Transcript Alcohol and Drug Abuse for Primary Care Providers

Part 1
Recognition and Intervention
The Problem
• An estimated 17% to 27% of the US population will misuse alcohol,
tobacco, or other drugs in their lifetime.
• Studies also report that 10% to 50% of hospitalized patients suffer
from a disorder related to substance misuse.
• More than 20% of adults seen by primary care physicians have a
current or past alcohol, tobacco, or other drug misuse disorder.
• About 539,000 deaths in the United States each year are
attributable to alcohol, tobacco, and other drug misuse, with an
aggregate societal cost that exceeds $238 billion.
• Clearly, these ailments are too common to be dealt with only by
specialists; yet, they are poorly diagnosed and treated by most
physicians.
Screening Recommendations
• The USPSTF recommends that clinicians screen adults age 18
years or older for alcohol misuse and provide persons engaged in
risky or hazardous drinking with brief behavioral counseling
interventions to reduce alcohol misuse.
• The USPSTF recommends that clinicians ask all adults about
tobacco use and provide tobacco cessation interventions for those
who use tobacco products.
• The USPSTF recommends that clinicians provide interventions,
including education or brief counseling, to prevent initiation of
tobacco use in school-aged children and adolescents.
• The USPSTF concludes that the current evidence is insufficient to
assess the balance of benefits and harms of screening adolescents,
adults, and pregnant women for illicit drug use.
Public Beach, Vieques, Puerto Rico
Barriers to Recognition and Intervention
• Several obstacles keep physicians from assisting substance abusing
patients.
• These include physician pessimism about the effectiveness of
intervention and treatment, a moralistic approach to substance
misuse, and a perceived lack of time and training necessary to
participate in successful interventions.
• Several predictive patterns are also evident in the management of
patients who misuse alcohol, tobacco, and other drugs.
• Many physicians simply refer patients with addictive diseases to
psychiatric or social services, thereby jeopardizing continuity of care.
• Others scold patients, and some even administer benzodiazepines to
hospitalized alcoholic patients to prevent withdrawals, but fail to
address the disease formally.
Barriers to Recognition and Intervention
• Many health care professionals simply ignore the diagnosis, failing
to recognize these conditions as chronic psychiatric diseases
characterized by relapses and remissions.
• Like a patient with untreated hypertension, those who are
substance misusers will continue to use health care services
heavily until their underlying disease is addressed.
Harbor at Esperanza, Vieques, Puerto Rico
Complications of Alcoholism
• High levels of alcohol intake are associated with impairment of
multiple organs, including brain, liver, pancreas and the immune
system.
• The first stage of liver damage following chronic alcohol
consumption is the development of fatty liver, which may be
followed by inflammation, apoptosis, fibrosis and cirrhosis.
• Alcohol and its metabolite acetaldehyde are carcinogens, and
excessive alcohol consumption is associated with increased risk for
mouth and oropharyngeal cancer, breast cancer and liver cancer.
• Depression, epilepsy, hypertension and hemorrhagic stroke occur
secondary to alcohol consumption.
• Finally, alcohol consumption during pregnancy can result in birth
defects that comprise fetal alcohol syndrome
Complications of Alcoholism
Alcoholism is a common substance-abuse
disorder that leads to significant medical
complications. Alcohol affects virtually
every organ system, and alcoholics are at
increased risk for cirrhosis,
gastrointestinal (GI) bleeding,
pancreatitis, cardiomyopathy, trauma,
mental health disorders, and a wide
variety of cancers. Patients should be
made aware of the numerous devastating
short- and long-term complications of
alcohol abuse. The computed tomography
(CT) scan shown in the slide demonstrates
an unresectable pancreatic
adenocarcinoma surrounding the superior
mesenteric artery (sma), a malignancy
that is more common in alcoholics.
Complications of Alcoholism
Alcohol abuse is the second most
common cause of cirrhosis in the
United States, after hepatitis C.
Damage to the liver parenchyma
from alcohol leads to progressive
fibrosis, producing a nodular contour
to the liver (white arrows). The
subsequent increased resistance to
portal blood flow induces portal
hypertension, which may cause
splenomegaly (yellow arrow),
transudative ascites (red arrow), and
varices. The CT image shown in the
slide demonstrates very prominent
esophageal varices (green arrow).
