Transcript Identification and Treatment of Alcohol Use Disorders in Primary Care

Identification and
Treatment of Alcohol
Use Disorders in
Primary Care
Valerie Carrejo, MD
Resident school 8/31/2016
Objectives
• Know who to screen for alcohol use in the primary care setting
• Know how to screen for and interpret screening for at risk
drinking and alcohol use disorders in the primary care setting
• Know how to start a conversation about alcohol use in
patients who may drink too much
• Know how to identify patients who may need medication
assisted treatment for their alcohol use disorder
• Know the three FDA approved medications for treating alcohol
use disorders in the outpatient setting
• Review other medications that may be beneficial for treating
alcohol use disorders in the outpatient setting
Do you know this patient?
• 54 yo male with a history of hepatitis C and alcohol use who is
admitted to the family medicine service after having a
witnessed seizure.
• The patient says “my doctor told me to quit drinking because I
have cirrhosis”
Alcohol use affects us all
Why should we care?
We all know it is a problem
• Excessive alcohol use can increase a person’s risk of
developing serious health problems in addition to those issues
associated with intoxication behaviors and alcohol withdrawal
symptoms.
• Many Americans begin drinking at an early age. In 2012, about
24% of eighth graders and 64% of twelfth graders used alcohol
in the past year.
• http://www.samhsa.gov/disorders/substance-use
Short-term health risks
• Injuries, such as motor vehicle crashes, falls, drownings, and
burns
• Violence, including homicide, suicide, sexual assault, and
intimate partner violence
• Alcohol poisoning, a medical emergency that results from high
blood alcohol levels
• Risky sexual behaviors, including unprotected sex or sex with
multiple partners
• STDs
• Unintended pregnancies
• Still births, miscarriage and fetal alcohol syndrome
• http://www.cdc.gov/alcohol/fact-sheets/alcohol-use.htm
Long-term health risks
• High blood pressure, heart disease, stroke, liver disease, and
digestive problems
• Cancer of the breast, mouth, throat, esophagus, liver, and
colon
• Learning and memory problems, including dementia and poor
school performance
• Mental health problems, including depression and anxiety.
• Social problems, including lost productivity, family problems,
and unemployment
• Alcohol dependence, or alcoholism
• http://www.cdc.gov/alcohol/fact-sheets/alcohol-use.htm
National statistics
• According to the Centers for Disease Control and Prevention
(CDC), excessive alcohol use causes 88,000 deaths a year.
• National Survey on Drug Use and Health (NSDUH)
• slightly more than half (52.7%) of Americans ages 12 and up
reported being current drinkers of alcohol. Most people drink
alcohol in moderation.
• However, of those 176.6 million alcohol users, an estimated 17
million have an AUD.
New Mexico
In 2007, the estimated cost of excessive alcohol consumption in New
Mexico was more than $2.8 billion, or $1,400 per person.*
• Over the last 15 years, New Mexico’s death rate for alcohol related
injury has consistently been among the worst in the nation ranging
from 1.4 to 1.8 times the national rate.*
• Over the past 25 years, New Mexico’s rate of Alcohol-related Chronic
Liver Disease (AR-CLD) has increased 14% while the national rate has
decreased 24%.**
• Since 1998, the death rate from AR-CLD has been 45-50% higher
than the death rate from alcohol-related motor vehicle crashes.**
• *The State of Health in New Mexico 2013 , NM Dept of Health
• **New Mexico Substance Abuse Epidemiology Profile, New Mexico Department
of Health, October 2010
Who do we treat?
• Only about 13 percent of persons with alcohol dependence
receive specialized addiction treatment
• Only 24 percent seek any kind of help.
• Only the most severely dependent drinkers attend alcohol
rehabilitation programs.
• For those who do, there is a 10-year gap between the onset
of the disorder (21 years of age, on average) and first
treatment.
When use becomes a disorder
• Problem drinking that becomes severe is given the medical
diagnosis of “alcohol use disorder” or AUD.
• Approximately 7.2 percent or 17 million adults in the United
States ages 18 and older had an AUD in 2012.
• 11.2 million men and 5.7 million women.
