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In the Clinic Alcohol Use © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 164 (1): ITC1-1. Which health conditions have definite links to alcohol use? Hypertension, stroke, cardiomyopathy, arrhythmias Cirrhosis, acute and chronic pancreatitis Brain atrophy Hypogonadism with osteoporosis, sexual dysfunction Various types of cancer GERD, esophagitis, peptic ulcers Seizures Acute alcohol poisoning from heavy episodic drinking Increased incidence chronic diseases Poor nutrition Mental health and social consequences Drinking during pregnancy may harm the fetus © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 164 (1): ITC1-1. Common alcohol-prescription medication interactions by class Cardiovascular agents: ACE inhibitors, beta-blockers, diuretics Central nervous system agents: anticonvulsants, anxiolytic/sedative/hypnotics, opioids Coagulation modifiers: anticoagulants Metabolic agents: antidiabetic, antihyperlipidemic Psychotherapeutic agents: antidepressant Respiratory agents: antihistamines Other: antibiotics, NSAIDs © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 164 (1): ITC1-1. Does alcohol use have positive health effects? Unhealthy alcohol use increases the risk of CVD but moderate alcohol use appears to be protective in some studies Underlying mechanisms may include: development of favorable lipid profiles, inhibition of platelet activation, decreased fibrinogen levels, and anti-inflammatory effects Because of the lack of data from randomized clinical trials at this time, clinicians should not recommend initiation of low-level alcohol use for cardioprotective effects © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 164 (1): ITC1-1. Which groups are at particularly high risk for adverse health outcomes from alcohol use? Individuals < 21 years old and college-aged Individuals > 65 years old, especially with: Chronic medical conditions Taking medications that may interact with alcohol and those with polypharmacy Women Minorities and underserved populations People with certain chronic medical conditions that make them more sensitive to alcohol © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 164 (1): ITC1-1. CLINICAL BOTTOM LINE: Health effects... Unhealthy alcohol use is associated with adverse medical, psychiatric, and behavior-related outcomes Special caution with alcohol use is appropriate among: Young adults and older adults Women and minorities Underserved populations Those with chronic medical conditions Those taking prescribed medications © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 164 (1): ITC1-1. When should clinicians screen for unhealthy alcohol use? Unhealthy alcohol use has negative consequences and often goes unrecognized NIAAA, USPSTF, and CDC recommend routine screening of adults for unhealthy alcohol use Potentially effective treatments for unhealthy alcohol use are available © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 164 (1): ITC1-1. NIAAA recommended screening opportunities During routine examinations Before prescribing a medication with potential interactions with alcohol In the emergency department or urgent care center When seeing patient who: Is pregnant or planning conception Has risk factors for unhealthy alcohol use Has potentially alcohol-related health problems Has a chronic condition resistance to usual treatment © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 164 (1): ITC1-1. What are effective self-report-based methods to screen for unhealthy alcohol use in clinical settings? Single-Item Screening Question (SISQ) “How many times in the past year have you had ≥4 drinks (women) or ≥5 drinks (men) in a day?” Positive screen: ask about frequency and quantity of use CAGE questionnaire (4 questions) AUDIT (10-item screening tool) or AUDIT-C (3-item) Michigan Alcohol Screening Test (25 questions) For screening lifetime alcohol use disorders more than lower levels of problem drinking or binge drinking © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 164 (1): ITC1-1. CLINICAL BOTTOM LINE: Prevention and screening... Incorporate standardized processes to facilitate routine screening of all patients for unhealthy alcohol use Counsel patients with negative screening results on maintaining lower-risk alcohol use or abstinence Evaluate those with positive results for alcohol use disorders and alcohol-related consequences Provide appropriate treatment © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 164 (1): ITC1-1. How should clinicians distinguish between “moderate” alcohol consumption, at-risk drinking, and alcohol use disorders? Moderate alcohol use Men ≤65: ≤4 drinks on single day and ≤14 drinks/wk Men >65, women: ≤3 