Alcohol - Reinsurance Group of America fileantidepressants, anticoagulants, antibiotics,...
Transcript of Alcohol - Reinsurance Group of America fileantidepressants, anticoagulants, antibiotics,...
Alcohol
Elyssa Del Valle, M.D.Vice President and Medical Director
Elizabeth PfefferAssociate Underwriting Consultant
September 12, 2017
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Substance abuse is a complex topic and a common problem seen in underwriting and a medical problem dating back centuries
The two most common aspects of the problem in the U.S. today are –alcohol abuse and prescription opioid abuse
This presentation will concentrate on alcohol as a disease as well as a substance of abuse
Introduction and Overview
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Review the scope of alcohol abuse and it’s associated problems
Discuss the health effects, both unfavorable and favorable
Review tools for clinical screening as well as treatment
Present an approach to underwriting and classifying risk in individuals with these problems
• Distinguish at-risk use or abuse, dependence
• Explore the various definitions, tests and other criteria that help us make these decisions
• Look at a rational approach to ratings based on our assessment
• Case reviews
Goals
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Almost 75% of adults in the U.S. use at least some alcohol
One of most prevalent causes of advanced liver disease in US and Europe
Estimated 10-35% of alcoholics in US have alcoholic liver disease
About 1 out of every 10 deaths among working age adults is a result of excessive alcohol use!
About 40% of traffic fatalities are alcohol-related
85,000 deaths a year in the U.S. are alcohol-related
75% of the deaths attributable to binge drinking
The costs of alcohol problems in the U.S. were estimated at $250 billion in 2010
Most liver transplants are for those with histories of ALD and Hep C w/6,000 transplants performed annually in US
Scope of Alcohol-Related Problems
Sacks JJ, Gonzales KR, Bouchery EE, Tomedi LE, Brewer RDAm J Prev Med. 2015 Nov;49(5):e73-9. Epub 2015 Oct 1.Accessed uptodate.com 05/24/2016.
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Short-term
• Acute hepatitis: Associated with heavy alcohol use for 10-20 years
o Leads to cirrhosis
• Acute pancreatitis: accounts for about 30% of the cases of acute pancreatitis
• Esophagitis and gastritis with GI bleeding
• Alcohol poisoning (2200/year; 76% age 35-64, 76% men per CDC)
• Seizures
• Accidents
• Mental health problems
o Depression, suicide
o Domestic abuse
Adverse Health Effects of Alcohol Use
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Long term
• Hypertension and cardiovascular disease
• Stroke
• Cardiomyopathy
• Cirrhosis
• Chronic pancreatitis
• Gastroesophageal reflux disease (GERD)
• Brain atrophy secondary to acute and chronic encephalopathy from toxic effects of alcohol- Thiamine deficiency/ Vit B1 and B12/Folate deficiency
• Peripheral neuropathy- Thiamine deficiency/ Vit B1, B12 and Folate Vit B9 deficiency
o Can also be seen with bariatric surgery patients that do not take their supplements properly
Adverse Health Effects
So. Y MD/Phd. Wernicke Encephalopathy. Uptodate.com. Updated May 05,2015. Accessed 05/19/2016.
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Long term (continued)
• Osteoporosis
• Cancers
o Head and neck cancers (throat, larynx)
o Esophageal
o Liver
o Likely breast and colon
• Cardiac arrhythmias: atrial fibrillation or “holiday heart”
• Bone marrow suppression
Adverse Health Effects
Tetrault, JM, MD., O’Connor, PG, MD. Risky drinking and alcohol use disorder: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and
diagnosis.Uptodate.com.Last up dated 05/2016.Accessed on 05/19/2016.