• An estimated 855,000 adolescents ages 12–17 had an AUD.
• Unfortunately, only of a fraction of people who could benefit
from treatment receive help.
• In 2012, 1.4 million adults received treatment for an AUD at a
specialized facility (8.4 percent of adults in need). This included
416,000 women (7.3 percent of women in need) and 1.0 million
men (8.9 percent of men in need).
• https://www.niaaa.nih.gov/alcohol-health/overview-alcoholconsumption/alcohol-use-disorders
Who should we screen?
Who should we screen?
• USPSTF
• Adults age 18 and older
• The USPSTF recommends that clinicians screen ALL adults aged 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.
• Grade B recommendation
• Adolescents
• The USPSTF concludes that the current evidence is insufficient to
assess the balance of benefits and harms of screening and behavioral
counseling interventions in primary care settings to reduce alcohol
misuse in adolescents
• Grade I statement
How should we screen?
How should we screen?
• One question
• “Do you drink alcohol?”
• Then move on if the answer is yes
How should we screen?
• The USPSTF recommends one of the following tools
• AUDIT questionnaire
• Abbreviated AUDIT-Consumption
• Single Question of alcohol use
• “How many times in the past year have you had five (for men) or
four (for women and all adults older than 65 years) or more
drinks in a day?”
• This single-question screen has been shown to be as sensitive and
specific as other screening methods
Standard Drink
Counsel all patients who drink
• Advise to stay within recommended limits
• For healthy men up to age 65— no more than 4 drinks in a day
AND no more than 14 drinks in a week
• For healthy women (and healthy men over age 65)— no more
than 3 drinks in a day AND no more than 7 drinks in a week
• Recommend lower limits or abstinence as medically indicated;
for example, for patients who
• take medications that interact with alcohol
• have a health condition exacerbated by alcohol
• are pregnant (advise abstinence)
• Express openness to talking about alcohol use and any
concerns it may raise
• Rescreen annually
Levels of consumption
• Moderate Drinking—According to the Dietary Guidelines for
Americans, moderate drinking is up to 1 drink per day for
women and up to 2 drinks per day for men.
• Binge Drinking—
• SAMHSA defines binge drinking as drinking 5 or more alcoholic
drinks on the same occasion on at least 1 day in the past 30 days.
• The National Institute on Alcohol Abuse and Alcoholism (NIAAA)
defines binge drinking as a pattern of drinking that produces
blood alcohol concentrations (BAC) of greater than 0.08 g/dL. This
usually occurs after 4 drinks for women and 5 drinks for men over
a 2 hour period.
• Heavy Drinking—SAMHSA defines heavy drinking as drinking 5
or more drinks on the same occasion on each of 5 or more
days in the past 30 days.
Alcohol Use Disorder
• More than moderate, binge or heavy drinking
• May require more specific questioning
• Use DSM criteria to help decide
Risky Drinking
• State your concern and recommendation clearly
• “You are drinking more than is medically safe”
• “I encourage you to cut back or quit drinking”
• “Are you willing to consider making this change?”
• Helping Patients Who Drink Too Much
Is the patient ready to change?
NO
•
•
•
•
Don’t be discouraged
Restate your concern
Encourage reflection
Reaffirm your willingness
to help
YES
• Help set goals
• Agree on a plan
• Specific steps/goals
• How will it be tracked
• Arrange follow up
• Provide tools
• Offer referral for
counseling
Behavioral support
• Counseling
•
•
•
•
Cognitive behavioral therapy
Motivational enhancement therapy
Marital and family therapy
Brief Interventions
• Mutual Help Groups
• Alcoholics anonymous
• Other 12-step programs
• Al Anon- for family members
• Online recovery services
• SMART Recovery
• Life Process Program
Behavioral Health Supports
•
•
•
•
Developing the skills needed to stop or reduce drinking
Helping to build a strong social support system
Working to set reachable goals
Coping with or avoiding the triggers that might cause relapse
Your patient likely has AUD,
now what?
