Transcript How should care of patients with an alcohol use disorder be

In the Clinic
Alcohol Use
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (1): ITC1-1.
Which health conditions have definite links
to alcohol use?
 Hypertension, stroke, cardiomyopathy, arrhythmias
 Cirrhosis, acute and chronic pancreatitis
 Brain atrophy
 Hypogonadism with osteoporosis, sexual dysfunction
 Various types of cancer
 GERD, esophagitis, peptic ulcers
 Seizures
 Acute alcohol poisoning from heavy episodic drinking
 Increased incidence chronic diseases
 Poor nutrition
 Mental health and social consequences
 Drinking during pregnancy may harm the fetus
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (1): ITC1-1.
Common alcohol-prescription medication
interactions by class
 Cardiovascular agents: ACE inhibitors, beta-blockers,
diuretics
 Central nervous system agents: anticonvulsants,
anxiolytic/sedative/hypnotics, opioids
 Coagulation modifiers: anticoagulants
 Metabolic agents: antidiabetic, antihyperlipidemic
 Psychotherapeutic agents: antidepressant
 Respiratory agents: antihistamines
 Other: antibiotics, NSAIDs
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (1): ITC1-1.
Does alcohol use have positive health
effects?
 Unhealthy alcohol use increases the risk of CVD but
moderate alcohol use appears to be protective in some
studies
 Underlying mechanisms may include: development of
favorable lipid profiles, inhibition of platelet activation,
decreased fibrinogen levels, and anti-inflammatory effects
 Because of the lack of data from randomized clinical
trials at this time, clinicians should not recommend
initiation of low-level alcohol use for cardioprotective
effects
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (1): ITC1-1.
Which groups are at particularly high risk for
adverse health outcomes from alcohol use?
 Individuals < 21 years old and college-aged
 Individuals > 65 years old, especially with:
 Chronic medical conditions
 Taking medications that may interact with alcohol and
those with polypharmacy
 Women
 Minorities and underserved populations
 People with certain chronic medical conditions that
make them more sensitive to alcohol
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (1): ITC1-1.
CLINICAL BOTTOM LINE: Health
effects...
 Unhealthy alcohol use is associated with adverse medical,
psychiatric, and behavior-related outcomes
 Special caution with alcohol use is appropriate among:
 Young adults and older adults
 Women and minorities
 Underserved populations
 Those with chronic medical conditions
 Those taking prescribed medications
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (1): ITC1-1.
When should clinicians screen for
unhealthy alcohol use?
 Unhealthy alcohol use has negative consequences and
often goes unrecognized
 NIAAA, USPSTF, and CDC recommend routine screening
of adults for unhealthy alcohol use
 Potentially effective treatments for unhealthy alcohol
use are available
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (1): ITC1-1.
NIAAA recommended screening
opportunities
 During routine examinations
 Before prescribing a medication with potential
interactions with alcohol
 In the emergency department or urgent care center
 When seeing patient who:
 Is pregnant or planning conception
 Has risk factors for unhealthy alcohol use
 Has potentially alcohol-related health problems
 Has a chronic condition resistance to usual treatment
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (1): ITC1-1.
What are effective self-report-based
methods to screen for unhealthy alcohol
use in clinical settings?
 Single-Item Screening Question (SISQ)
 “How many times in the past year have you had ≥4 drinks
(women) or ≥5 drinks (men) in a day?”
 Positive screen: ask about frequency and quantity of use
 CAGE questionnaire (4 questions)
 AUDIT (10-item screening tool) or AUDIT-C (3-item)
 Michigan Alcohol Screening Test (25 questions)
 For screening lifetime alcohol use disorders more than
lower levels of problem drinking or binge drinking
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (1): ITC1-1.
CLINICAL BOTTOM LINE: Prevention
and screening...
 Incorporate standardized processes to facilitate routine
screening of all patients for unhealthy alcohol use
 Counsel patients with negative screening results on
maintaining lower-risk alcohol use or abstinence
 Evaluate those with positive results for alcohol use disorders
and alcohol-related consequences
 Provide appropriate treatment
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (1): ITC1-1.
How should clinicians distinguish between
“moderate” alcohol consumption, at-risk
drinking, and alcohol use disorders?