drinks on single day and ≤7 drinks/wk At-risk drinking Use that increases risk for alcohol-related consequences When lower-risk alcohol use thresholds exceeded When drinking in lower amounts increases risk Alcohol use disorder Individual meets ≥2 DSM-5 criteria © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 164 (1): ITC1-1. DSM-5 criteria for alcohol use disorder Mild 2-4 symptoms; Moderate 4-5; Severe 6+ Alcohol taken in larger amounts or for longer than intended Persistent desire / unsuccessful efforts to cut down or control use Great deal of time spent obtaining, using, or recovering from use Craving or strong desire to use alcohol Failure to fulfill major obligations due to alcohol use Continued use despite problems caused or exacerbated by use Important activities given up or reduced because of alcohol use Recurrent alcohol use in physically hazardous situations Continued use despite knowledge of physical or psychological problems that are caused or exacerbated by alcohol Tolerance Withdrawal © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 164 (1): ITC1-1. What is the role of the physical exam and lab testing in the evaluation of patients with unhealthy alcohol use? Exam: Helps identify, evaluate unhealthy alcohol use Patients with worsening hypertension or tachycardia may be manifesting withdrawal Liver, cardiac, or neurocognitive disease may signal longer-term consequences of alcohol use Labs: May signal unhealthy alcohol use Increased mean corpuscular volume of RBCs Elevated gamma-glutamyl transferase Increased aspartate to alanine aminotransferase ratio Under investigation: markers related to ethanol metabolism © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 164 (1): ITC1-1. Findings that May Indicate Unhealthy Alcohol Use Hypertension Jaundice Spider angiomata Cardiomyopathy Atrial fibrillation Gynecomastia Hepatosplenomegaly Ascites Testicular atrophy Palmar erythema, plethoric facies Peripheral neuropathy Cognitive abnormalities © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 164 (1): ITC1-1. Which other conditions should clinicians be alert for in patients with unhealthy alcohol use? Conditions that often co-occur with unhealthy alcohol use Substance use disorders Mental illness Chronic pain Sexual risk behaviors Underlying conditions can affect treatment decisions and response © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 164 (1): ITC1-1. CLINICAL BOTTOM LINE: Diagnosis... Diagnosis relies on a comprehensive evaluation History and physical exam Supporting labs: various markers can detect alcohol use and measure impact on health Patient self-reported information Screen for prevalent comorbid conditions Substance use Mental illness Chronic pain Sexual risk behaviors © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 164 (1): ITC1-1. What is appropriate language to use when treating patients with unhealthy alcohol use? Avoid imprecise and stigmatizing language Use “people-first” language Focus on medical aspects of condition and treatment Avoid using slang and idioms (alcoholic, alcohol abuser) Compare unhealthy alcohol use to another chronic medical condition Where the cause is also based on genetic and behavioral factors and treatment is comprehensive © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 164 (1): ITC1-1. What should clinicians do if they identify patients with hazardous or at-risk alcohol use? Provide brief, empathic interventions Provide specific advice on recommended alcohol use Give feedback on impact of alcohol on the patient’s health Empathize with patient’s responsibility to make a change List options for facilitating change Discuss situations likely to trigger excessive use Establish drinking agreement and follow-up Brief, multi-contact interventions are most effective © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 164 (1): ITC1-1. How should care of patients with an alcohol use disorder be prioritized? Patients may have a ranging set of treatment needs Promote patient safety and stabilization first Initial goal is reduction in alcohol consumption But few are able to maintain controlled drinking So abstinence is typically the goal of therapy © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 164 (1): ITC1-1. How should alcohol withdrawal be addressed in the primary care setting? Withdrawal may manifest with range of signs and symptoms Some patients can safely be managed as outpatients Patients at greater risk for harm or unlikely to follow-up should be referred to an inpatient setting Use standardized instruments to guide treatment Clinical Inst. Withdrawal Assessment for Alcohol, revised Multiple dosing strategies and medication regimens may be used to treat withdrawal