Disclosure Diagnosis and No financial conflicts treatment of - PowerPoint PPT Presentation

2/24/2017 Disclosure Diagnosis and No financial conflicts treatment of alcohol use disorder in primary care Trade names may be used for clarity Scott Steiger, MD, FACP, FASAM HS Associate Clinical Professor of Medicine and Psychiatry UCSF-ZSFG Learning Objectives Cases… On list for clinic this afternoon: You should be able to: • 44 yo F smoker c/o insomnia to NAL • Screen for alcohol use disorder • 55 yo F hospital DC for hip fx • Diagnose alcohol use disorder • 56 yo M with HTN, DM, GERD, anxiety, • ID multiple peer support options for AUD hypertriglyceridemia, chronic pain • ID multiple medication options for AUD • 62 yo M homeless M with ESLD • 29 yo F new patient here to establish care Who should be screened for alcohol use? 1

2/24/2017 Comorbidities with Alcohol use Screen for Alcohol Use Disorder Hypertension • USPSTF recommends universal (category GERD B) Obesity Trauma • “Single” question 82% sensitive, 79% DM specific* Anemia Liver disease – “ Do you ever drink alcohol?” Depression Anxiety – “How many times in the past year have you PTSD had ___ or more drinks in a day?” Insomnia • 4 for women or men > 65 yo **If one of above not controlled on max therapy, or you see 3-4 • 5 for men < 65 yo on problem list, ask about alcohol! Smith PC, et al. J Gen Intern Med . 2009 Some stats • 87.6% lifetime prevalence of alcohol use – 56.9% drank in the last month • ~25% binge in the last month • 9.2% men, 4.6% women with AUD • 88,000 die annually in US from alcohol SAMHSA 2014 data. See “Alcohol Facts and Statistics” from NIAAA: http://pubs.niaaa.nih.gov/publications/AlcoholFacts&Stats/AlcoholFacts& http://www.nhtsa.gov/people/injury/research/pub/impaired_driving/triangle.gif Stats.htm 2

2/24/2017 Diagnosis of Alcohol Use Diagnosis of Alcohol Use Disorder Disorder 1 Had times when you ended up drinking more, or longer, than 7 Given up or cut back on activities that were important or interesting to you, or gave you pleasure, in order to drink? you intended? 8 More than once gotten into situations while or after drinking that 2 More than once wanted to cut down or stop drinking, or tried increased your chances of getting hurt (such as driving, swimming, to, but couldn't? using machinery, walking in a dangerous area, or having unsafe sex)? 3 A great deal of time is spent in activities necessary to obtain 9 Continued to drink even though it was making you feel depressed or alcohol, use alcohol, or recover from its effects. (See DSM-IV, anxious or adding to another health problem? Or after having had a criterion 9.) memory blackout? 4 Spent a lot of time drinking? Or being sick or getting over other 10 Had to drink much more than you once did to get the effect you aftereffects? want? Or found that your usual number of drinks had much less effect than before? 5 Found that drinking—or being sick from drinking—often 11 Found that when the effects of alcohol were wearing off, you had interfered with taking care of your home or family? Or caused job withdrawal symptoms, such as trouble sleeping, shakiness, troubles? Or school problems? restlessness, nausea, sweating, a racing heart, or a seizure? Or 6 Continued to drink even though it was causing trouble with sensed things that were not there? your family or friends? NIAAA, 2016. Accessible at http://pubs.niaaa.nih.gov/publications/dsmfactsheet/dsmfact.htm NIAAA, 2016. Accessible at http://pubs.niaaa.nih.gov/publications/dsmfactsheet/dsmfact.htm Diagnosis of Alcohol Use The 4C’s of Addiction Disorder • craving 2-3 symptoms: Mild • loss of control of amount or frequency of 4-5 symptoms: Moderate use 6+ symptoms: Severe • compulsion to use • use despite consequences Treatment Decisions Depend on Severity and patient goal 3

2/24/2017 Treatment options depend on Treatment options depend on severity patient’s goal • Mild (2-3 criteria) • Abstinence? – Trial of abstinence (TOA) • Reduction in # drinks? • Diagnostic and therapeutic • Moderate (4-5 criteria) • Reduction in # drinking days? – TOA • Reduction in harm to pt from drinking? – Peer support – Pharmacotherapy • Severe (6+ criteria) – TOA � medically supervised withdrawal – Peer support – pharmacotherapy Treatment options depend on The Case: 42 yo M +EtOH comorbidities screen • Depression/anxiety? 42 yo M presents for txfer care HTN, insomnia. • ESLD? +needs 3-4 now to get “buzz” • Homeless? +hangovers led to missed work twice • Chronic pain on opioids? Doesn’t see EtOH as ongoing problem • Other substance use disorder? Any “tests” or treatment would you recommend? 4

