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    Knowing the OD's role in substance abuse

    Recognize the signs and symptoms and plan ahead to manage impaired patients


    Optometrists may be the first healthcare provider to become aware of a patient’s substance abuse problem. Substance abuse is not uncommon in society, and optometrists provide care in primary-, secondary-, and tertiary-care settings.

    A U.S. Surgeon General report highlights the scope of the nation’s substance use problem, advising that addiction is a chronic neurological disorder rather than a “moral failing” or a “character flaw” while imploring for change in both the public perception and the health care system.1

    The dilemma of handling patients with substance abuse problems, while seldom discussed in training and practice, is relevant to optometry’s role in society. As optometry strives for improved community recognition and increased scope, the responsibilities associated with primary care provision come along for the ride.

    In my experience, it’s virtually impossible to avoid contact with patients recently using drugs or presenting to the office while impaired (I had a private practice in the area of the country described in the book Methland).

    Substance use disorders (SUD) are defined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition as: “clinically and functionally significant impairments caused by substance use, including health problems, disability, and failure to meet major responsibilities at work, school, or home.”

    SUDs affected 20.8 million Americans in 2015; this is about the prevalence of diabetes and more than 1.5 times the annual prevalence of all cancers.1

    Substance abuse stats

    Drug use and abuse is common, affecting patients of any demographic (age, gender, ethnicity, region, socioeconomic, etc.).

    Alcohol use disorder (AUD) affects 15.1 million adults (age 18+) and 623,000 adolescents (ages 12-17). Of people age 18 and older, 26.9 percent reported engaging in binge drinking (five or more alcoholic drinks on the same occasion on at least one day in the past 30 days); AUD is more prevalent in the college student population.2

    Marijuana use is also prevalent; the National Survey on Drug Use and Health reported usage of marijuana/hashish in the past year as 12.6 percent in people ages 12-17; 32.2 percent in ages 18-25; and 10.4 percent in ages 26 and older.3

    Related: Marijuana’s role in optometry and beyond

    While marijuana remains illegal under federal law, 29 states and the District of Columbia allow medical marijuana use. Nine states (Alaska, California, Colorado, Maine, Massachusetts, Nevada, Oregon, Vermont, Washington) and the District of Columbia currently permit recreational use.

    Opioid abuse is relevant to primary care as well; the epidemic abuse of prescription opioids is a risk factor for heroin use.4

    ODs may encounter multiple other drugs, such as the “club drugs” (GHB, Rohypnol, ketamine, MDHD (Ecstasy), LSD), methamphetamine, cocaine, inhalants, anabolic steroids, synthetic cannabinoids (K2, Spice), synthetic cathinones (bath salts), and more.

    Managing substance abuse

    Evidence exists of knowledge and performance gaps in diagnosing and managing drug use and addiction.

    A survey indicated that less than 20 percent of primary-care physicians felt very prepared to identify alcoholism or illicit drug use, while greater than 50 percent of patients reported that their physician did not address their problem.5

    A 2012 report from The Center on Addiction and Substance Abuse at Columbia University stated that physicians and other medical professionals receive little education and training in addiction science, prevention, and treatment. These medical professionals also fail to identify the disorder, and they do not know what to do with patients presenting with identifiable signs and symptoms.6

    The report concluded that about only one in 10 patients with addictions to alcohol or drugs receives treatment for the condition—this is a treatment gap of 20.7 million citizens.6

    Other obstacles to care include:

    • Doctor and patient comfort levels

    • Limited time with patients

    • Availability of services

    • Inadequate or poor insurance coverage

    • Physician attitude (blaming, bias, misunderstanding).

    To address the serious risks associated with extended release and long-acting opioids, the Food and Drug Administration (FDA) has required a risk evaluation and mitigation strategy (REMS), including a REMS-compliant continuing education (CE) program and other tools for prescribers of schedule II and III controlled substances.7

    Michael W. Ohlson, OD, FAAO
    Dr. Ohlson received his doctorate from the University of Houston College of Optometry. He earned Diplomate status in the American ...

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