Patients with Alcohol Problems

1. Patients with Alcohol Problems Authors: Colin Gallahan, M.D., Maxwell Prempeh, M.D., and Anja Wagner, M.D. Editor: Amy Shaheen, MD Assistant Professor of Clinical Medicine Duke University Medical Center

2. LEARNING OBJECTIVES • To appreciate the prevalence of alcohol use in this country and its associated costs • To understand the spectrum of alcohol use disorders • To learn effective ways to screen for alcohol use in the primary care setting • To learn the common health and psychosocial problems that can be caused by chronic alcohol use • To understand the treatment options for acute alcohol withdrawal and for chronic alcohol dependence • To become familiar with easily accessible resources for helping patients with alcohol problems

3. Epidemiology • In the US, 85,000 deaths are attributed to the use of alcohol each year. • The estimated annual cost in this country attributed to alcohol use is $185 billion. • The prevalence of alcohol use is as follows: 7-20% of outpatients; 30-40% among patients in the ER; and 50% among patients involved in trauma • About half of all cases of cirrhosis, nonischemic cardiomyopathy, pancreatitis, and cancers of the esophagus, larynx, and mouth are secondary to alcohol.

4. Definitions / Terms Definitions of Unhealthy Alcohol Use…

5. Definitions / Terms Risky Use • For women and persons > 65, > 7 standard drinks per week or > 3 drinks per occasion • For men ≤ 65, > 14 standard drinks per week of > 4 drinks per occasion • No alcohol related consequences • Does not meet criteria for alcohol dependence (Standard drink is 12 -14 g of ethanol, which is 12 oz of beer, 5 oz of wine, or 1.5 oz of 80-proof liquor)

6. Definitions / Terms Problem Drinking • Risky use of alcohol which is accompanied by alcohol-related consequences • Does not meet criteria for alcohol dependence

7. Definitions / Terms Alcohol Abuse • Maladaptive pattern of alcohol use leading to clinically significant impairment or distress, manifested within a 12 month period by one or more of the following: -- Failure to fulfill role obligations at work, school, or home -- Recurrent use in hazardous situations -- Legal problems related to alcohol use -- Continued use despite alcohol-related social or interpersonal problems

8. Definitions / Terms Alcohol Dependence • Maladaptive pattern of alcohol use leading to clinically significant impairment or distress, manifested within a 12 month period by 3 or more of the following: -- Tolerance -- Withdrawal -- Use of larger amounts over a longer period of time -- Persistent desire or failed attempts to cut down or control use -- Great deal of time spent obtaining, using, or recovering from use -- Important social, occupational, or recreational activities given up or reduced -- Use despite knowledge of alcohol-related physical or psychological problems

9. Definitions / Terms The Spectrum of Alcohol Use Alcoholism / Alcohol Dependence ↑ Harmful Use / Alcohol Abuse ↑ Problem Drinking ↑ Risky Use ↑ Low-Risk use ↑ Abstinence

10. Screening Screening for alcohol use in the primary care setting…

11. Screening Why do it? • The U.S. Preventive Services Task Force (USPSTF) recommends screening and behavioral counseling interventions in the primary care setting to reduce alcohol misuse by adults. (Grade B recommendation)

12. Screening • The USPSTF found good evidence that screening in primary care can accurately identify patients who do not have alcohol dependence, but whose pattern of alcohol consumption places them at risk for increased morbidity and mortality. • The USPSTF found some evidence that interventions lead to positive health outcomes four or more years post-intervention, but there was only limited evidence that screening and behavioral counseling actually reduces alcohol-related morbidity.

13. SCREENING First, the basic history: • Ask all patients about current and past alcohol use and also about family history of alcohol use; • In patients who report alcohol use, obtain detailed history about quantity and frequency of use; • Use one of the standardized questionnaires to detect possible problem drinking (see next two slides); • In patients with suspected alcohol misuse, ask more detailed questions to evaluate for possible abuse or dependence, and to evaluate for other medical or psychosocial complications which may be attributable to alcohol use

14. SCREENING QUESTIONNAIRES CAGE questions • Have you ever felt you should cut down on your drinking? • Have people annoyed you by criticizing your drinking? • Have you ever felt guilty about your drinking? • Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (eye-opener)? (1 or 2 positive responses has a sensitivity of 53-92% and specificity of 81-95% for unhealthy alcohol use)