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Worsens treatment of diabetes and other disorders
• Compliance and worsened blood sugar control
Interacts with many prescription medications (opioids, anti-epileptics, antidepressants, anticoagulants, antibiotics, beta-blockers)
• Decreases or prolongs effect of other medications
Poor nutrition and vitamin deficiency
Mortality reaches 80% with just 50% reduction of normal protein intake
Fetal alcohol syndrome in pregnant women
Adverse Health Effects
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Light to moderate drinking is associated with favorable cardiovascular outcomes
• Defined as 2 drinks/day for males and 1 drink/day for females
• Type (i.e., wine, beer, liquor) does not matter
• May increase HDL, reduce thrombosis and inflammation
• “French paradox”
Caution
• These benefits are modest at best
• The AHA does not recommend starting drinking for these benefits
• A true alcohol-addicted individual cannot drink without problems
Positive Health Effects
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This is the key to underwriting this impairment
• The bulk of this talk will explore the various definitions, screening tests, lab tests and other data that help to distinguish between moderate alcohol consumption, at risk drinking and alcohol abuse/dependence
• The definition of alcohol abuse sometimes relates to the perspective of the observer, clinician or underwriter; objectivity is important
oDefinitions are not always consistent
o “Standard drink” is 10-14 grams of ethanol: 5 oz wine, and 1.5 oz of 80 proof liquor, or 12 ounces of beer• Risk increases with increased consumption oIncreases risk for both short term and long term consequences
Distinguishing Harmful from Non-harmful Use/Abuse
Tetrault, JM, MD., O’Connor, PG, MD. Risky drinking and alcohol use disorder: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and
diagnosis.Uptodate.com.Last up dated 05/2016.Accessed on 05/19/2016.
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World Health Organization (WHO)
• Hazardous drinking – at risk for adverse consequences from alcohol
• Harmful drinking – alcohol is causing physical or psychological harm
National Institute on Alcohol Abuse and Alcoholism
• Men <65: >14/week or >4 per occasion
• Women <65: >7/week or >2 per occasion
• Men and women >65: >1/day
• Binge Drinking defined as drinking 5 or more drinks in men or 4 or more drinks in women within 2 hours
Definitions
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Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition(DSM-V) – Alcohol Use Disorder
• At least 2 of the following events in a year
o Recurrent use resulting in failure to meet major role obligations
o Recurrent use in hazardous situations
o Craving, or a strong desire to use alcohol
o Continued use despite social or interpersonal problems caused or exacerbated by alcohol use
oGreat deal of time spent obtaining alcohol, using it or recovering from its effects
o Drinking more or longer than intended
Definitions
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DSM-V – Alcohol Use Disorder
• 2 or more of the following events in a year (continued)
o Tolerance; increased amounts to achieve effect, diminished effect from the same amount
o Withdrawal; characteristic withdrawal syndrome for alcohol or alcohol or a closely related substance such as a benzodiazepine used to relieve or avoid symptoms
o Important activities given up or reduced because of alcohol
o Persistent desire or unsuccessful efforts to cut down or control alcohol use
o Use continued despite knowledge of having a physical or psychological problem caused or exacerbated by alcohol
Definitions
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AUDIT
• 10-question screen takes about 5 minutes
• Asks about patterns of use, amounts, frequency and any related problems
• AUDIT-C is an abbreviated form with 3 questions
CAGE – 4 questions
• Has anyone been Concerned about your drinking?
• Have you been Annoyed when criticized about your drinking?
• Have you ever felt Guilty about your drinking?
