Substance Use Disorder and Diabetes

It should be of no surprise that we have a prescription drug abuse epidemic in this country.  How does that impact diabetes management and education? What about other substances?  Cigarette smoking and alcohol use are prevalent among individuals with diabetes in the US, but little is known about screening and treatment for substance use disorders in the diabetes population.

What are the clinical implications of the public health problem of coexisting substance use and diabetes? Diabetes is major cause morbidity and mortality in the US with an estimated 24 million adults in the US with type 2 diabetes.  In addition, prescription drug abuse affects nearly 3 million adults.

Approximately 20% of adults aged 18 years or older with diabetes report current cigarette smoking. The prevalence of current alcohol use in the diabetic population is estimated to be around 50%–60% in epidemiological surveys and treatment-seeking populations. Cigarette smoking is associated with an increased risk of type 2 diabetes in a dose-dependent manner and is an independent modifiable risk factor for development of type 2 diabetes. Patients with diabetes patients with an alcohol or other drug use disorder show a higher rate of adverse health outcomes including more frequent and severe health complications as well as an increased risk of hospitalization, and longer hospital stays. They are also less likely to seek routine care for diabetes or adhere to diabetes treatment than those without an alcohol or other drug use disorder.

There is an increased trend to facilitate integration of preventive services and evidence-based treatments for substance use disorders with diabetes care in community-based medical settings.  Do you know the treatment options in your community? How do you address substance abuse disorders in your patients with diabetes?

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A pharmacy business model that’s bad for pharmacy and bad for some patients

We’ve all heard about and experienced the impact of high medication costs in recent years (http://www.endocrinologyadvisor.com/diabetes/insulin-prices-rising/article/640087/). While the ACA has increased the number of people who can obtain insurance, it has done nothing to help patients actually afford their medications. While there is no one person to blame, there is one piece of the puzzle that has a domino effect on medication costs.  The Pharmacy Benefit Manager (PBM) is a 4thparty in the mix of insurance that directly manages the prescription benefit for insurance companies.  It is the PBM who negotiates with manufacturers, insurance companies, and pharmacies. It is the PBM that offers different ‘formularies’ to health plans, in many cases disenfranchising patients who may need medications not on the ‘formulary’. A perfect example is the insulin marketplace.  (http://www.nbcnews.com/business/consumer/desperate-families-driven-black-market-insulin-n730026)  Here is a good visual and explanation of how PBM’s work: )  I think they have created a perfect storm of healthcare inefficiency that costs patients access to medications and increases the overall cost of healthcare. Why?  I could list a bunch of reasons, but what do you think?