Breaking the Habit: Treating Diabetes in Drug Addicted Patients

For patients living with diabetes, maintaining a plan of diabetes medication, proper diet, and physical activity prescribed by their physicians is a constant daily struggle. When the patient is also addicted to drugs, the struggle becomes intensely more difficult.

Reports in 2012 estimated that 23.9 million Americans (9.2% of the population) over age 12 had used an illicit drug or abused a prescription medication in the past month, according to the National Institute on Drug Abuse. Marijuana was the most commonly used substance, and its popularity has recently increased.

With the number of people using drugs, those with diabetes are clearly not immune — some research has suggested the prevalence of use may be even higher.

An Internal Medicine Journal study in 2012 revealed that of the 504 people with type 1 diabetes who responded to an anonymous survey, 388 (77%) had used recreational drugs at least once and 237 (47%) had used drugs within the last year. Among the study participants who used drugs, 24% reported daily use and 68% used three or more drugs. The most common drugs were marijuana, Ecstasy, and speed.

“We believe the prevalence estimate based on an anonymous survey may be more reflective of what happens in real life,” says lead author and endocrinologist, Paul Lee, MBBS, from the Garvan Institute of Medical Research in Sydney, Australia.

“Regardless of what the true prevalence is, the key message of the study is that drug use does occur and may lead to potentially life-threatening metabolic complications,” he adds.

A Complicating Habit

The likelihood of having poor glycemic control is increased among drug users. Drug users are more likely to forget to take their insulin dose, forget to eat as scheduled, and underreport their glucose levels. Research has also identified recurrent diabetic ketoacidosis (DKA) as another risk factor of drug use.

Another study in the April 2013 issue of Acta Diabetologica investigated adult diabetes patients in a Spanish hospital. Over four years, in 152 patients, there were 253 episodes of DKA. A drug screening was done in 40% of these episodes, and 20.6% showed substance abuse — mostly cocaine and marijuana. Of those patients who consumed drugs, 70% were admitted to the hospital more than once.

“There is a truism that drug and alcohol dependence complicates the treatment of any chronic disease, just as it complicates obtaining and maintaining employment, marriage, family dynamics, etc., in the non-medical world,” says Paul R. Chelminski, MD, associate professor of medicine at the University of North Carolina at Chapel Hill.

Chelminski says treatment of drug-abusing diabetes patients is “remarkably inconsistent across specialties.” Drug and alcohol abusers, for instance, are disqualified from receiving bariatric surgery.

“This may seem reasonable, except for the fact that these patients are eligible and receive a variety of other non-emergent medical and surgical interventions designed to enhance their function and quality of life,” he adds. “For example, joint replacements, bypass surgery…are commonly done in people regardless of their substance abuse status. The ostensible argument is that they will do less well with the follow-up regimen of bariatric surgery, but I have never seen any science to support this.”

“For medical interventions, things may seem different, but are they really?” Chelminski adds. “Take insulin, a drug with a narrow therapeutic margin. We still prescribe it to drug and alcohol addicted people despite the fact that there are real risks with this medication that are magnified in people who may spend a significant amount of time stuporous, underfed or erratically fed, and broke. It is the right thing to do, but it is riskier.”

Diabetes Care vs. Drug Counseling

There’s no doubt that this patient population provides challenges for treating physicians. Susan Herzlinger Botein, MD, of the Joslin Diabetes Center, Boston, Mass., says that she’s been especially surprised by the number of her patients in their 60s who still use marijuana every night to sleep. She does, however, draw a distinction between them and her heavier users.

“I’d say the only problem in [using marijuana to sleep] is when there’s a lot of snacking afterwards and not necessarily an appropriate use of medication for the snacks,” she explains. “People can get hyper- or hypoglycemic depending on their reaction to it. For example, when someone eats an entire bag of gummy bears and then thinks, ‘Oh no,’ and takes too much insulin in response. So that’s just the kind of habitual, low-dose marijuana use that I put in a separate category.”

Patients who are heavier smokers prove a tougher challenge to manage, Herzlinger Botein says.

“I’ve seen in a number of younger men who use marijuana all day long, who are not working and are depressed, I think [marijuana’s] effects on cognitive function start to manifest and there’s a lack of follow through on plans, particularly affecting type 1 diabetes to planning meals, planning insulin, checking blood sugar, that becomes much more spotty.”

Different Drugs, Different Hurdles

“There is a man we see in the hospital a lot and every time he uses cocaine, he gets very hyperglycemic and it causes some cardiac symptoms and he gets admitted,” Herzlinger Botein recalls. “He knows he does this and he keeps trying not to but then it happens again.”

She also spoke of a middle-aged man who had been an active heroin user who needs insulin. “He found that using a vial and syringes was a trigger for him [to shoot heroin] so switching him to pen needles helped tremendously.”

So are clinicians expected to be dual addiction counselors and convince their diabetes patients to quit drug use?

“We usually encourage patients to address their addiction issues but I don’t make that contingent on managing their care, their diabetes, because we don’t want them to, as I would say, drown in the complexity of their care,” says Chelminski. “I encourage them to think that they can do both, that they can overcome their addiction but they can manage their diabetes as well.”

Herzlinger Botein agrees. “My general approach is to not focus on a value judgment of the drug use because that’s neither here nor there, but to look hard at the way it’s affecting their diabetes because that’s why they’re seeing me.”

“Your time is a limited resource and we are not addiction specialists, but we can encourage people to optimize their health as much as possible and I really think that deep down inside, a lot of these patients are ashamed of their addiction or they’re, at the very least, not proud of it,” says Chelminski. “They know it’s a blemish on them and I don’t think it helps making people feel bad about themselves.”

— Fauntleroy is a Carmel, Ind. – based freelance writer and regular contributor to Endocrine News. She wrote about the endocrine impact of head injuries in the October issue

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