• Have you ever had a drink in the morning to steady your nerves or get rid of a hangover? (Eye-opener)
Clinical Screening Questions
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Michigan Alcohol Screening Test (MAST)
• Focuses more on alcohol dependence and problems associated with drinking
• A short version is available (SMAST)
• A geriatric version is available (MAST-G)
The National Institute on Alcohol Abuse and Alcoholism recommends the AUDIT
Most commonly we see either AUDIT or CAGE in APSs, but unfortunately we rarely see any screening questionnaires at all
Clinical Screening Questionnaires
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Gamma-Glutamyl Transferase (GGT)
• Very sensitive to alcohol use but not very specific
• Because of the non-specificity clinicians rarely use this test and tend to dismiss the result
Aspartate Aminotransferase (AST) and Alanine Aminotransferase (ALT)
• So-called liver function tests are also not very specific
• An AST/ALT ratio >1 is a red flag and much more specific for alcohol-related liver damage
Laboratory Tests
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Carbohydrate-Deficient Transferrin (CDT)
• Indicates the use of 50-80g of alcohol per day (5-6 drinks/day) for the preceding two weeks
• Very specific but variable sensitivity depending on lab, other underlying impairments, age and gender
• Sensitivity increases with elevated GGT
• Specimen hemolysis or delays in processing can result in false positives
• This is the only lab test currently approved by the FDA for alcohol screening
Hemoglobin-Associated Acetaldehyde (HAA)
• By-product of alcohol metabolism
• Most sensitive when associated with elevated GGT, AST or high HDL
• Not approved by the FDA
Alcohol Markers
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High-density lipoprotein (HDL) elevation
Mean corpuscular volume (MCV) elevation (usually mild, 100-108)
Smoking
Triglycerides elevation
MVR
Financial
Physical findings generally don’t appear unless liver disease is advanced
Insurance alcohol questionnaires
Other Findings
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Physical Findings of Advanced Liver Disease
o Stigmata of Chronic Liver Disease
o Ascites
o Gynecomastia
o Distended abdominal veins
o Facial telangiectasia
o Palmar Erythema
o Terry’s Nails
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Clinical Signs of Advanced Liver Disease
Encephalopathy
Esophageal Varices
Spontaneous Bacterial Peritonitis
CBC abnormalities: Low Platelets (< 160K), low WBC, Macrocytic anemia
Prolonged INR or Protime
Low Albumin
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Alcohol “criticism”
• Amount of alcohol reportedly used
• Actual recommendation to reduce or eliminate alcohol use
• May also be colored by the experiences of the provider and by the context of the situation
“Social history”
• Often will give information on smoking and alcohol use
• Also may note marital status and employment status as well as socio-legal problems
APS
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Social and employment effects
Family history
Financial problems
Legal problems
Driving problems
Other Considerations
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Medical Conditions Associated with Problematic Drinking
Medical issues/associated impairments
• Hypertension
• CAD
• Liver disease/hepatitis
• Neuropathy
• Diabetes
• Depression
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Alcohol Withdrawal
Shakiness, Sweating, Loss of Appetite
Agitation, Restlessness, Irritability
Nausea and Vomiting
Tachycardia, Tremor, Disorientation, Headache, Insomnia, Seizures
Can begin as early as 2 hours after last drink
Delirium Tremens (DTs) characterized by confusion, tachycardia, fever and with death rate up to 5%
Life Threatening condition that requires urgent medical treatment
Symptoms
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Detoxification
In-patient vs. out-patient
Behavioral counseling/addiction specialists
Support and accountability groups
• 12-step programs/Alcoholics Anonymous
• Faith-based and culture-based organizations
• Optimally lifetime attendance
Medications
• Disulfiram (Antabuse)
• Naltrexone
• Acamprosate (Campral)
• Off label— Topiramate (Topamax), Valproic acid (Depakote)
Treatment
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General approach
• No single finding or test will give us the means to properly risk-classify these individuals
• We need to look at all the available information
Consider amount of alcohol used
Consider the pattern of alcohol use or abuse
Consider gender
• While more men have alcohol problems than women, women are more susceptible to the effects of alcohol
Consider the other factors involved
RatingCurrent use
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Alcohol use
• Can include intermittent or “social” drinking
• Usually low-risk if driving not involved and no other problems are associated
Alcohol abuse without dependence
• Excessive consumption and often has associated social and legal problems
• Requires a rating
Alcohol dependence
• Definite excess consumption with significant mental and physical problems
• Highly rated to decline
Patterns of Use and Abuse
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“Binge” drinking
• Drinking to the point of drunkenness or obvious intoxication
• Amount depends on build, gender and tolerance and is difficult to quantify
• Up to 1/6 of adults in the U.S.
