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Gastroenterologists can play a key role in managing substance misuse in Crohn’s disease, both in the exam room and through referral to mental health clinicians.
For much of this Peer-to-Peer program, we have examined substance misuse among patients with Crohn’s disease (CD). Here, we provide an overview of the primary guidance from experts that gastroenterologists can use to manage substance abuse in patients with CD.
In the first article for this series, Po-Hung (Victor) Chen, MD, PhD, spoke with Physician’s Weekly (PW) about findings from a retrospective cohort study of 37,323 Medicaid recipients with incident CD that he and colleagues conducted to identify patients who had newly diagnosed CD and had used alcohol, opioids, cocaine, amphetamine, or cannabis.
“Existing data on the prevalence of substance misuse among patients with CD are quite limited, which was one reason we conducted our study,” Dr. Chen told PW. “We found substance misuse in individuals with newly diagnosed CD to be generally more common than published estimates for the general US population in the same period.”
The findings of the study, which was published in Gastro Hep Advances, were “not uniform,” Dr. Chen noted.
“Alcohol and opioid misuse seemed more common among individuals with CD than in the general population, while cannabis misuse was less commonly reported. In a separate analysis our team published on tobacco use in the same cohort, estimates for tobacco use were also higher than in the general US population.”
Further, Dr. Chen explained that substance abuse can arise for several distinct reasons with CD.
“Symptoms of CD can lead to substance use as a coping strategy,” he says. “Up to a quarter of patients with CD manifest depressive symptoms. Depression and other mental health conditions are well-described as associated cyclically with substance use disorders. I am only aware of scientific data supporting the notion that tobacco use may increase the risk for developing CD. However, studies point toward alcohol and opioids as worsening symptoms among individuals with established CD.”
The Gastroenterologist’s Role: Dr. Chen
In the second article of the series, Dr. Chen talked with PW about the gastroenterologist’s role in managing substance misuse in patients with CD.
He encourages all gastroenterologists to perform substance use screenings for patients with CD and become comfortable providing brief interventions. He also notes that patients with moderate or severe disorders will need a referral to specialized treatment services.
“However, each gastroenterologist’s familiarity with managing substance use disorders will dictate the timing of referral. I recommend using a resource from the Substance Abuse and Mental Health Services Administration (SAMHSA) to help patients find the right treatment programs.”
There are several tools available, Dr. Chen continued. For those who prefer the ease of single-item screening questions, the National Institute on Drug Abuse Quick Screen is “more feasible in busy clinics.” Gastroenterologists who prefer more extensive risk stratification can use longer instruments like the Tobacco, Alcohol, Prescription medication, and other Substance use (TAPS) tool.
“I encourage gastroenterologists to take advantage of existing educational resources for themselves and their patients from SAMHSA, the National Institute on Drug Abuse, and the National Institute on Alcohol Abuse and Alcoholism, which are all federal agencies that promote service delivery efforts and research for mental health and substance misuse,” he says. “The American Society of Addiction Medicine is another good resource.”
The Gastroenterologist’s Role: Dr. Bernstein
To wrap up the discussion on substance use in CD, PW spoke with Charles Bernstein, MD. He says gastroenterologists should play “a large role” in educating patients with CD about the risks associated with substance use.
“I strongly believe gastroenterologists should be discussing smoking and mental health with all their patients,” he says. “These are two issues that can have an impact on disease course (smoking in relation to CD and mental health disorders in relation to symptoms and outcomes in both CD and ulcerative colitis). If a patient has an active substance use disorder, this will impact their ability to adhere to medical advice and medicines. Hence, gastroenterologists should be inquiring about substance use and be aware of where to refer patients who want help with quitting.”
Dr. Bernstein also encourages multidisciplinary collaboration with addiction specialists and primary care physicians for patients who “acknowledge the issue and want help quitting.”
Finally, he said he hopes gastroenterologists become more comfortable addressing psychological issues: “It’s not all about scoping!”