 Moderate alcohol use
 Men ≤65: ≤4 drinks on single day and ≤14 drinks/wk
 Men >65, women: ≤3 drinks on single day and ≤7 drinks/wk
 At-risk drinking
 Use that increases risk for alcohol-related consequences
 When lower-risk alcohol use thresholds exceeded
 When drinking in lower amounts increases risk
 Alcohol use disorder
 Individual meets ≥2 DSM-5 criteria
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (1): ITC1-1.
DSM-5 criteria for alcohol use disorder
Mild 2-4 symptoms; Moderate 4-5; Severe 6+
 Alcohol taken in larger amounts or for longer than intended
 Persistent desire / unsuccessful efforts to cut down or control use
 Great deal of time spent obtaining, using, or recovering from use
 Craving or strong desire to use alcohol
 Failure to fulfill major obligations due to alcohol use
 Continued use despite problems caused or exacerbated by use
 Important activities given up or reduced because of alcohol use
 Recurrent alcohol use in physically hazardous situations
 Continued use despite knowledge of physical or psychological
problems that are caused or exacerbated by alcohol
 Tolerance
 Withdrawal
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (1): ITC1-1.
What is the role of the physical exam and
lab testing in the evaluation of patients
with unhealthy alcohol use?
 Exam: Helps identify, evaluate unhealthy alcohol use
 Patients with worsening hypertension or tachycardia may
be manifesting withdrawal
 Liver, cardiac, or neurocognitive disease may signal
longer-term consequences of alcohol use
 Labs: May signal unhealthy alcohol use
 Increased mean corpuscular volume of RBCs
 Elevated gamma-glutamyl transferase
 Increased aspartate to alanine aminotransferase ratio
 Under investigation: markers related to ethanol metabolism
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (1): ITC1-1.
Findings that May Indicate Unhealthy
Alcohol Use
 Hypertension
 Jaundice
 Spider angiomata
 Cardiomyopathy
 Atrial fibrillation
 Gynecomastia
 Hepatosplenomegaly
 Ascites
 Testicular atrophy
 Palmar erythema, plethoric facies
 Peripheral neuropathy
 Cognitive abnormalities
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (1): ITC1-1.
Which other conditions should clinicians
be alert for in patients with unhealthy
alcohol use?
 Conditions that often co-occur with unhealthy alcohol use
 Substance use disorders
 Mental illness
 Chronic pain
 Sexual risk behaviors
 Underlying conditions can affect treatment decisions and
response
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (1): ITC1-1.
CLINICAL BOTTOM LINE: Diagnosis...
 Diagnosis relies on a comprehensive evaluation
 History and physical exam
 Supporting labs: various markers can detect alcohol use
and measure impact on health
 Patient self-reported information
 Screen for prevalent comorbid conditions
 Substance use
 Mental illness
 Chronic pain
 Sexual risk behaviors
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (1): ITC1-1.
What is appropriate language to use when
treating patients with unhealthy alcohol use?
 Avoid imprecise and stigmatizing language
 Use “people-first” language
 Focus on medical aspects of condition and treatment
 Avoid using slang and idioms (alcoholic, alcohol abuser)
 Compare unhealthy alcohol use to another chronic
medical condition
 Where the cause is also based on genetic and
behavioral factors and treatment is comprehensive
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (1): ITC1-1.
What should clinicians do if they identify
patients with hazardous or at-risk alcohol use?
 Provide brief, empathic interventions
 Provide specific advice on recommended alcohol use
 Give feedback on impact of alcohol on the patient’s health
 Empathize with patient’s responsibility to make a change
 List options for facilitating change
 Discuss situations likely to trigger excessive use
 Establish drinking agreement and follow-up
 Brief, multi-contact interventions are most effective
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (1): ITC1-1.
How should care of patients with an
alcohol use disorder be prioritized?
 Patients may have a ranging set of treatment needs
 Promote patient safety and stabilization first
 Initial goal is reduction in alcohol consumption
 But few are able to maintain controlled drinking
 So abstinence is typically the goal of therapy
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (1): ITC1-1.
How should alcohol withdrawal be
addressed in the primary care setting?
 Withdrawal may manifest with range of signs and symptoms
 Some patients can safely be managed as outpatients
 Patients at greater risk for harm or unlikely to follow-up
should be referred to an inpatient setting
 Use standardized instruments to guide treatment
 Clinical Inst. Withdrawal Assessment for Alcohol, revised
 Multiple dosing strategies and medication regimens may be
used to treat withdrawal symptoms, prevent seizure
 Benzodiazepines safest and most effective
 Monitor closely: withdrawal begins as early as 5-8 h and up to
72 h after last drink
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (1): ITC1-1.