Complications of Alcoholism
• Hepatocellular carcinoma (HCC) is one of the most common
causes of cancer-related death worldwide.
• Life expectancy after diagnosis is generally in the range of 6-20
months. Roughly 30% of HCCs are due to excessive alcohol use.
• In patients with 10 years of chronic alcohol use, risk is increased
fivefold.
• Among patients who drink more than 30 g of ethanol daily, the risk
ratio for squamous cell carcinoma of the esophagus is 4.61 in
comparison with abstainers.
• Dysphagia with solids and eventually with liquids is the most
common presenting symptom .
Complications of Alcoholism
• Stroke is the third leading cause of death in the United States and
is a major cause of disability.
• Although low-to-moderate alcohol use is associated with a
reduced risk of stroke, heavy alcohol use significantly increases
the risk of both ischemic and hemorrhagic stroke.
• In addition to the increased risk of head trauma in alcohol abusers,
alcohol has an anticoagulant effect. Although this effect may be
protective at lower levels of alcohol consumption, it is thought to
be partly responsible for the increased risk of hemorrhagic stroke
at higher levels of consumption.
• Alcohol abuse is the second most common cause of acute
pancreatitis, after gallstones. Pancreatitis may develop either
from an isolated episode of binge drinking or from habitual abuse.
Injury to the pancreatic acinar cells creates an inflammatory
cascade, leading to significant damage to the pancreas.
Complications of Alcoholism
• Alcohol induces a number of pathologic changes to the heart.
• The classic manifestation is heart failure from dilated
cardiomyopathy.
• Patients have subsequent systolic dysfunction and are at risk for
arrhythmias, thromboembolism, and sudden death.
• Holiday heart syndrome refers to the development of rhythm
disturbances after alcohol use in patients without structural heart
disease. Atrial fibrillation is the most common disturbance, and
most cases are self-limiting.
• Chronic alcohol abuse suppresses the immune system. The
chemotactic ability of neutrophils is impaired, and this impaired
chemotaxis leads to poor response to injury and infection .
Complications of Alcoholism
35-year-old woman presents to the clinic with her husband after discovering
she is pregnant. She does not know when her last menstrual period was, but
US confirms a gestational sac (blue arrow) with yolk sac (red arrow). Your
triage nurse determines that the patient has been drinking alcohol,
sometimes to excess. The patient and her husband are concerned about
complications to the pregnancy. You advise them that maternal alcohol
consumption can be associated with fetal alcohol syndrome (FAS).
During which period of pregnancy does maternal alcohol consumption pose
an especially high risk of FAS?
A.First trimester
B.Second trimester
C.Third trimester
D.Post dates (post term)
E.None of the above; the effect is equivalent throughout pregnancy
Complications of Alcoholism
Complications of Alcoholism
• Alcohol-related psychosis is a secondary psychosis that manifests
as prominent hallucinations and delusions occurring in a variety of
alcohol-related conditions.
• For patients with alcohol use disorder, psychosis can occur during
phases of acute intoxication or withdrawal, with or without
delirium tremens. In addition, alcohol hallucinosis and alcoholic
paranoia are 2 uncommon alcohol-induced psychotic disorders,
which are seen only in chronic alcoholics who have years of severe
and heavy drinking.
• In chronic alcoholic patients, lack of thiamine is a common
condition. Thiamine deficiency is known to lead to WernickeKorsakoff syndrome, which is characterized by neurological
findings on examination and a confusional-apathetic state.
Bioluminescent dinoflagellates, Mosquito Bay, Vieques, Puerto Rico
Brief Intervention for Alcohol Use
• For the past two decades, evidence has accumulated that supports
the effectiveness of brief interventions for patients suffering from
substance misuse.
• The literature contains nearly 40 controlled studies on brief
interventions targeting drinking behavior.
• These studies included more than 6,000 problem drinkers in
various clinical settings and across 14 nations.
• Brief interventions were consistently found to be effective in
reducing alcohol consumption and facilitating treatment referral.