• High risk, usually requires additional debits or decline depending on frequency of binges and amount of alcohol used
o Accounts for ½ of the 80,000 deaths in the U.S. attributed to alcohol
o Arrhythmias/myocardial infarction
o Accidents and suicides
o Alcohol poisoning
o “Blackouts”/amnesia
Patterns of Use and Abuse
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Consider years of abstinence
Consider relapses
Consider any current drinking
• With history of dependence and any current drinking generally an offer cannot be made
Association with other substance abuse (polydrug abuse)
• Generally we cannot make an offer unless there is a long history of successful abstinence
o Look for both street/illicit drugs and drugs that are prescribed
Recovery
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Cross-addiction
• Other drugs
• Alcohol
• Very high risk/decline
Recovery
• Generally long-term recovery is not achieved without an initial in-patient treatment regimen followed by continued counseling and support group attendance like Alcoholics Anonymous
• Generally long postpone period before consideration is possible
Ratings
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Alcohol is an ever-increasing problem encountered by underwriters, with significant mortality implications
Distinguishing appropriate and inappropriate use is the key to underwriting these individuals
A number of factors identify inappropriate and high-risk use, and these cases are generally rated or declined
Recovery is possible, but postpone periods are required before we can reconsider
Summary
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40 yo male for $500K.
DUI 1/11, 3/11. Was going through a divorce at the time, underwent counseling and now only drinks an occasional beer.
LFTs and CDT are normal.
MVR shows failure to yield right of way in 8/15
Case 1: Std, Mildly substandard, Moderately substandard, Highly substandard, RNA
Cases
Case 1
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33 year old male smoker for $2 million
For his 33rd birthday in 6/16 he had 25 drinks, passed out, woke up the next morning with abdominal pain that continued several days and he went to his doctor
His wife told him he had been wrestling
Doctor attributed pain to minor injury or gastritis
On alcohol questionnaire he reported 3 drinks on Fridays and Saturdays
Case 2 : Std, Mildly substandard, Moderately substandard, Highly substandard, RNA
CasesCase 2
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32 year old male, $500,000: smoker pack/day x10 years, Ht-5’7”, Wt=150# (stable), BP=119/74. Hx of mild hypertension, mildly elevated cholesterol, and mild depression/anxiety. Current meds Benicar HCT 20 mg/d, Simvastatin 20 mg/d. Habits: 2 drinks 1-2x per week. MVR: speeding ticket dismissed 2 years ago.
5/15 Lab: Hgb=15.3, MCV=92.5, WBC=7,300, plate=178,000, A1C=5.5, chol=176, HDL=48, LDL=100, trigs=140, bili=0.6, ALT=34, AST=28, GGT=101, albumin=5.0, Hep B, C-neg, HOS cot >1.00 mcg/ml
Followed by AP for over 12 years: 11/04 drank <1 beer per day; 11/11 drank 6-7 beers per day
Case 3: Std, Mildly substandard, Moderately substandard, Highly substandard, RNA
CasesCase 3
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33 year old male, $1,000,000, NS, Ht=6’1”, Wt=180#, BP=117/67. Investment management. Alcohol use is 2 glasses of wine per week. In questionnaire admitted to 5 or more drinks (binge) once every five years. His only chronic illness is gout and his only medication is allopurinol 300 mg/day.
10/12 acute attack of gout, admitted to 4 drinks per week, uric acid=8.1 mg%, ALT=21
5/14 acute attack of gout, uric acid=8.6 mg %
3/15 acute attack of gout after a wine country trip-usual treatment-colchicine and allopurinol
2/15 ins lab: bili=1.0, AST=14, ALT=17, GGT=15, alb=5.0, CDT (+), HAA=10.6 (<10.5), chol=203, HDL=87, LDL=103, trigs=62
Case 4, Std, Mildly substandard, Moderately substandard, Highly substandard, RNA
CasesCase 4
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50 year old male, $2,000,000, NS, Ht=5’9”, Wt=165#, BP=128/82. Med hx is unremarkable except for cholesterol elevation. Medications he takes include Simcor 20 mg/day and Klonopin 1 mg at bedtime. He admitted to drinking beer or spirits 1-3 drinks 2-3 times per week. Extensive APS revealed no alcohol concerns or problems possibly related to alcohol use.