Indications for referral for inpatient detoxification
 Reasons for immediate referral for inpatient detoxification
 Moderate to severe withdrawal
 History of seizures or delirium tremens
 Unable to adhere to daily follow-up
 Comorbid psychiatric or medical complications requiring
hospitalization
 Unable to take oral medication
 Unsuccessful outpatient detoxification
 Pregnancy
 Reasons to strongly consider inpatient detoxification
 Coexisting benzodiazepine use
 High risk for severe alcohol withdrawal
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (1): ITC1-1.
What is the role of psychotherapeutic
interventions for alcohol use disorder?
 Cognitive behavioral therapy
 Patients identify thoughts, feelings, circumstances that
occur before and after alcohol use
 New behaviors and techniques help patients cope with
these triggers
 Motivational enhancement therapy
 Increases internal motivation to change alcohol use
 Twelve-step facilitation
 Underlying premise that alcohol use disorders are
secondary to medical and spiritual disease
 Community reinforcement and behavioral couples therapy
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (1): ITC1-1.
When should clinicians consider
pharmacotherapy for relapse prevention?
 Consider for for all patients with alcohol use disorder
 Disulfiram
 Appropriate when abstinence is the initial goal
 Nausea, flushing, palpitations associated with alcohol use
 Acamprosate
 Dosed 3x/d and commonly leads to diarrhea, vomiting
 Dose adjustment needed with renal insufficiency
 Naltrexone
 Once daily oral or long-acting injectable
 Decreases the reward pathways associated with alcohol use
 Opioids contraindicated
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (1): ITC1-1.
When should clinicians consider
antidepressants or anxiolytics in treating
patients with unhealthy alcohol use?
 Antidepressants treat depressive symptoms but not
alcohol use disorders
 Benzodiazepines
 Standard treatment for managing acute withdrawal phase
 Ineffective for treating alcohol use disorder
 Poses risk of creating additional substance use disorder
 Consider delaying treatment of co-occurring mental
illness until abstinence achieved for at least several
weeks
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (1): ITC1-1.
Are any medications of particular concern
in the setting of unhealthy alcohol use?
 Cardiovascular agents
 Anticoagulants
 Ace-inhibitors
 Metabolic agents
 Beta-blockers
 Antidiabetic
 Diuretics
 Antihyperlipidemic
 Central nervous system
agents
 Antidepressants
 Anticonvulsants
 Antihistamines
 Other
 Anxiolytic/sedative/hypno
 Antibiotics
tics
 Opioids
 NSAIDS
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (1): ITC1-1.
What additional care should be considered
for patients with unhealthy alcohol use to
promote health?
 Comorbid conditions
 Other substance use (tobacco, drug use disorders)
 Mental health disorders (anxiety, mood, personality disorders)
 For those with longstanding alcohol use disorder: specific
cognitive and neurologic deficits
 Also: insomnia, anemia, osteoporosis, and liver disease
 Hepatitis B and C vaccinations for those with established
liver disease
 Screening for STIs
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (1): ITC1-1.
What type of follow-up care and referrals
should clinicians provide for patients with
unhealthy alcohol use?
 Patients need regular, ongoing monitoring for:
 Alcohol use
 Associated medical, psychiatric and behavioral-related AEs
 Treatment effects
 Refer patients to specialty care for:
 At-risk alcohol use that doesn’t respond to brief intervention
 Alcohol use disorder and/or significant comorbid medical or
psychiatric condition, if office-based treatments ineffective
 Use American Society of Addiction Medicine criteria
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (1): ITC1-1.
CLINICAL BOTTOM LINE: Treatment…
 For at-risk drinking, brief interventions can be effective
 For alcohol use disorder, treatment hinges on patient safety
and stabilization
 Benzodiazepines: decrease withdrawal symptoms, seizures
 Hospitalization: indicated for patients with moderate to
severe withdrawal and high risk for complications
 Prevent relapse with psychotherapeutic interventions,
pharmacotherapy, self-help groups
 Comprehensive care includes optimizing medication regimens
 Refer to specialty services
 Patients who don’t respond to treatment
 Patients who show evidence of alcohol use disorder or
significant comorbidity
© Copyright Annals of Internal Medicine, 2016
Ann Int Med. 164 (1): ITC1-1.