Alcohol UseDisorder

A Patient-Centered, Evidence-Based Diagnostic and Treatment Process1,2,3

A Presentation for SOMC Medical Education

Kendall L. Stewart, MD, MBA, DLFAPAOctober 18, 2012

1This presentation is designed as a problem-based learning module.2You will be surprised by many of your patients throughout your career.3Some of you and your colleagues will abuse alcohol.

Why is this important?

• Alcohol misuse is a leading cause of morbidity and mortality.

• Alcohol problems are often comorbid with other physical and mental disorders.

• Alcohol-related healthcare costs are already north of $250 billion per year.

• Alcohol-related problems are under-diagnosed and under-treated.

• Treatment outcomes for alcohol use disorders are as good or better than those for other chronic illnesses.

• After listening to this presentation, you will be able to answer the following questions:

– Why is this important?– What are the diagnostic criteria?– What are some of the

demographics of alcohol use disorder?

– What are some clues to alcohol abuse?

– What is the CAGE screening tool?– What counseling techniques are

helpful?– What medications are helpful?– What should you do?1

1 Not surprisingly, these people are often untruthful; their families will call you with the real scoop.

What diagnoses will likely be included in this category in DSM-5?

• Alcohol-Related Disorders– Alcohol Use Disorder– Alcohol Intoxication– Alcohol Withdrawal– Alcohol Use Disorder Not Elsewhere

Classified (NEC)

What are the diagnostic criteria?1

• Problematic pattern of alcohol use causing significant impairment or distress– Alcohol used in greater amounts and longer than intended– Unsuccessful efforts to cut down usage– A great deal of time consumed by alcohol-related

activities and complications– An alcohol-related failure to fulfill obligations at school,

work or home– Continued alcohol use in spite of the problems it causes– Alcohol use negatively impacts social, occupational or

recreational activities– Recurrent use when physically hazardous– Continued use in spite of alcohol-related complications– Tolerance– Withdrawal– Craving

1 These are the proposed DSM-5 criteria.

How many people does drinking kill each year?1

Disease 34,000

Accidents 41,000

1 NBCNews.com.

What are some of the key demographics of alcohol use?1

• About 61% of Americans drink alcohol.• About 15% of those abuse it.• About 14% binge drink (5 or more drinks

during one episode)• Heavy use is more frequent in men (10%)

than in women (3%).2

• Maximum moderate alcohol use is 2 drinks per day for men and 1 drink per day for women.

• Alcohol use disorders are as common as hypertension and much more common than diabetes.

1Rakel and Rakel, Textbook of Family Medicine2Family physicians and anesthesiologists are over-represented among physician alcoholics.

What are some clues to alcohol abuse?1

• History– Arrest for operating a

vehicle while intoxicated (OVI)2

– Tremor– Pancreatitis– Gastritis– Hypertension– Stress– Trauma– Domestic disputes

• Lab– Mean cell volume (MCV) >

100– Aspartate transaminase (

AST) > alanine transaminase (ALT)

– Leukopenia– Thrombocytopenia– Positive response to the

carbohydrate-deficient transferrin (CDT) level

– Elevated Gamma-glutamyl transpeptidase (GGT)

1Rakel and Rakel, Textbook of Family Medicine2An OVI conviction means there is likely a problem; those so convicted rarely acknowledge this.

What is the CAGE1 screen for alcohol abuse?

• Have you ever felt you should cut down on your drinking?

• Have people annoyed you by criticizing your drinking?

• Have you ever felt bad or guilty about your drinking?

• Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (eye opener)?

• (Any positive answer is a source of concern.)

1Ewing JA, Detecting Alcoholism: The CASE Questionnaire. JAMA 1984; 252: 1905-1907.

What are some of the complications of alcohol use disorder?1

• Intoxication• Coma• Withdrawal• Withdrawal seizures• Withdrawal delirium (DTs)• Wernicke-Korsakoff Syndrome• Wernicke’s encephalopathy• Korsakoff’s psychosis• Fetal alcohol spectrum disorder

1Stern TA and others, MGH Comprehensive Clinical Psychiatry.

What counseling techniques may be helpful in alcohol use disorder?1

• Brief intervention• Classic intervention• Alcoholics Anonymous• Inpatient treatment• Outpatient treatment

1Rakel and Rakel, Textbook of Family Medicine

What medications may be helpful in alcohol use disorder?1

• Disulfiram (Anabuse) 500 mg QAM after being off alcohol for 12 hours

• Naltrexone (ReVia) 50 mg PO QAM after patient has been opioid free for 7 days; subcutaneous administration may be more effective

• Acamprosate (Campral) 666 mg PO TID after withdrawal; continue if relapse occurs

• Topiramate (Topamax) Slowly increase to 200 mg BID.