3/16 ins lab: bili=0.53, AST=33. ALT=38, GGT=102, alb=4.8, CDT (+), chol=215, HDL=63, LDL=114, trigs=193
Case 5: Std, Mildly substandard, Moderately substandard, Highly substandard, RNA
CasesCase 5
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55 year old male, $590,000, NS, Ht=5’11”, Wt=228#, BP=156/101. He admitted to having high BP and abnormal lipids. Medications included Lisinopril 10 mg/day and Lipitor 10 mg/day. He drinks two wine or beers two times per week.
5/16 ins lab: bili=1.0, AST=26, ALT=34, GGT=54, alb=4.9, chol=193, HDL=58, LDL=91, trigs=216
6/14 cardiac evaluation due to age and risk factors: echo-mild LVH (no measurements), LV EF=60%; TM-1-1.5 mm ST depression, short episode of NSVT (number of beats unknown), perfusion scan-normal, LV EF~50%, went 7:44, BP to 240/140; heart cath-minimal CAD (no report)
8/14 4-6 beers per day; 12/12 normal PE captain’s exam for scuba diving
Case 6: Std, Mildly substandard, Moderately substandard, Highly substandard, RNA
CasesCase 6
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39 year old female, divorced, $300,000, NS, Ht=5’1”, Wt=108#, BP=106/69. She admitted to a hx of prior antiphospholipid antibody syndrome and in vitro fertilizations. Her current medication is Lo-estrin BC pills. She admitted to drinking alcohol 2 drinks 3x per week.
MVR showed a DWI in 11/10 with a BAC=0.18 and successful completion of an alcohol clinic course program.
5/16 ins lab: bili=0.6, AST=21, ALT=19, GGT=33, alb=4.2, chol=180, HDL=83, trigs=65.
Review of APS revealed atypical chest pain 9/14 and a normal echo. She also was noted to have some insomnia and sweating at night, chronic, not severe.
Case 7: Std, Mildly substandard, Moderately substandard, Highly substandard, RNA
CasesCase 7
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54 year old male with hx of alcoholism. He was admitted in 2014 for upper GI bleed due to esophageal varices.
Last OVN noted reported abdominal pain and bloated abdomen. His wife reported declining memory. PE noted distended abdomen with fluid wave. He had stopped drinking after the GI bleed
Most recent labs include CBC with WBC 4.7, Hgb of 12.1 with MCV of 110 and platelets of 120K. LFTs revealed AST of 22 and ALT 10 with albumin of 3.3.
Case 8: Std, Mildly substandard, Moderately substandard, Highlysubstandard, RNA
CasesCase 8
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Wilson, JF, et al.; “In the Clinic – Alcohol Use.” Annals of Internal Medicine,3 Mar 2009.
Tinsley JA, Finlayson RE and Morse RM. “Developments in the Treatment of Alcoholism.” Mayo Clinic Proceedings 1998; 73:857-63.
Holt, JB. “Vital Signs: Binge Drinking Prevalence, Frequency and Intensity Among Adults – United States, 2010.” MMWR Jan. 13, 2012. 61(01):14-19.
Quick stats MMWR 1/9/15 64(01); 32.
USA Today, “Campus Rivalry,” July 12, 2011.
Jones, DE et al. “Pharmacotherapy for Adults with Alcohol-Use Disorders in Outpatient Settings.” JAMA 2014; 311(18): 1889-1900.
So. Y MD/Phd. Wernicke Encephalopathy. Uptodate.com. Updated May 05,2015. Accessed 05/19/2016.
Bibliography
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Questions?
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