this type of medication, and she may worry what others would think of her if they knew. When she tells you, “I’m feeling terrible, do something for me,” be aware that this doesn’t automatically mean she’ll actually take the medication that you prescribe.

 

 

 

MENTAL HEALTH CARE IN A PRIMARY CARE SETTING CAN BE CHALLENGING

 

Let’s say you have a patient who is not chronically mentally ill, but recently she has started experiencing debilitating panic attacks.  As her primary care provider, you prescribe an antidepressant, and then (assuming she even takes the medication), two or three days into her treatment, she experiences a spike in anxiety. Having had a bad experience with the medication, she quits taking it and spends the next several months feeling terrible. In the end, she winds up going to a psychiatrist.

 

MENTAL HEALTH CARE IN A PRIMARY CARE SETTING CAN ALSO BE HIGHLY EFFECTIVE

 

Let’s take this same patient. Her experience can have a different outcome if, before prescribing an antidepressant, you let her know that before she feels better, she may briefly feel more anxious. Tell her if this happens, you can make available benzodiazepines to get her through the difficult part of starting the antidepressant. Further, tell her to call if she’s having difficulty.  At the time you first prescribe an antidepressant, you might want to schedule a ten-minute follow-up office visit for a week later. You can tell her if everything is fine 24-48 hours before her appointment, she can go ahead and cancel it. For the woman who is ambivalent about taking medication, the mere fact of knowing ahead of time that she has a professional who will monitor closely how she is doing, and who can help her adjust the plan if things aren’t going well, can greatly decrease her anxiety and increase the likelihood that she will not only take her medication but also stick with it.  If a brief follow-up consultation is impractical, then have someone from your office call her just to make sure things are going well.  The follow-up visit or phone call means a small investment in time, but the payoff can be that she avoids months of unnecessary suffering and may avoid having to see a specialist.

 

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