Brief Intervention for Alcohol Use
• A Canadian randomized study evaluating three brief interventional
methods in 159 adults showed a reduction in the frequency and
quantity of drinking of 66% for men and 74% for women.
• There was no difference in the length of the intervention or
whether the advice was given by the patient's own physician, an
assigned physician, or a nurse.
• A meta-analysis of 12 randomized controlled trials showed that
those receiving brief interventions were twice as likely to have
moderated their drinking at 6 to 12 months' follow-up as those
who received no intervention. This was consistent across sex,
intensity of intervention, or type of clinical setting.
Brief Intervention for Alcohol Use
• In Spain, a multicenter randomized controlled trial with a follow-up of
12 months evaluated brief interventions in 229 patients.
• It showed that a 15-minute physician intervention led to 67% of
patients reaching their target to reduce alcohol consumption
compared with 44% of patients who were given only 5 minutes of
physician advice.
• A randomized controlled clinical trial in the U.S., with a follow-up of a
year looked at the efficacy of brief physician interventions in 723
problem drinkers.
• The intervention consisted of two 10 to 15 minute counseling visits
delivered by physicians using a script including advice and education.
• On follow-up, a significant reduction was found in the mean number
of weekly drinks, episodes of binge drinking, frequency of excessive
drinking, and length of hospital stays.
300 year-old Ceiba tree, Vieques, Puerto Rico
Substance Use Disorder DSM-V
• Substance use disorder in DSM-5 combines the DSM-IV categories of
substance abuse and substance dependence into a single disorder
measured on a continuum from mild to severe.
• Each specific substance (other than caffeine, which cannot be diagnosed
as a substance use disorder) is addressed as a separate use disorder
(e.g., alcohol use disorder, stimulant use disorder, etc.), but nearly all
substances are diagnosed based on the same overarching criteria.
• Whereas a diagnosis of substance abuse previously required only one
symptom, mild substance use disorder in DSM-5 requires two to three
symptoms from a list of 11.
Substance Use Disorder DSM-V
• The DSM-V explains that activation of the brain’s reward system is
central to problems arising from drug use –- the rewarding feeling
that people experience as a result of taking drugs may be so
profound that they neglect other normal activities in favor of
taking the drug.
• This occurs because in persons with addiction, the substance used
stimulates dopamine release, and/or interacts with dopamine in a
unique way.
• While the pharmacological mechanisms for each class of drug is
different, the activation of the reward system is similar across
substances in producing feelings of pleasure or euphoria, which is
often referred to as a “high.”
Substance Use Disorder DSM-V
Substance-Use Disorder
A. A maladaptive pattern of substance use leading to clinically significant
impairment or distress, as manifested by 2 (or more) of the following,
occurring within a 12-month period:
1. Recurrent substance use resulting in a failure to fulfill major role
obligations at work, school, or home (e.g., repeated absences or poor work
performance related to substance use; substance-related absences,
suspensions, or expulsions from school; neglect of children or household)
2. Recurrent substance use in situations in which it is physically hazardous
(e.g., driving an automobile or operating a machine when impaired by
substance use)
3. Continued substance use despite having persistent or recurrent social or
interpersonal problems caused or exacerbated by the effects of the
substance (e.g., arguments with spouse about consequences of intoxication,
physical fights)
Substance Use Disorder DSM-V
4. Tolerance, as defined by either of the following:
a. a need for markedly increased amounts of the substance to achieve intoxication or
desired effect
b. markedly diminished effect with continued use of the same amount of the
substance (Note: Tolerance is not counted for those taking medications under
medical supervision such as analgesics, antidepressants, ant-anxiety medications or
beta-blockers.)
5. Withdrawal, as manifested by either of the following:
a. the characteristic withdrawal syndrome for the substance (refer to Criteria A and B
of the criteria sets for Withdrawal from the specific substances)
b. the same (or a closely related) substance is taken to relieve or avoid withdrawal
symptoms (Note: Withdrawal is not counted for those taking medications under
medical supervision such as analgesics, antidepressants, anti-anxiety medications or
beta-blockers.)
