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AUD in General Hospitals High Prevalence 25% Lifetime abuse or dependence 35% Trauma surgical patients 20% Burn patients Very costly $166 Billion/yr: ↓work, ↑crime, ↓health Comorbid AUD ↑ stay and cost © AMSP 2012 2 ↑ Medical Complications Alcohol ↓ interacts with meds General health Poor nutrition © AMSP 2012 3 This Lecture Reviews: Definitions Screening/evaluation Medical/psych complications, comorbidity and Rx Interventions in the hospital © AMSP 2012 4 Definitions Standard Drink (~10 grams alcohol) 12 oz. Beer 5 oz. Wine 1.5oz. Hard liquor (80 proof) Hazardous Drinking Men: >14 drinks/wk or >4 drinks/sitting Women: >7 drinks/wk or >3 drinks/sitting © AMSP 2012 5 Abuse & Dependence Abuse 1+ of: Failure in roles Hazardous use Social/interpersonal problems Legal problems (Not alc dependent) © AMSP 2012 Dependence 3+ of: Tolerance Withdrawal Unable to ↓ or quit Longer than intended ↑ Time find/use ↓ Important activities Despite consequences 6 This Lecture Reviews Definitions Screening/evaluation Medical/psych complications, comorbidity, and Rx Interventions in the hospital © AMSP 2012 7 Screening/Evaluation Often undetected by MDs Reasons include: Inadequate training Misperceptions/stereotyping Uncertain about what to do © AMSP 2012 8 Psychiatric Consultation Ask why refer Review records/labs/etc. Review all meds Interview/examine patient © AMSP 2012 9 Psychiatric Consultation Interview Order collateral diagnostic tests Formulate Discuss assessment & plan w/ referring clinician © AMSP 2012 10 Taking AUD History Current/past patterns of use Usual drinks/day Binge pattern Periods of abstinence History of treatment Withdrawal Family history © AMSP 2012 11 Screening/Evaluation Alc Use Disorders Identification Test 10 questions, scored 0-4 ≥8 = hazardous drinking (Sens=98%) ≥10 = alc dependence (Sens=99%) Short Michigan Alcohol Screening Test 13 questions, self-administered Accuracy=25 item MAST (Sens 90%) AMSP 2012 12 Screening/Evaluation Lab markers Gamma-glutamyltransferase Aspartate & Alanine Aminotransferase Carbohydrate Mean deficient transferrin Corpuscular Volume © AMSP 2012 13 Lab Markers 1 (GGT) Gamma-glutamyltransferase ↑ With heavy drinking ↑ In: heart disease, kidney disease, preg GGT >35 -Heavy drinking -↑ Before liver damage -Sensitivity for heavy drinking ~75% GGT >50 may indicate liver damage Normalizes ~5 weeks of abstinence © AMSP 2012 14 Lab Markers 2 (LFT) Liver enzymes: 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 © AMSP 2012 15 Lab Markers 3 (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 © AMSP 2012 16 Lab Markers 4 (MCV) Mean Corpuscular Volume Size of red cells (nl =80-100u) ↑ By heavy drinking >90u suggests heavy drinking MCV ↑ in other conditions © AMSP 2012 17 Screening/Evaluation Signs and symptoms Irregular heart rhythm Enlarged tender liver (alc hepatitis) Hard small liver (cirrhosis- in 20% of AUD) Ascites (abdom. cavity fluid in liver failure) Jaundice (yellow skin/eyes in liver failure) Tremor (hangover or withdrawal) Hyperactive reflexes/↑ pulse/ etc. 18 © AMSP 2012 This Lecture Reviews Definitions Screening/evaluation Medical/psych complications, comorbidity, and Rx Interventions in the hospital © AMSP 2012 19 Alcohol Withdrawal Cessation or ↓ heavy use 2+ w/in hrs: Tremor (hands, arms, legs, tongue) ↑ Pulse Insomnia Agitation (restlessness/agitation/aggression) Anxiety Visual/tactile/auditory hallucinations (rare) Grand mal seizure (rare) © AMSP 2012 20 Alcohol Withdrawal 6-8 hours after last drink Declining BAC (not at zero) Symptoms R/O → distress/↓ functioning general medical or mental dx Delirium Tremens (DT’s) (rare) © AMSP 2012 21 Delirium Tremens (DT’s) Seen in ~5% AUD Disorientation (confusion) Fluctuating consciousness Hyperactivity/excitation ↑ Pulse, bp, temp, etc. © AMSP 2012 22 Delirium Tremens (DT’s) Hallucinations Can be fatal if med problems Onset ↑ 48-96 hours after last drink Risk prior episodes/med probs R/O other causes © AMSP 2012 23 Withdrawal Tx Benzodiazepines (e.g. diazepam [Valium]) Correct transmitter problems Day 1: give enough to ↓ symptoms ↓ Dose ~20% day 1 dose each day ↑ Dose if symp ↑; ↓ dose next day Anticonvulsants not needed © AMSP 2012 24 Clinical Case 80 y/o female ↑BP, 3 days s/p hip surgery Keeps trying to get out of bed Confused Agitated ↑ BP and bilateral hand tremor Dx: EtOH