Laboratory evaluation
• CBC
• Mean corpuscular volume (MCV) may be elevated in alcohol
induced macrocytic anemia
• Platelets may be suppressed in heavy drinkers
• Liver function testing
• AST commonly elevated over ALT
• Elevated GGT plus elevated AST has high specificity for heavy
alcohol use
• Chemistry
• Assess renal function and glucose
• HIV, HCV and other STD testing
• Pregnancy test in women
Assess for risk of alcohol
withdrawal
• Definitions of withdrawal:
• Simple Withdrawal: Sweating, tremor, anxiety, palpitations
• Complicated Withdrawal: Seizure or Delirium Tremens
• Risk factors for ANY withdrawal:
• Former history of withdrawal
• Conscious with a B.A.L. over 0.3 % by volume
• Risk factors for complicated withdrawal:
• Former history of withdrawal seizure or Delirium Tremens
• Traumatic brain injury
• Acute illness (increases the likelihood of DTs)
Consider acute detoxification
• Inpatient detoxification is recommended if risk for significant
alcohol withdrawal
• Outpatient management of alcohol withdrawal
• May be fixed schedule or symptom triggered
• Chlordiazepoxide taper (Librium)
• Metabolized by the liver
• Do not use if suspect significant liver disease
• Lorazepam taper (Ativan)
• Oxazepem taper (Serax)
Medication Assisted Treatment
• There are 4 medications have been FDA approved for MAT for
alcohol use disorder
• Three oral medications
• Disulfuram (Antabuse)
• Naltrexone (Depade, ReVia)
• Acamprosate (Campral)
• One long acting injectable medication
• Extended release injectable naltrexone (Vivitrol)
Disulfiram
• Usual adult dosage
• Oral dose: 250mg daily (range 125mg to 500mg)
• Do not take for at least 12 hours after last drink
• Action
• Inhibits immediate metabolism of alcohol
• Build up of acetaldehyde causes flushing, nausea, sweating and
tachycardia
• Contraindications
• Concomitant use of alcohol containing products
• Coronary artery disease
• Hypersensitivity to rubber derivatives
• Precautions
• Hepatic cirrhosis, cerebral vascular disease, psychosis, diabetes,
epilepsy, hypothyroidism, renal impairment, pregnancy
Disulfiram
• Serious adverse reactions
•
•
•
•
•
Disulfiram-alcohol reaction
Hepatotoxicity
Optic neuritis
Peripheral neuropathy
Psychotic reactions
• Common side effect
• Metallic after-taste
• Dermatitis
• Transient drowsiness
Naltrexone
• Usual adult dosing
• 50 mg daily oral dose
• 380mg IM monthly dose
• Patient must be opioid free for 7-10 days prior to first dose
• Action
• Blocks opioid receptors resulting in reduced craving and reduced
reward to drinking
• Patient cuts back on alcohol use over time
• Contraindications
• Currently using opioids or in acute opioid withdrawal
• Anticipated need for opioid analgesics
• Acute hepatitis or liver failure
Naltrexone
• Precautions
• Hepatic disease, renal impairment, suicide attempt or depression,
pregnancy
• Serious adverse reactions
• Will precipitate severe opioid withdrawal if patient is dependent
on opioids
• Hepatotoxicity (not at recommended doses)
• Common side effect
•
•
•
•
Nausea, vomiting, decreased appetite
Headache, dizziness
Fatigue, somnolence
Anxiety
Acamprosate
• Usual adult dosing
• 666mg (two 333mg tablets) three times per day
• Renal impairment (CrCl 30-50 mL/min) reduce dose to 333mg
three times per day
• Action
• Affects glutamate and GABA neurotransmitter systems
• Contraindications
• Severe renal impairment (CrCl <30mL/min)
Acamprosate
• Precautions
• Moderate renal impairment, reduce dose to 333mg TID
• Depression or suicidal ideation and behavior
• Pregnancy
• Serious adverse reactions
• Rare events of suicidal ideation and behavior
• Common side effect
• Diarrhea
• Somnolence
Other pharmaceutical options
may be coming
Gabapentin
• Mason, BJ et al. “Gabapentin Treatment for Alcohol
Dependence: A Randomized Controlled Trial” JAMA Intern
Med. 2014;174(1):70-77.
