Patients with Alcohol Problems

Copyright © 2005, Duke Internal Medicine Residency Curriculum and DHTS Technology Education Services

Duke Internal Medicine Residency Curriculum

Patients with Alcohol Problems

Authors: Colin Gallahan, M.D., Maxwell Prempeh, M.D., and Anja Wagner, M.D.

Editor: Amy Shaheen, MDAssistant Professor of Clinical Medicine

Duke University Medical Center



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



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.



Definitions / Terms

Definitions of Unhealthy Alcohol Use…



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)



Definitions / Terms

Problem Drinking

• Risky use of alcohol which is accompanied by alcohol-related consequences

• Does not meet criteria for alcohol dependence



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



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



Definitions / Terms

The Spectrum of Alcohol Use

Alcoholism / Alcohol Dependence↑

Harmful Use / Alcohol Abuse↑

Problem Drinking↑

Risky Use↑

Low-Risk use↑

Abstinence



Screening

Screening for alcohol use in the primary care setting…



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)



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.



SCREENING

First, the basic history:

1) Ask all patients about current and past alcohol use and also about family history of alcohol use;

2) In patients who report alcohol use, obtain detailed history about quantity and frequency of use;

3) Use one of the standardized questionnaires to detect possible problem drinking (see next two slides);

4) 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



SCREENING QUESTIONNAIRES

CAGE questions

1) Have you ever felt you should cut down on your drinking?

2) Have people annoyed you by criticizing your drinking?

3) Have you ever felt guilty about your drinking?4) 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)



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




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




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




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



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



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.)



Health Problems with Acute Alcohol Intoxication

- Accidents- Traffic fatalities- Trauma- Domestic violence- Homicide- Suicide



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




• 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)




• 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)



Health Problems with Chronic Alcohol Abuse

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



Treatment

Brief InterventionsHeavy 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



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



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)



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



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 1. Initiate with 25mg x1 and if no withdrawal signs within 1 hour give

another 25mg2. Can be used to treat problem drinkers as well

- Acamprosate (Campral) 666mg PO tid1. A lower dose (4 tablets/day or 1332mg) may be considered in

patients with low body weight (eg, <60 kg). 2. Just for patients with alcohol dependence who have initiated

abstinence- Disulfiram (Antabuse) 250mg PO qday 1. Initiate with 500mg PO qday for 1-2 weeks2. For alcohol dependent patients who have abstained from ethanol for

at least 12 hours




• 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




• 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




• 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




DisulfiramD- Drowsiness and fatigue as side effectsI- 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 breastfeedingL- 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




• 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.



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



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?

A) Re-evaluate for liver disease as an occult cause of itchingB) 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 alcoholismC) Suspecting this level is not unusual for her, send her home with information on AA and other

community based options for treatmentD) 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.



QUESTION 2

2. Which is not a CAGE question?

1) Cut down2) Craved alcohol more than once a week3) Annoyed by questions4) Feel Guilty5) Eye-opener

*Answer: 2

2a. What is the specificity of 2 positive CAGE questions?A) 81-95% B) 52-92% C) 100% D) 30%*Answer: A



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:1. Outpatient referral for psychosocial support in alcohol management2. #1 and Disulfiram3. Hospital admission4. 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.



QUESTIONS

4. Which of the following is not associated with alcohol abuse?

1) Elevated MCV2) Elevated AST and ALT (more AST)3) Elevated GGT4) Elevated White blood cell count5) Elevated carbohydrate-deficient transferrin

*Answer: Elevated White blood count. This is not usually indicative of alcohol use.