• Baclofen (Lioresal) Increase slowly to a max of 80 mg/day TID or QID.

1Rakel and Rakel, Textbook of Family Medicine

What should you do?1

• You must be the change you want to see in the world. Mahatma Gandhi

• Become a wellness champion and continue that lifestyle as long as you live.

• If you abuse alcohol, stop now; if you cannot, seek treatment and stick with it.

• Support prevention efforts for kids.• Ask every new patient about alcohol use.• If a patient drinks alcohol, screen them for

misuse.• Inquire whether patients who are abusing

alcohol are ready to stop—at every visit.1Rakel and Rakel, Textbook of Family Medicine

What else should you do?1

• Seize every teachable moment to urge quitting.

• View this as a chronic disease.• Remember that relapse is the rule rather

than the exception.• Focus on what you can do instead of fretting

about what you can’t do.• Bear in mind that the prognosis is not

hopeless.• Never, never, ever give up.

1Rakel and Rakel, Textbook of Family Medicine

The Psychiatric InterviewA Patient-Centered, Evidence-Based Diagnostic and Therapeutic Process

• Introduce yourself using AIDET1.• Sit down.• Make me comfortable by asking some

routine demographic questions.• Ask me to list all of problems and concerns.• Using my problem list as a guide, ask me

clarifying questions about my current illness(es).

• Using evidence-based diagnostic criteria, make accurate preliminary diagnoses.

• Ask about my past psychiatric history.• Ask about my family and social histories.• Clarify my pertinent medical history.• Perform an appropriate mental status

examination.

• Review my laboratory data and other available records.

• Tell me what diagnoses you have made.• Reassure me.• Outline your recommended treatment

plan while making sure that I understand.

• Repeatedly invite my clarifying questions.

• Be patient with me.• Provide me with the appropriate

educational resources.• Invite me to call you with any

additional questions I may have.• Make a follow up appointment.• Communicate with my other

physicians.1Acknowledge the patient. Introduce yourself. Inform the patient about the Duration of tests or treatment. Explain what is going to happen next. Thank your patients for the opportunity to serve them.

Where can you learn more?

• American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, 2000

• Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry, Third Edition, 2008

• Stern, et. al., Massachusetts General Hospital Comprehensive Clinical Psychiatry, 2008. You can read this text online here.

• Flaherty, AH, and Rost, NS, The Massachusetts Handbook of Neurology, April 2007• Stead, L, Stead, SM and Kaufman, M,

First Aid© for the Psychiatry Clerkship, Second Edition, March 2005• Klamen, D, and Pan, P,

Psychiatry Pre Test Self-Assessment and Review, Twelfth Edition, March 20093

• Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007• Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain, January

2008• Medina, John,

Brain Rules: 12 Principles for Surviving and Thriving at Home, Work and School, February 2008

• Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous Patients,” 2000• Order the Kindle version of the Rakel and Rakel Textbook of Family Medicine here.

Where can you find evidence-based information about mental disorders?

• Explore the site maintained by the organization where evidence-based medicine began at McMaster University here.

• Sign up for the Medscape Best Evidence Newsletters in the specialties of your choice here.

• Subscribe to Evidence-Based Mental Health and search a database at the National Registry of Evidence-Based Programs and Practices maintained by the Substance Abuse and Mental Health Services Administration here.

• Explore a limited but useful database of mental health practices that have been "blessed" as evidence-based by various academic, administrative and advocacy groups collected by the Iowa Consortium for Mental Health here.

• Download this presentation and related presentations and white papers at www.KendallLStewartMD.com.

• Learn more about Southern Ohio Medical Center and the job opportunities there at www.SOMC.org.

• Review the exceptional medical education training opportunities at Southern Ohio Medical Center here.

How can you contact me?1

Kendall L. Stewart, M.D.VPMA and Chief Medical OfficerSouthern Ohio Medical Center

Chairman & CEOThe SOMC Medical Care Foundation, Inc.

1805 27th StreetWaller Building

Suite B01Portsmouth, Ohio 45662

740.356.8153

StewartK@somc.org KendallLStewartMD@yahoo.com

www.somc.orgwww.KendallLStewartMD.com

1Speaking and consultation fees benefit the SOMC Endowment Fund.

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Are there other questions?

Thomas Carter, DO

Justin Greenlee, DO