Drinking Patterns. Harmless Use At-Risk. Abuse. 4% Dependence. Financial Disclosures. Alcoholism: Recognition and Management.

Transcription

1 Alcoholism: Recognition and Management Timothy W. Fong MD UCLA Addiction Psychiatry PRI-MED West Current Clinical Issues March 2014 Financial Disclosures Speaker Bureau Reckitt Benckiser Research Support NIDA OPG (California) Annenberg Foundation Tulare County Psyadon Overview Drinking Patterns Alcohol Intake in the US Screening and Assessment Treatment Strategies Medications Psychosocial Interventions Harmless Use At-Risk Abuse Dependence Alcohol Use Patterns Use Problems 90% Have ever drank 60% Current drinkers 21% At-risk drinking 5% Abuse 4% Dependence (past year) (past year) By age 18: 75% tried alcohol 60% intoxicated 1x Quantities peak in early 20s Then quantities Ongoing quantities problems Onset use to dependence ~ 15yrs O Malley 2014 O Malley

2 Risk Of Alcoholic Cirrhosis Alcohol Cirrhosis Odds Ratio (drinks/day) (%) for Cirrhosis Teetotaler < > > Alcohol Use Disorders: Alcohol Abuse Recurrently met 1 or more criteria in the same year Failure to fulfill major obligations Physically hazardous Legal problems Social / interpersonal problems Bellentani, S. Journal of Hepatology. 2001;35: Alcohol Dependence 3+ in the same year: Tolerance Withdrawal Larger amounts / longer period than intended Attempts to cut down Excessive time spent with alcohol Activities given up due to alcohol Continued use despite problems DSM-5 Changes Addiction and Related Disorders Alcohol Use Disorder (single category) Cravings added 11 symptoms Severity: Mild (<2), moderate (3-5), severe (6+) Dimensional Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association. Alcohol Use Disorder Alcohol Use Disorder 1. is often taken in larger amounts or over a longer period than was intended. 2. There is a persistent desire or unsuccessful efforts to cut down or control use. 3. A great deal of time is spent in activities necessary to obtain, or recover from its effects. 4. Craving, or a strong desire or urge to use 5. Recurrent use resulting in a failure to fulfill major role obligations at work, school, or home. 6. Continued use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol. 7. Important social, occupational, or recreational activities are given up or reduced because of use. 8. Recurrent use in situations in which it is physically hazardous. 9. 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 alcohol. 10.Tolerance, as defined by either of the following: 1. A need for markedly increased amounts of alcohol to achieve intoxication or desired effect. 2. A markedly diminished effect with continued use of the same amount of 11.Withdrawal, as manifested by either of the following: 1. The characteristic withdrawal syndrome for alcohol (refer to Criteria A and B of the criteria set for alcohol withdrawal). 2. is taken to relieve or avoid withdrawal symptoms. Impaired Control (1-4) larger amounts, can t cut down, spends time, craves has there has ever been a time when you had such strong urges to take the drug that they could not think of anything else. Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, (Copyright 2013). American Psychiatric Association. All rights reserved. 2

3 Alcohol Use Disorder Social Impairment (5-7) Failure to fulfill obligations Social/interpersonal problems Reduced activities / given up Alcohol Use Disorder Risky Use Using in hazardous situations Using despite physical or psychological harm Failure to abstain despite difficulty it is causing Alcohol Use Disorder Pharmacological Criteria Tolerance Increased dose to achieve effect Reduced effect with usual dose Differentiate from individual sensitivity Withdrawal Occurs with decline in blood/tissue levels Etiology and Clinical Characteristics Alcohol: Neurotransmitters Neurotransmitter Increases Dopamine Decreases Serotonin Effects + Opiates Euphoria Pleasure, reward, craving Impulsivity, Disinhibition + GABA Sedation, Hypnotic, Inhibits Glutamate Amnesia, Learning Impairments Genetic Contribution Explain ~ 50% risk for problems Operate via 4 characteristics 1. Impaired breakdown of alcohol: risk 2. Low level sensitivity to alcohol: risk 3. Some psychiatric disorders: risk 4. Some personality traits: risk 3

4 Personality Trait Contributors Sensation seeking Conscientiousness Impulsivity Negative mood Mood lability Environmental Contributors Family Lower level support risk Peers Heavy drinking risk Social/cultural Belief most people drink heavily risk Current status Lack of rewards/stress risk Current situation Easy alcohol access (cheap, close) risk Key Opportunities for Screening Screening and Assessment Annual exam, first visit Medications that interact with alcohol ER or urgent care (trauma) Vulnerable populations Smokers, adolescents, young adults Presence of health problems that may be alcohol induced Presence of chronic illness not responding to treatment Pregnant or trying to conceive SBIRT Screening: identifies risky substance use behaviors using standardized screening tools. Anytime. Anyplace. Brief Intervention: engages a patient with risky substance use behavior in a short conversation, providing feedback and advice Referral to Treatment: for patients who screen in need of additional services Alcohol Quantity Equivalents NIAAA Helping Patients Who Drink Too Much 4