6. The substance is often taken in larger amounts or over a longer period
than was intended
Substance Use Disorder DSM-V
7. There is a persistent desire or unsuccessful efforts to cut down or control
substance use
8. A great deal of time is spent in activities necessary to obtain the
substance, use the substance, or recover from its effects
9. important social, occupational, or recreational activities are given up or
reduced because
of substance use
10. the substance use is continued despite knowledge of having a persistent
or recurrent
physical or psychological problem that is likely to have been caused or
exacerbated by
the substance
11. Craving or a strong desire or urge to use a specific substance.
Substance Use Disorder DSM-V
Severity specifiers:
• Mild: 2-3 criteria positive
• Moderate: 4-5 criteria positive
• Severe: 6 or more criteria positive
Specify if:
• With Physiological Dependence: evidence of tolerance or withdrawal
• Without Physiological Dependence: no evidence of tolerance or withdrawal
Course specifiers:
•
•
•
•
•
•
Early Full Remission
Early Partial Remission
Sustained Full Remission
Sustained Partial Remission
On Agonist Therapy
In a Controlled Environment
Playa Chiva (Blue Beach), Vieques, Puerto Rico
Genetics of Addiction
• Twin studies have demonstrated that the amount of alcohol one
consumes has a genetic influence.
• Age at first drink appears to be associated with alcohol-related
problem behavior, but progression to alcoholism is under stronger
genetic control than initiation, and the effect of early exposure to
predict outcome is genetically mediated.
• Alcohol-related phenotypes are typical quantitative traits, with
population variation attributable to multiple segregating loci with
effects that are sensitive to environmental exposures.
Genetics of Addiction
• The main pathway of ethanol metabolism involves its conversion
to acetaldehyde by alcohol dehydrogenase.
• Acetaldehyde is oxidized to acetate by aldehyde dehydrogenase.
The activated form of acetate, acetyl-CoA, can be metabolized
into ketone bodies, fatty acids, amino acids and steroids, in
addition to oxidation in the Krebs cycle. Cytochrome P450s and
catalase also metabolize a small fraction of ingested ethanol.
• Multiple ADH and ALDH enzymes are encoded by different genes,
and different ADH and ALDH alleles can differ in expression levels
and in the rate at which their corresponding enzymes metabolize
ethanol or acetaldehyde.
• ADH1B, ALDH2 and ADH4 influence alcohol consumption and
have been implicated as risk factors for developing alcohol abuse
or dependence.
Alcohol metabolism
Ethanol is converted to acetaldehyde by alcohol dehydrogenase (ADH) and
subsequently to acetate by aldehyde dehydrogenase (ALDH). Acetate is
conjugated to coenzyme A and the resulting acetyl-CoA can be metabolized in
the Krebs cycle, or utilized for the synthesis of fatty acids. In addition, a small
fraction of ethanol is metabolized by cytochrome P450 2E1 (CYP2E1) and in the
brain by catalase. Accumulation of acetaldehyde is responsible for the
physiological malaise commonly known as 'hangover'.
Genetics of Addiction
• The positive reinforcing effects of alcohol are mediated through
the corticomesolimbic dopaminergic reward pathway, which
extends from the ventral tegmental area to the nucleus
accumbens and is modulated by a wide range of
neurotransmitters.
• This pathway is indirectly activated by alcohol through the release
of other neurotransmitters, including acetylcholine, dopamine,
glutamate, gamma-aminobutyric acid (GABA), opioids and
serotonin.
• Several candidate genes in neurotransmitter pathways associated
with the ventral tegmental area and nucleus accumbens have been
associated with alcohol dependence.
Resources
The Genetic Basis of Alcoholism: Multiple Phenotypes, Many Genes,
Complex Networks. Tatiana V Morozova, David Goldman, Trudy FC Mackay
and Robert RH Anholt. Genome Biology 2012; 13(2): 239
Alcohol-Related Problems: Recognition and Intervention. SANDRA K.
BURGE, PH.D., and F. DAVID SCHNEIDER, M.D., M.S.P.H., University of
Texas Health Science Center, San Antonio, Texas. Am Fam Physician. 1999
Jan 15;59(2):361-370.
Red Beach, Vieques, Puerto Rico