15. Screening Questionnaire Alcohol Use Disorders Identification Test (AUDIT) • Questions on next slide • Overall score of 8 or more has a sensitivity of 51-97% and specificity of 78-96% for unhealthy alcohol use • Score of 4 or more on first three questions (AUDIT-C) has a sensitivity of 86% and specificity of 72% for unhealthy alcohol use • Score of one or more on question #3, has a sensitivity of 77% and specificity of 83% for unhealthy alcohol use

16. Screening Questionnaire 1) How often do you have a drink containing alcohol? Never, 0 Points Monthly or less, 1 pts 2-4 x a month, 2 pt 2-3 x a week, 3 pt 4 or more x a week, 4 pts 2) How many drinks containing alcohol do you have on a typical day when you are drinking? 1 or 2, 0 Points 3 or 4, 1 pt 5 or 6, 2 pts 7 or 9, 3 pts 10 or more, 4 pts 3) How often do you have 6 or more drinks on one occasion? Never, 0 Points Less than monthly, 1 pt Monthly, 2 pts Weekly, 3 pts Daily or almost daily, 4 pts 4) How often during the past year have you found that you were not able to stop drinking once you had started? Never, 0 pts Less than monthly, 1 pt Monthly, 2 pts Weekly, 3 pts Daily or almost daily, 4 pts

17. Screening Questionnaire 5) How often during the past year have you failed to do what was normally expected from you because of drinking? Never, 0 pts Less than monthly, 1 pt Monthly, 2 pts Weekly, 3 pts Daily or almost daily, 4 pts 6) How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? Never, 0 pts Less than monthly, 1 pt Monthly, 2 pts Weekly, 3 pts Daily or almost daily, 4 pts 7) How often during the past year have you had feelings of guilt or remorse after drinking? Never, 0 pts Less than monthly, 1 pts Monthly, 2 pts Weekly, 3 pts Daily or almost daily, 4 pts

18. Screening Questionnaire 8) How often during the past year have you been unable to remember what happened the night before because you had been drinking? Never, 0 pts Less than monthly, 1 pt Monthly, 2 pts Weekly, 3 pts Daily or almost daily, 4 pts 9) Have you or someone else been injured as a result of your drinking? No, 0 pts Yes, but not in the past year, 2 pts Yes, during the past year, 4 pts 10) Has a relative, friend, or doctor or other health worker been concerned about your drinking or suggested you cut down? No, 0 pts Yes, but not in the past year, 2 pts Yes, during the past year, 4pts

19. Screening Unhealthy Alcohol Use should be considered in patients with the following: • Refractory hypertension • Depression • Insomnia • GERD • Anemia • Thrombocytopenia • Trauma • Difficulties with social life or work

20. Screening Abnormal lab values possibly associated with unhealthy alcohol use: • Elevated MCV with or without anemia • Elevated AST and ALT, with disproportionate elevation of AST • Elevated GGT  Elevated carbohydrate-deficient transferrin (perhaps the most sensitive and specific test for screening, though not routinely recommended.)

21. Health Problems with Acute Alcohol Intoxication • Accidents • Traffic fatalities • Trauma • Domestic violence • Homicide • Suicide

22. Acute Alcohol Intoxication What to do with the patient who walks into your clinic with signs of acute alcohol intoxication? Priceless thoughts running through your mind: Why did he/she come today and into my clinic? How dare he/she walk in here… Maybe that’s just root beer I smell on his/her breath He/she always did have a slightly slurred speech

23. Acute Alcohol Intoxication • Idenitfy the clinical features consistent with intoxication • Slurred speech, nystagmus, unsteady gait, memory impairment, incoordination, stupor, or coma • Confirm alcohol consumption • Serum ethanol level • Rule out other potential causes for signs and symptoms • CBC, chem7, electrolytes, serum glucose, UA, drug screen, ammonia, medication list, and brain imaging if necessary • Assess severity and potential toxicity • Level of serum ethanol in the appropriate context (ie chronic abuser, weight, time of consumption), end-organ damage (ie brain, liver, heart, lungs, and kidneys) • Supportive care • Abstinence, intravenous fluids (IVFs), thiamine (prevent wernicke’s encephalopathy), dextrose, close monitoring for deterioration and need for invasive support (ie respiratory intubation)