withdrawal delirium (DT) © AMSP 2012 25 Clinical Case Review criteria for DT’s Symptom onset at 72 hours Confusion Psychomotor ↑ agitation Blood pressure/pulse/etc. © AMSP 2012 26 Clinical Case Rx recommendations: 1:1 observation Folate R/O 1mg/d, thiamine 100mg/d other causes Benzodiazepine © AMSP 2012 27 Benzodiazepine Rx Chlordiazepoxide (Librium);diazepam (Valium) Longer half-life=smoother withdrawal Better seizure protection But can over-sedate elderly and liver impaired Lorazepam (Ativan)=better choice in this pt Shorter half-life = ↓ risk of oversedation ↓ Risk if liver prob; not metabolized in liver © AMSP 2012 28 Wernicke Encephalopathy Cause: ↓ thiamine (Vit B1) Emergency: untreated →20% death Triad: Confusion, ataxia (incoordination), ophthalmoplegia (eye muscle paralysis) Rx: IV thiamine (to optimize absorption) © AMSP 2012 29 Korsakoff’s Syndrome Impaired memory in alert, responsive pt Limited insight to memory loss Confabulation -- makes up stories Retrograde & anterograde memory loss © AMSP 2012 30 Psychiatric Disorders: MDE Co-morbid major depression Gen pop major depressive episode (MDE) ~15% AUD slightly ↑ even when not drinking MDE unrelated to drinking -Alcohol ↑ depressive symptoms -Alcohol intoxication/withdrawal ↑ suicidal ideation © AMSP 2012 31 Psychiatric Disorders: AID Alcohol induced: severe intoxication → temporary MDE in ~30% Causal relationship--psychiatric disorder not predating AUD Treatment = abstinence (≠ meds) Depression ↓↓ in 2 d to 4 wks abstinence © AMSP 2012 32 Psychiatric Disorders: Psychosis Psychosis – Hallucinations Delirium (e.g. post surgery, DT’s) --usually disappear as delirium resolves ~3% AUD during severe intoxication -No delirium -Alcohol-induced psychosis -Disappears 2 d to 4 wks without meds -Antipsychotics (e.g. risperidone) control symp © AMSP 2012 33 This Lecture Reviews Definitions Screening/evaluation Medical/psych complications, comorbidity, and Rx Interventions in the hospital © AMSP 2012 34 Interventions Brief intervention for heavy drinkers Non-dependent Goal: ~10 (e.g.regular >3 drks/d) early intervention & prevention min educ. or MotivationaI Interviewing Delivered by MD/staff © AMSP 2012 35 Motivational Interviewing (MI) Behavior change (e.g. taking meds) Change: process with multiple steps Stage of change model Collaboration (not confrontation) ↑ Pt’s motivation Respect pt’s own decision © AMSP 2012 36 Stages of Change Model Precontemplative Contemplative Preparation Action not a problem – considers change - makes plans - changes behavior Maintenance - sustains change © AMSP 2012 37 Motivational Interviewing General principles: Empathy Discuss ambivalence to change Skillful listening Point out behavior contrast to goals Roll with resistance Support self-efficacy © AMSP 2012 38 Clinical Case 45 year old male high school principal 3rd admission for alcoholic pancreatitis Given AUD treatment options in past No follow up Now: marital discord, job lay-off, etc. Admits alcohol a problem © AMSP 2012 39 Clinical Case Stage of change: contemplative Express empathy for situation/stressors Discuss barriers to change Discuss goals vs behavior Support ability to change if desired Result: pt takes initiative Stage : contemplation→preparation © AMSP 2012 40 Treatment All options work to: Change thinking about AUD -Chronic disorder -Can be managed Help prevent relapse -Recognize triggers -Avoid high risk situations -Cope with cravings © AMSP 2012 41 Referral Option 1 Inpatient/residential rehabilitation Lessons/support in 24 hr milieu Typically 14-28 days Learn through group discussions Intensive Outpatient Treatment (IOP) Groups multiple days of week Provided in “real world” setting © AMSP 2012 42 Referral Option 2 Outpatient treatment Substance or mental health Rx provider Provided in variety of settings Self-help groups (AA) Introduced in rehab or IOP Requires only desire to stop drinking Change through working “12 steps” © AMSP 2012 43 Medications Naltrexone (ReVia or Vivitrol) Oral (50mg/d) or injectable (380mg/mo) Opioid receptor antagonist ↓Cravings Acamprosate (Campral) Oral (~2g/d) NMDA receptor antagonist ↓ Post-withdrawal symptoms Rx 3-6 months ~15% improvement © AMSP 2012 44 Conclusions AUD important issue in general hospital Effective screening and evaluation Multiple medical/psychiatric complications Effective interventions for Rx and referral © AMSP 2012 45