2/24/2017 Diagnosis of Alcohol Use Diagnosis of Alcohol Use Disorder Disorder 1 Had times when you ended up drinking more, or 7 Given up or cut back on activities that were important or interesting to you, or gave you pleasure, in order to drink? longer, than you intended? 8 More than once gotten into situations while or after drinking that 2 More than once wanted to cut down or stop drinking, or increased your chances of getting hurt (such as driving, swimming, tried to, but couldn't? using machinery, walking in a dangerous area, or having unsafe sex)? 9 Continued to drink even though it was making you feel depressed or 3 A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects . anxious or adding to another health problem? Or after having had a memory blackout? 4 Spent a lot of time drinking? Or being sick or getting 10 Had to drink much more than you once did to get the effect you over other after effects? want? Or found that your usual number of drinks had much less effect than before ? 5 Found that drinking—or being sick from drinking—often 11 Found that when the effects of alcohol were wearing off, you had interfered with taking care of your home or family? Or withdrawal symptoms, such as trouble sleeping, shakiness, caused job troubles? Or school problems? restlessness, nausea, sweating, a racing heart, or a seizure? Or sensed things that were not there? 6 Continued to drink even though it was causing trouble with your family or friends? NIAAA, 2016. Accessible at NIAAA, 2016. Accessible at http://pubs.niaaa.nih.gov/publications/dsmfactsheet/dsmfact.htm http://pubs.niaaa.nih.gov/publications/dsmfactsheet/dsmfact.htm 42 yo M mild-moderate AUD 42 yo M moderate AUD Mild-Moderate AUD, new to pt: Brief Intervention • Wants another TOA • Educate on alcohol effects • “I’ll do it this time, doc, 10 out of 10” – “Can I tell you a little about how alcohol and sleep?” • Give the diagnosis – “ You meet criteria for Alcohol Use Disorder” Other next steps? • TOA – Patient agrees to 2 week trial of abstinence: 8/10 confidence • Schedule follow-up – made it 5 days without (“sleep was a little tough”), then family reunion. 4 more nights since, 3 of them 5+ drinks. 5

2/24/2017 www.aasf.org Something for everyone PEER SUPPORT GROUPS Do 12-step groups work? www.smartrecovery.org • Meta-analysis says no* • Project MATCH: AA as good as CBT if facilitated to get there** – 35% 3 y abstinence *Ferri et al., Cochrane Syst Rev, 2006 6

2/24/2017 www.sfmindfulnessfoundation.org/eve www.refugerecovery.org nts 42 yo M moderate-severe AUD • 2 weeks f/u: drank again by day 3. Increased arguments with GF. “I think I need some more help” What pharmacotherapy might you offer? There’s a pill (or a shot) for that PHARMACOTHERAPY FOR AUD 7

2/24/2017 Maintain abstinence: Meds to treat alcohol use disorder acamprosate Maintain abstinence Decrease binges Pro Con • Well studied: MA (n= • 6 pills per day • Acamprosate • Naltrexone 6915) • Contraindicated in ESRD • ?naltrexone • Gabapentin* – NNT 9 to prevent one • SE: diarrhea in 10-15% relapse within 8-24 wks* • Gabapentin* • Topiramate* • ?mechanism • Safe in liver dz • No help with active • ?Baclofen* • Baclofen* • FDA-approved drinker cutting down • Disulfiram** • Ondansetron* Ideal candidates: post-medically supervised withdrawal, no ESRD, able • Varenicline* to manage pills Rx: 666 mg po tid *not FDA-approved **in highly structured *Rosner S, et al., Cochrane Database Syst Rev , 2010 environment only Decrease binges: naltrexone Maintain abstinence: disulfiram Pro Pro Con Con • Mu-opioid antagonist • ?improvement in abstinence • Inhibits aldehyde • MA: n=492 no diff reduces endogenous dehydrogenase placebo* – MA (n=2347): risk reduction reward from EtOH 0.05 (0.1 – 0.002) effectively punishing – Pt “learns” not to drink too • SE: severe hepatitis much • SE: transaminitis EtOH intake (rare), reaction with • Well-studied for preventing • Contraindications: opioids, • FDA-approved “hidden” EtOH return to heavy drinking: LFTs > 5x ULN (mouthwash, sauce) – MA (n=7793) RR 0.83* – MA (n=2875) NNT 12** Ideal candidate: patient in methadone maintenance (or other clinic with • Safe to take with EtOH DOT capability) Rx: 250 mg po qday Ideal candidate: actively drinking patient not on opioids who wants help to “cut down” Rx: 50 mg po qday or 380 mg IM q4wks *Jonas DE, et al., JAMA , 2014 *Rosner S, et al., Cochrane Database Syst Rev , 2010 **Jonas DE, et al., JAMA , 2014 8