24. Acute Alcohol Intoxication • Patients with mild intoxication can be managed with supportive care in the clinic as long as they can be closely monitored and is expected to be completely sober in 2-3 hrs • Keep in mind how busy the clinic can be and how quickly the patient can deteriorate if severity and potential toxicity is miscalculated • Typically do not need IV catheter placement and IVFs • Ideally can be discharged into the care of a sober individual • Patients with moderate to severe intoxication should be sent to the ED via ambulance for further observation and management with appropriate disposition as deemed fit by the ED clinician • Will need IV catheter placement with infusion of intravenous fluids along with closer monitoring, repeated re-evaluation for the need for electrolytes replacement/correction and/or neuroimaging • Admission into the hospital is encouraged for patients with history of chronic abuse given increased risk of complications (ie severe withdrawal symptoms)

25. MEDICAL Fetal alcohol syndrome Malnutrition Anemia, Thrombocytopenia, Leucopenia GERD, Gastritis Hypertension Cardiomyapathy Pancreatitis Liver Fibrosis, Cirrhosis, Steatosis, Hepatitis Esophageal Varices Increased Cancer rates; liver, esophagus, throat, and larynx Death Neurologic / Cognitive  Alcohol Withdrawal Syndrome Myopathy: 50-60% of chronic alcohol abusers Peripheral Neuropathy: 20-30% Cerebellar Degeneration Korsakoff’s Amnestic Syndrome Wernicke-Korsakoff Encephalopathy (WE) Psychosocial Anxiety/Depression Suicide Unemployment Isolation Divorce Health Problems with Chronic Alcohol Abuse

26. Treatment Brief Interventions Heavy Drinkers • 10-15 minutes of physician counseling about alcohol use, providing feedback, goal-setting, and making follow-up plans • Have been shown to decrease drinking and its consequences at six-month follow-up, with a decrease by 10.5% in the prevalence of risky drinking among patients with heavy drinking but without alcohol dependence • Have been shown to be cost effective for both the patient and health care system

27. Treatment Alcohol dependence • Must consider inpatient versus outpatient therapy • Referral to Alcoholics Anonymous (AA) meetings • Pharmacotherapy, in conjunction with psychosocial therapy, to prevent relapse and reduce frequency of drinking • Follow-up during abstinence

28. Treatment Inpatient versus Outpatient Therapy • Symptoms of mild or moderate withdrawal can be managed as an outpatient • insomnia, tremulousness, mild anxiety, gastrointestinal upset, headache, diaphoresis, palpitations, or anorexia • Symptoms of severe withdrawal, history of seizures, or high risk clinical features of failure with outpatient treatment should be managed as an inpatient • Seizure activity, history of withdrawal seizures or complications, depression with suicidal ideation, hallucinations, severe coexisting medical or psychiatric conditions, extremely unstable home situation, failure to respond to outpatient treatment, pregnancy, multiple previous detoxifications, and delerium tremens (fever, hypertension, tremors, hallucinations, agitation, and disorientation) • Treatment is with Benzodiazepines (lorazepam, diazepam, and chlordiazepoxide) • The Clinical Institute Withdrawal assessment for Alcohol Scale can be used to determine the severity of withdrawal (http://www.aafp.org/afp/20040315/1443.html)

29. Treatment-Counseling Alcohol Anonymous (AA) Meeting • The AA organization is a fellowship of men and women who share their experiences with alcoholism and help each other overcome their dependence • There are no dues or fees as the organization is self-supporting • Physicians should take an active role in referring their patients to AA meetings • AA meetings have been shown to be cost effective when compared to other outpatient alcohol treatment programs in patients with alcohol dependence

30. Treatment-Pharmacotherapy • For detoxification or treatment of withdrawal  Benzodiazepines every 1-2 hours until symptoms subside (Diazepam, Chlordiazepoxide, Lorazepam) ● For treatment of alcohol dependence to prevent relapse  Maintenance dosing: - Naltrexone (ReVia) 50-100mg PO qday • Initiate with 25mg x1 and if no withdrawal signs within 1 hour give another 25mg • Can be used to treat problem drinkers as well - Acamprosate(Campral) 666mg PO tid • A lower dose (4 tablets/day or 1332mg) may be considered in patients with low body weight (eg, <60 kg). • Just for patients with alcohol dependence who have initiated abstinence - Disulfiram (Antabuse) 250mg PO qday • Initiate with 500mg PO qday for 1-2 weeks • For alcohol dependent patients who have abstained from ethanol for at least 12 hours

31. Treatment-Pharmacotherapy • Naltrexone is an opioid antagonist that reduces the pleasurable effects of alcohol and enhances the effectiveness of psychosocial therapy • Shown to increase abstinence rates (50% versus 25%) and reduce number of drinking days, alcohol craving, and alcohol relapse (specified number of drinks per occasion or per week) • One study showed approximately 50% reduction in the relapse rate compared to placebo (26% versus 53%) in patients who completed drug therapy • Expected relapse rates in all patients treated with naltrexone range from 25-50% • Most trials show trend toward reduced relapse rates with naltrexone as compared to placebo, but the reduction becomes statistically significant with increased adherence

