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Alcoholism and unhealthy alcohol use – 2013
 

Alcoholism and unhealthy alcohol use – 2013

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Information arranged from JHH learning modules

Information arranged from JHH learning modules

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    Alcoholism and unhealthy alcohol use – 2013 Alcoholism and unhealthy alcohol use – 2013 Presentation Transcript

    • Alcoholism and Unhealthy Alcohol Use – 2013 Information by Johns Hopkins Medicine Internet Learning Center Arranged By: Benjamin Tabibian DO
    • Why this module?
    • Health Effects of Alcohol  Question 1  Mr. Stubbs is a 50 year-old executive who is brought to the emergency department after his car hit a tree. He says he was on his way home from a party where he had two glasses of wine with dinner. He is awake, alert and oriented, but somewhat irritable. His blood alcohol level is 112 mg/dL
    • Health Effects of Alcohol  a).His blood alcohol level is consistent with drinking two glasses of wine.  b).He is not legally intoxicated.  c).His blood alcohol level is equivalent to a BAC of 1.12%.  d).His blood alcohol level would cause a significant impairment in reflexes and reaction time.
    • Health Effects of Alcohol  ETOH is the most common substance of abuse  1 unit is commonly thought of as  12oz beer  5oz wine  1.5oz shot
    • Health Effects of Alcohol  The acute effect of a given amount of alcohol on an individual will vary depending on a number of factors:  Weight (higher weight, less impact).  Gender (women tend to be affected more).  Genetics (variations in absorption and metabolism).  Rapidity of consumption (faster consumption leads to higher levels).  Presence of food in the stomach (slows absorption).  Tolerance (those who consume alcohol regularly develop a tolerance to the effects and metabolize alcohol more rapidly).
    •  BAC of 0.08% (80 mg/dL) or higher is considered intoxicated (in the USA)  general rule of thumb is that two standard drinks will increase the average person's blood alcohol concentration by roughly 50 mg/dL (0.05%), therefore one would generally need to consume at least 3 drinks to be over this threshold.  10-15 mg/dL per hour; those who abuse alcohol chronically generally metabolize it at a higher rate of about 20-30 mg/dL per hour  risk of death with blood alcohol concentrations over 300 mg/dL
    • The Abuser  Signs of a pt presenting  Odor of etoh  Slurred speech  Having just consumed prior to visit  Having signs of withdrawal because they chose to obtain  Multiple traumatic injuries  work or family problems, depression, anxiety, sleep disorders, gastrointestinal problems, sexual dysfunction, heavy cigarette smoking and family history of alcoholism  Blood test abnormalities
    • Withdrawal
    • However…  moderate alcohol consumption has not been shown to have deleterious health effects; in fact, it is associated with a reduced risk of a number of medical problems, including heart disease (5), type II diabetes (6), and dementia
    • Diagnosis  Mr. Stubbs, our 50 year-old executive, sees you for a routine physical exam after his car accident when he was legally intoxicated. He has no current complaints. Past medical history is notable for an episode of paroxysmal atrial fibrillation four years ago, which has not since recurred. Family history is notable for a mother with hypertension; his father died of liver failure. When you question him about his alcohol use, he tells you he has "a few drinks" each night, typically vodka martinis. When you try to quantify this further, the patient states that he does not feel that this is a problem and changes the subject.
    •  a).Men typically under report their quantity of alcohol intake.  b).The diagnosis of "alcoholism" requires that an individual has developed some level of tolerance to alcohol.  c).Denial is a characteristic of alcoholism.  d).Someone who has driven while intoxicated meets the criteria for unhealthy alcohol use.
    •  According to the 2010 National Survey on Drug Use and Health (NSDUH), among Americans aged 12 and older, about half are current alcohol users (drank in the last month), 23% reported binge drinking (more than 5 drinks on one occasion in the last month), and 7% reported heavy alcohol use (binge drinking at least 5 of the last 30 days). An estimated 11% drove under the influence of alcohol at least once in the previous year; this rate was highest among those in the 21-25 years age group (23%)
    •  No clear line between healthy and unhealthy use… but we can approximate  This is per NIAA recommendations  Men over 65 should follow women parameters
    • Alcoholism  "primary, chronic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. The disease is often progressive and fatal. It is characterized by impaired control over drinking, preoccupation with the drug alcohol despite adverse consequences, and distortions in thinking, most notably denial. Each of these symptoms may be continuous or periodic”
    • DSM IV creiteria must have 3/7
    • Question 3  You continue to evaluate the business executive presenting for a routine evaluation. You are intrigued by his history of atrial fibrillation in the past, and wonder if that was related to alcohol ingestion. Knowing that patients do not do well at assessing the impact of alcohol on their life, you decide to screen him with a set of specific questions on his drinking.
    •  a).His wife complains about his drinking.  b).He has recently cut down on his drinking.  c).He has an eye-opener in the morning.  d).He feels he should drink less.
    • AUDIT and CAGE  10-item Alcohol Use Disorders Identification Test (AUDIT)  4-item CAGE questionnaire  AUDIT is designed to detect unhealthy alcohol use as well as alcoholism, while the CAGE is designed to screen for alcohol dependence