• Importance: Approved medications for alcohol dependence
are prescribed for less than 9% of US alcoholics.
• Objective: To determine if gabapentin, a widely prescribed
generic calcium channel/γ-aminobutyric acid–modulating
medication, increases rates of sustained abstinence and no
heavy drinking and decreases alcohol-related insomnia,
dysphoria, and craving, in a dose-dependent manner.
Gabapentin
• Design, Participants and Setting: A 12-week, double-blind,
placebo-controlled, randomized dose-ranging trial of 150 men
and women older than 18 years with current alcohol
dependence, conducted from 2004 through 2010 at a singlesite, outpatient clinical research facility adjoining a general
medical hospital.
• Interventions: Oral gabapentin (dosages of 0 [placebo], 900
mg, or 1800 mg/d) and concomitant manual-guided
counseling.
• Main Outcomes and Measures: Rates of complete abstinence
and no heavy drinking (coprimary) and changes in mood,
sleep, and craving (secondary) over the 12-week study.
Gabapentin
• Results: Gabapentin significantly improved the rates of
abstinence and no heavy drinking.
• The abstinence rate was 4.1% in the placebo group, 11.1% in the
900-mg group, and 17.0% in the 1800-mg group
• The no heavy drinking rate was 22.5% in the placebo group,
29.6% in the 900-mg group, and 44.7% in the 1800-mg group
• Similar linear dose effects were obtained with measures of
mood, sleep, and craving
• There were no serious drug-related adverse events, and
terminations owing to adverse events, time in the study, and rate
of study completion did not differ among groups.
Gabapentin
• Conclusions and Relevance Gabapentin (particularly the
1800-mg dosage) was effective in treating alcohol dependence
and relapse-related symptoms of insomnia, dysphoria, and
craving, with a favorable safety profile. Increased
implementation of pharmacological treatment of alcohol
dependence in primary care may be a major benefit of
gabapentin as a treatment option for alcohol dependence.
Baclofen- may be useful
• Rigal, L, et al. “Abstinence and ‘Low-Risk’ Consumption 1 Year
after the Initiation of High-Dose Baclofen: A Retrospective
Study among ‘High Risk’ Drinkers. Alcohol and Alcoholism Vol
47, No. 4, pp. 439-442, 2012.
• DOI: http://sx.doi.ort/10.1093/alcalc/ags028
• Aim
• To assess the proportions of “high risk” drinkers’ abstinent or
with “low-risk” consumption levels 1 year after the initiation of
high dose baclofen
• Methods
• Retrospective open study
• Outcome was to assess the level of alcohol consumption in the
12th month of treatment
Baclofen- continued
• Results
• 132 or 181 patients completed study
• After 1 year, 80% of the 132 were either abstinent (n=78) or
drinking at low risk levels (n=28) in their 12th month of treatment
• Mean baclofen dose was 129 +/- 71mg/day
• Conclusion
• High-dose baclofen should be tested in randomized placebocontrolled trials among high risk drinkers.
References
• CDC http://www.cdc.gov/alcohol/fact-sheets/alcohol-use.htm
• ECHO ACCESS: Alcohol Use Disorder Protocol
• Mason, BJ et al. “Gabapentin Treatment for Alcohol Dependence: A
Randomized Controlled Trial” JAMA Intern Med. 2014;174(1):70-77.
• Rigal, L, et al. “Abstinence and ‘Low-Risk’ Consumption 1 Year after
the Initiation of High-Dose Baclofen: A Retrospective Study among
‘High Risk’ Drinkers. Alcohol and Alcoholism Vol 47, No. 4, pp. 439442, 2012.
• National Institute on Alcohol use and Alcoholism
https://www.niaaa.nih.gov/alcohol-health/overview-alcoholconsumption/alcohol-use-disorders
• SAMSHA http://www.samhsa.gov/disorders/substance-use
• Willenbring, ML, et al. “Helping Patients Who Drink to Much: An
Evidence Based Guide for Primary Care Physicians” Am Fam
Physician. 2009;80(1):44-50.
Questions?