32. Treatment-Pharmacotherapy • Acamprosate (calcium acetyl homotaurinate) is a synthetic derivative of homotaurine, a structural analog of gamma-aminobutyric acid (GABA) • Thought to reduce the ‘craving’ that is experienced by alcohol dependent patients • Also shown to reduce relapse rate and number of drinking days • Meta-analysis has shown that the outcome effects are comparable to naltrexone

33. Treatment-Pharmacotherapy • Disulfiram (tetraethylthiuram disulfide) acts as a deterrent to drinking by causing painful symptoms if alcohol is consumed • Reduces the rate of oxidation of acetaldehyde, causing a 5- to 10-fold increase in the concentration of acetaldehyde. The increased acetaldehyde levels are thought to produce the unpleasant side effects associated with acetaldehyde syndrome • Mixed data with regard to its efficacy at reducing alcohol relapse and decreasing the number of alcohol days. • One study showed approx 43% decrease in the number of drinking days as compared to placebo. There was no significant difference with regard to percent of patients who had complete abstinence. However, patients who adhered to the drug regimen had higher rate of complete adherence. • Compliance is the greatest predictor of outcome, and monitoring for compliance may increase efficacy

34. Treatment-Pharmacotherapy Disulfiram D- Drowsiness and fatigue as side effects I- Ingestion of alcohol will lead to accumulation of Acetaldehyde S- Systemic reaction caused when alcohol taken U- Unsuitable if severe personality disorder, pregnant, cardiac failure, psychosis, CHD, CVA, elevated BP, or breastfeeding L- Libido reduced F- Flushing face with alcohol I- Irregular heart, palpitations, arrhythmias with alcohol R- Renal impairment or respiratory distress - caution A- Adjunct treatment in chronic alcohol dependence M- Mouthwashes and some medicines may cause reaction because they contain alcohol

35. Treatment-Pharmacotherapy • Combination Therapy • A randomized controlled double blinded trial of 160 alcoholics after detoxification found the combination of naltrexone and acamprosate to be more efficacious in preventing relapse at 12 weeks than acamprosate alone (statistically significant) and naltrexone alone (not statistically significant). • Medication compliance was similar across treatment groups, with an overall mean rate of 81.1% based on returned capsule or tablet count. • Of note, with regard to compliance in actual practice, naltrexone is a once daily drug as opposed to acamprosate which is 3 times a day. Therefore compliance may be different in actual practice.

36. Treatment Follow-up • Physicians should have routine follow-up with encouragement for continued abstinence and continued involvement with AA meetings • Reasons for relapse include depression, boredom, loneliness, stopping AA, and anxiety • Physicians should look for and treat comorbid disorders such as cigarette smoking, anxiety, and depression, among others

37. QUESTION 1 1. Mrs. S comes into clinic for the fourth time in 3 months. Her complaint is diffuse pruritis. Physical exam, lab tests and skin biopsy have been unremarkable except an MCV of 99 and an AST on one visit of 66 (ULN=40). She is quite anxious and somewhat agitated on this particular visit at 9:00a.m. She also smells of alcohol. She admits drinking to control her itching and reports alcohol has always been a large part of her and her husband’s social lives. An EToH level in clinic is 79. She refuses help to stop drinking as she thinks this is therapeutic for her itching. What should you do at this point? • Re-evaluate for liver disease as an occult cause of itching • Keep patient in clinic for 2-3 hours and call her husband to pick her up. Give both information on AA and other community based options for alcoholism • Suspecting this level is not unusual for her, send her home with information on AA and other community based options for treatment • Prescribe disulfiram and acomprosate with follow-up in one week *Answer is B. Her level is elevated but not terribly so. She has no signs of chronic liver disease. Keeping her and the community safe by securing transportation is the correct medical legal thing to do. Referral for help and early follow-up is indicated. Work-up for other liver disease can wait until she is not drinking. It may not be indicated at all once she is sober.