    • AUDIT-C  AUDIT-C; a score of 3 or more has a sensitivity of 98% for heavy drinking and 90% for alcohol abuse or dependence, but a specificity of only 60% (i.e., 40% false-positive rate).
    • CAGE  Looking for 2 or more positive answers  when using a cutoff of two or more positive answers, the sensitivity was 74% and specificity 91%; using a cutoff of one or more positive answers increased the sensitivity to 89% while lowering the specificity to 81%
    • Question 4  While your patient offers negative answers for all four of the CAGE questions, he does admit to having more than 5 drinks at a party a few weeks ago.
    •  a).Counseling alone is not effective.  b).Counseling unhealthy alcohol users is effective, but the effect disappears after a few months.  c).In order to be effective, counseling must be delivered by trained mental health professionals.  d).Brief counseling has been shown to reduce unhealthy alcohol use for up to 4 years.
    • Counseling for Unhealthy Use  brief counseling for unhealthy alcohol use is effective at reducing alcohol consumption  Studies on people who were not alcoholics
    •  be empathic and non-judgmental, while clearly stating your concerns and recommendations  the goal for unhealthy drinkers is not necessarily abstinence, but limiting alcohol consumption to healthy levels
    • For Alcoholics  brief advice alone has not been shown to be effective for alcoholics  The first step is confrontation: telling a patient that you believe they have a problem in an empathic manner, while offering hope and help. The alcoholic's initial response to confrontation is often denial and it may take time for this to break down
    • Question 5  You see the business executive back, and after a few visits and further discussion, your patient states that his problem with alcohol is more serious than he previously acknowledged. He now admits that he has been secretly drinking an "eye opener" to prevent "the shakes". The patient is concerned about suddenly stopping alcohol, as he has heard stories about people dying from "the DTs", although he has never experienced them himself.
    •  a).If untreated, most alcoholics will have seizures or develop delirium tremens during withdrawal.  b).Phenothiazines are an effective alternative to benzodiazepines for alcohol withdrawal.  c).Alcoholics can be safely detoxified as outpatients.  d).He should be started on phenytoin to prevent seizures while going through withdrawal.
    • Detoxification  withdrawal is an important barrier to sobriety and can, at times, be life- threatening  the most dangerous complications are seizures and delirium tremens  mild-moderate withdrawal symptoms, detoxification can be done in an outpatient setting
    • Delirium Tremens  Risk factors  Previous episodes of DT’s  High bp or hr on presentation  Older age  comorbidities
    •  Recommended indications for inpatient therapy  Moderate to severe withdrawal.  Previous seizures or delirium tremens.  Inability to cooperate with daily follow-up.  Comorbid medical or psychiatric illness that requires hospitalization.  Inability to take medications by mouth/persistent nausea and vomiting.  Unsuccessful previous attempts at outpatient detoxification.
    • Treatment  Benzodiazepine taper  no evidence that any particular benzodiazepine is better than any other, but most studies utilized diazepam, lorazepam or chlordiazepoxide  Lorazepam may be a better choice for severe liver disease  No real difference between fixed dose and as needed regements  patients with severe alcohol withdrawal may initially require much higher dosage for treatment of their withdrawal  For seizures phenytoin has not been shown to be effective (36).
    • Question 6  After successfully completing detoxification, your patient comes to see you and asks you what he should do to prevent a relapse
    •  a).Attendance at self-help groups like AA is associated with improved outcomes.  b).Disulfiram (antabuse) is the best drug to prevent relapse.  c).Benzodiazepines have been shown to reduce the risk of relapse.  d).Topiramate is effective for preventing alcohol- related seizures, but not decreasing alcohol consumption.
    • Staying Sober  Self-help groups, such as Alcoholics Anonymous (AA) and other rehabilitation programs have traditionally been the mainstay of maintenance of sobriety.  counseling (individual or group)  psychotherapy (especially cognitive behavioral therapy),  residential treatment programs
    • Pharmacotherapy  disulfiram (Antabuse)  inhibits the metabolism of alcohol and results in a buildup of acetaldehyde when alcohol is consumed, leading to nausea, vomiting and flushing  Studies of alcoholics prescribed this agent have failed to show lasting benefit in preventing relapse or reducing consumption of alcohol  associated with hepatitis and liver failure and should not be used in patients with pre-existing chronic liver disease
    •  Naltrexone (Revia)  thought to attenuate craving for alcohol by blocking endogenous opioids  Short term studies showed moderate decrease in consumption but questionable long term benefit  FDA approved for treatment of alcoholism  Acamprosate  GABA analogue and studies suggest that it may have modest benefit  May be used alone or with naltrexone  Very questionable benefit  FDA approved for treatment of alcoholism
    •  topiramate (Topamax)  effects on GABA transmission  Two randomized-controlled study of this antiseizure medication have reported a significant reduction in alcohol consumption and increase in abstinence over a 12-14 week period  Not FDA approved for treatment of alcoholism  Studies excluded cirrhotics  Baclofen  Effects on GABA transmission  Only one trial but showed some promise  placebo-controlled trial, among 84 alcoholics with cirrhosis, those who received baclofen (10 mg three times daily) were significantly more likely to achieve and maintain abstinence at 12 weeks (71 vs. 29%)  Not FDA approved