symptoms, prevent seizure Benzodiazepines safest and most effective Monitor closely: withdrawal begins as early as 5-8 h and up to 72 h after last drink © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 164 (1): ITC1-1. Indications for referral for inpatient detoxification Reasons for immediate referral for inpatient detoxification Moderate to severe withdrawal History of seizures or delirium tremens Unable to adhere to daily follow-up Comorbid psychiatric or medical complications requiring hospitalization Unable to take oral medication Unsuccessful outpatient detoxification Pregnancy Reasons to strongly consider inpatient detoxification Coexisting benzodiazepine use High risk for severe alcohol withdrawal © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 164 (1): ITC1-1. What is the role of psychotherapeutic interventions for alcohol use disorder? Cognitive behavioral therapy Patients identify thoughts, feelings, circumstances that occur before and after alcohol use New behaviors and techniques help patients cope with these triggers Motivational enhancement therapy Increases internal motivation to change alcohol use Twelve-step facilitation Underlying premise that alcohol use disorders are secondary to medical and spiritual disease Community reinforcement and behavioral couples therapy © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 164 (1): ITC1-1. When should clinicians consider pharmacotherapy for relapse prevention? Consider for for all patients with alcohol use disorder Disulfiram Appropriate when abstinence is the initial goal Nausea, flushing, palpitations associated with alcohol use Acamprosate Dosed 3x/d and commonly leads to diarrhea, vomiting Dose adjustment needed with renal insufficiency Naltrexone Once daily oral or long-acting injectable Decreases the reward pathways associated with alcohol use Opioids contraindicated © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 164 (1): ITC1-1. When should clinicians consider antidepressants or anxiolytics in treating patients with unhealthy alcohol use? Antidepressants treat depressive symptoms but not alcohol use disorders Benzodiazepines Standard treatment for managing acute withdrawal phase Ineffective for treating alcohol use disorder Poses risk of creating additional substance use disorder Consider delaying treatment of co-occurring mental illness until abstinence achieved for at least several weeks © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 164 (1): ITC1-1. Are any medications of particular concern in the setting of unhealthy alcohol use? Cardiovascular agents Anticoagulants Ace-inhibitors Metabolic agents Beta-blockers Antidiabetic Diuretics Antihyperlipidemic Central nervous system agents Antidepressants Anticonvulsants Antihistamines Other Anxiolytic/sedative/hypno Antibiotics tics Opioids NSAIDS © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 164 (1): ITC1-1. What additional care should be considered for patients with unhealthy alcohol use to promote health? Comorbid conditions Other substance use (tobacco, drug use disorders) Mental health disorders (anxiety, mood, personality disorders) For those with longstanding alcohol use disorder: specific cognitive and neurologic deficits Also: insomnia, anemia, osteoporosis, and liver disease Hepatitis B and C vaccinations for those with established liver disease Screening for STIs © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 164 (1): ITC1-1. What type of follow-up care and referrals should clinicians provide for patients with unhealthy alcohol use? Patients need regular, ongoing monitoring for: Alcohol use Associated medical, psychiatric and behavioral-related AEs Treatment effects Refer patients to specialty care for: At-risk alcohol use that doesn’t respond to brief intervention Alcohol use disorder and/or significant comorbid medical or psychiatric condition, if office-based treatments ineffective Use American Society of Addiction Medicine criteria © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 164 (1): ITC1-1. CLINICAL BOTTOM LINE: Treatment… For at-risk drinking, brief interventions can be effective For alcohol use disorder, treatment hinges on patient safety and stabilization Benzodiazepines: decrease withdrawal symptoms, seizures Hospitalization: indicated for patients with moderate to severe withdrawal and high risk for complications Prevent relapse with psychotherapeutic interventions, pharmacotherapy, self-help groups Comprehensive care includes optimizing medication regimens Refer to specialty services Patients who don’t respond to treatment Patients who show evidence of alcohol use disorder or significant comorbidity © Copyright Annals of Internal Medicine, 2016 Ann Int Med. 164 (1): ITC1-1.