5 Screening: Maximum Drink Limits (NIAAA Recommendations) Men: 4 drinks per day; up to 14 per week Women: 3 drinks per day; up to 7 per week One episode of heavy drinking in last 1 month >5 for men ; >4 for women NIAAA One-Question Screening: Alcohol How many times in the past year have you had >5 (men) or >4 (women) drinks in a day? If once, then proceed to additional screening and assessments National Institute of Alcohol Abuse and Alcoholism. Available at: National Institute of Alcohol Abuse and Alcoholism. Available at: Screening and Assessment Questionnaires CAGE Cut down, Annoyed, Guilt, Eye-opener MAST - 25 items Covers alcohol problems AUDIT 10 items Covers alcohol problems and patterns Screening/Evaluation AUDIT (Alcohol Use Disorders Identification Test) 10 questions, scored = hazardous drinking (Sens: 98%) 10 = alcohol dependence (Sens: 99%) MAST: Short Michigan Alcohol Screening Test 13 questions, self-administered Accuracy=25 item MAST (Sens: 90%) CAGE: Cut down; Annoyed; Guilt; Eye-opener MAST: Michigan Alcohol Screening Test AUDIT: Alcohol Use Disorders Identification Test Screening/Evaluation Lab markers Gamma-glutamyltransferase (GGT) Aspartate & alanine aminotransferase Carbohydrate deficient transferrin Mean corpuscular volume Lab Markers 1 (GGT) Gamma-glutamyltransferase With heavy drinking In: heart disease, kidney disease, pregnancy GGT >35 -Heavy drinking - Before liver damage -Sensitivity for heavy drinking ~75% GGT >50 may indicate liver damage Normalizes ~5 weeks of abstinence 5

6 Lab Markers 2 (LFT) Liver Function Test: AST and ALT ALT in liver, AST in many tissues In high use AND liver damage Absolute value &ratio important -AST (14-38 U/L normal range) -ALT (15-48 U/L normal range) -AST:ALT ratio >2 suggestive of alcohol Less sensitive than GGT Lab Markers 3 (CDT) CDT: Carbohydrate deficient transferrin Transferrin=protein; transports iron Abnormal form produced in drinking CDT >20 g/l indicates heavy drinking Few other conditions Sensitivity & specificity ~75% (=GGT) Normalizes ~1 month of abstinence Lab Markers 4 (MCV) Mean Corpuscular Volume Size of red cells (nl =80-100u) with heavy drinking >90u suggests heavy drinking MCV in other conditions Alcohol Markers A breathalyzer in every office Urine drug screen Not routinely measured Urine monitoring Urine ETG (ethylglucuronide) Urine EtS (ethylsulfate) Blood Peth (Phosphatidylethanol) Clinical Assessment and Diagnosis NIAAA Clinician s Guide Brief Interventions 6

7 Health Care Implications Abstinent: don t encourage to start Moderate drinkers: explain risks Hazardous drinkers: brief intervention Abuse/dependence: refer to specialist Brief Intervention Ask If yes, determine frequency, quantity Advise State concern, recommend change Assess Willingness to change Assist If ready, help change Arrange Reinforce change with follow-up Treatment Approaches to Addictive Disorders 1. Medications (Bio) Recovery A voluntarily maintained lifestyle characterized by sobriety, personal health and citizenship 2. Psychosocial (Psycho) 3. Lifestyle changes (Social) National Council on Alcoholism and Drug Dependence. Available at: FDA-Approved Medications Disulfiram Drugs of Abuse Alcohol Generic Name Disulfiram Naltrexone Naltrexone Acamprosate Dosing: 250 mg 500 mg qd Side effects: Nausea, metallic taste, dysphoria, fatigue, hepatitis, psychosis (dopamine) Effects can last 72 hours after last dose 7

8 Naltrexone FDA Approved: 1994 Mechanism of Action: Opiate Antagonist Decrease positive, reinforcing effects Increase negative aspects of drinking Decrease craving from first dose (prime) Decrease craving from cues Naltrexone Starting dose (50 mg tabs) Start at 25 mg; increase by 25 mg/week until side effects or target dose of 200 mg Side effects: Dysphoria, nausea, increased LFTs, $$$$ Modest effect, at best Decreased time to relapse, # of drinks, cravings IM Naltrexone Acamprosate MOA: same as oral naltrexone Dose: 380 mg IM q 4 weeks No oral lead-in Stop drinking 7 days prior (ideal) Gluteal IM Results: Decreases drinking days and heavy drinking days MOA: Made from taurine; restores NMDA receptor tone in the glutamate system; GABA-properties FDA approved in 2004 Targets negative reinforcement Efficacy: higher abstinence; higher % of days abstinent; increased time to 1 st drink Acamprosate Side effects: diarrhea, rash Dosing: 333mg bid 666 mg tid (1,998 mg) Start once detox is complete Continue taking during slips Emerging Medications Anticonvulsants Topiramate Gabapentin Carbamazepine Zonisamide Varenicline Antipsychotics These agents are NOT currently approved for treatment of alcoholism 8

9 Psychosocial Treatment Terms Inpatient Detoxification Intensive Outpatient / Partial Hospital Office-Based Treatment Residential Treatment Facility Sober Living Facility 12-Step Support Predictors of Treatment Success Length of time in treatment Multidisciplinary treatment team Combination of treatments Monitoring Strong social support Further Reading National Institute on Drug Abuse National Institute on Alcoholism American Academy of Addiction Psychiatry Substance Abuse and Mental Health Service Administration Contact Information Timothy Fong MD UCLA Addiction Medicine Clinic (appts) (office) tfong@mednet.ucla.edu uclagamblingprogram.org 9