5. In patients with alcohol dependence which of the following is appropriate for treatment?

1. Naltrexone for 6 months followed by psychosocial therapy2. Naltrexone and acamprosate without psychosocial

therapy3. Brief interventions by the primary care physician4. Acamprosate with concomitant psychosocial therapy

*Answer: 4. Acamprosate with concomitant psychosocial therapy-no therapy without psychosocial support has been studied or is currently appropriate



6. Which of the following statements about oral pharmacologic therapy is true?

1. Acamprosate is an opioid antagonist that reduces the pleasurable effects of the alcohol

2. Naltrexone is a synthetic analog of GABA which serves to reduce the craving associated with alcohol dependence

3. Disulfiram with alcohol causes increased serum acetaldehyde and flushed face

4. Disulfiram is not approved by FDA for alcohol dependence

*Answer: 3. Disulfiram with alcohol causes increased serum acetaldehyde and flushed face



Matching

7. Matching. Match the patient with the level of alcohol use:

1. The lawyer who drinks 8 beers Dependenceafter work three nights a week.

2. The lawyer who got fired because Risky Usehe was drinking too much and didn’tfinish his work.

3. The lawyer who presented with Problem Drinkingwithdrawal seizures.

4. The lawyer who just got his third AbuseDUI.



Matching

1. The lawyer who drinks 8 beers Dependenceafter work three nights a week.

2. The lawyer who got fired because Risky Usehe was drinking too much and didn’tfinish his work.

3. The lawyer who presented with Problem Drinkingwithdrawal seizures.

4. The lawyer who just got his third AbuseDUI.



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?

1) 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.



*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.



RESOURCES

• National Institute on Alcohol Abuse and Alcoholismhttp://www.niaaa.nih.gov/

Alcoholics Anonymous http://www.alcoholics-anonymous.org/

Al-Anon: for families of alcoholicshttp://www.al-anon.alateen.org/

● http://www.psychejam.com/disulfiram.htm

● http://www.aafp.org/afp/20040315/1443.html



REFERENCES

• ACP Journal Club. 2000 Sept-Oct;133:75. Fleming MF, Mundt MP, French MT, et al. Benefit-cost analysis of brief physician advice with problem drinkers in primary care settings. Med Care. 2000 Jan;38:7-18.

• American Psychiatric Association, Diagnostic and Statistical Manual, 4th ed, APA Press, Washington, DC 1994.

• O’Connor, P. Schottenfeld, R. Patients with alcohol problems. N Engl J Med 1998; 338: 592.• Saitz, R. Clinical practice. Unhealthy alcohol use. N Engl J Med 2005; 352:596.• U.S Preventative Task Force Service. Screening and Behavioral Counseling Interventions in Primary

Care to Reduce Alcohol Misuse: Recommendation Statement. Annals of Internal Medicine 2004; 140: 554.

• Yersin, B, Nicolet, JF, Dercry, H, et al. Screening for excessive alcohol drinking; Comparative value of carbohydrate deficient transferrin, gamma glutamyl transferase and mean corpuscular volume. Arch Intern Med 1995; 155:1907.

• Moore, RD. Prevalence, detection and treatment of alcoholism in hospitalized patients JAMA. 1989; 261:403.

• Harper, C. Wernicke's encephalopathy: a more common disease than realised. A neuropathological study of 51 cases. J Neurol Neurosurg Psychiatry 1979; 42:226.

• Caine, D, Halliday, GM, Kril, JJ, Harper, CG. Operational criteria for the classification of chronic alcoholics: identification of Wernicke's encephalopathy. J Neurol, Neurosurg Psychiatry 1997; 62:51.

• Sullivan JT; Sykora K; Schneiderman J; Naranjo CA; Sellers EM; Assessment of alcohol withdrawal: the revised clinical institute withdrawal assessment for alcohol scale (CIWA-Ar); Br J Addict 1989 Nov;84(11):1353-7

• Volpicelli JR; Volpicelli LA; O'Brien CP Medical management of alcohol dependence: clinical use and limitations of naltrexone treatment; Alcohol Alcohol 1995 Nov;30(6):789-98

• Fuller, Branchey, Brightwell, et al; Disulfiram treatment of alcoholism. A Veterans Administration

cooperative study; JAMA. 1986 Sep 19;256(11):1449-55



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

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