38. QUESTION 2 2. Which is not a CAGE question? • Cut down • Craved alcohol more than once a week • Annoyed by questions • Feel Guilty • Eye-opener *Answer: 2 2a. What is the specificity of 2 positive CAGE questions? • 81-95% B) 52-92% C) 100% D) 30% *Answer: A

39. Question 3 3. Mr. R. comes to clinic. His wife is accompanying him and demanding hospitalization for Mr. R for alcohol use. Mr. R.is 64 and his wife reports that he is drinking at least 750cc of grain alcohol daily. Mr. R is combative but coherent and adamantly refuses admission. He agrees to labs and possible outpatient treatment as his wife is threatening to leave him and clean out the checking account. Labs show an AST of 600 and ALT of 450. His PT is 14.1. His Albumin is 3.8. Platelets are 100K and HCT is 35 with an MCV of 102. Alcohol level is 279. The next appropriate step is: • Outpatient referral for psychosocial support in alcohol management • #1 and Disulfiram • Hospital admission • Schedule follow-up in 2 weeks, admonish him not to drink and then suggest outpatient alcohol treatment and naltrexone. *3-He is at high risk of complications from his alcohol abuse. He is likely to have significant withdrawal as his level is so high and yet he is coherent. This suggests dependence and tolerance. His abnormal labs suggest physical consequences and may worsen before improving.

40. QUESTIONS 4. Which of the following is not associated with alcohol abuse? • Elevated MCV • Elevated AST and ALT (more AST) • Elevated GGT • Elevated White blood cell count • Elevated carbohydrate-deficient transferrin *Answer: Elevated White blood count. This is not usually indicative of alcohol use.

41. 5. In patients with alcohol dependence which of the following is appropriate for treatment? • Naltrexone for 6 months followed by psychosocial therapy • Naltrexone and acamprosate without psychosocial therapy • Brief interventions by the primary care physician • Acamprosate with concomitant psychosocial therapy *Answer: 4. Acamprosate with concomitant psychosocial therapy-no therapy without psychosocial support has been studied or is currently appropriate

42. 6. Which of the following statements about oral pharmacologic therapy is true? • Acamprosate is an opioid antagonist that reduces the pleasurable effects of the alcohol • Naltrexone is a synthetic analog of GABA which serves to reduce the craving associated with alcohol dependence • Disulfiram with alcohol causes increased serum acetaldehyde and flushed face • Disulfiram is not approved by FDA for alcohol dependence *Answer: 3. Disulfiram with alcohol causes increased serum acetaldehyde and flushed face

43. Matching 7. Matching. Match the patient with the level of alcohol use: • The lawyer who drinks 8 beers Dependence after work three nights a week. 2. The lawyer who got fired because Risky Use he was drinking too much and didn’t finish his work. 3. The lawyer who presented with Problem Drinking withdrawal seizures. 4. The lawyer who just got his third Abuse DUI.

44. Matching • The lawyer who drinks 8 beers Dependence after work three nights a week. 2. The lawyer who got fired because Risky Use he was drinking too much and didn’t finish his work. 3. The lawyer who presented with Problem Drinking withdrawal seizures. 4. The lawyer who just got his third Abuse DUI.

45. 8. Right before you go in to see one of your established patients, his wife pulls you aside and says that she is worried about how much he drinks. How do you approach this patient? • Immediately call the DMV to have his driver’s license taken away. 2) Prescribe Disulfiram and ask that he take it before he goes out with his friends. 3) Recommend this great new sports bar you just discovered in Raleigh. 4) Spend 15 minutes counseling the patient about his alcohol use and make plans for a follow-up visit to further discuss his drinking.

46. *Answer: 4) Spend 15 minutes counseling the patient about his alcohol use and make plans for a follow-up visit to further discuss his drinking. • 10 – 15 minute brief interventions by physicians have been shown to decrease drinking and its consequences at six-month follow-up, with a decrease by 10.5% in the prevalence of risky drinking among patients with heavy drinking but without alcohol dependence.

47. RESOURCES • National Institute on Alcohol Abuse and Alcoholism http://www.niaaa.nih.gov/  Alcoholics Anonymous http://www.alcoholics-anonymous.org/  Al-Anon: for families of alcoholics http://www.al-anon.alateen.org/ ● http://www.psychejam.com/disulfiram.htm ● http://www.aafp.org/afp/20040315/1443.html

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49. REFERENCES • Volpicelli, Rhines, Rhines, et al; Naltrexone and alcohol dependence. Role of subject compliance; Arch Gen Psychiatry. 1997 Aug;54(8):737-42. • Kiefer F; Jahn H; Tarnaske T et al; Comparing and combining naltrexone and acamprosate in relapse prevention of alcoholism: a double-blind, placebo-controlled study; Arch Gen Psychiatry 2003 Jan;60(1):92-9