10/15/2018 Management of the Hospitalized Patient with an Alcohol Use Disorders: Case Workshop Soraya Azari, MD Learning Objectives • At the end of this workshop you should be able to… 1. Feel confident in how to do an effective screen for alcohol use disorders 2. Be familiar with how to manage common complications of the alcohol withdrawal syndrome (AWS) 3. Be able to counsel patients on a menu of different treatment options for alcohol use disorder (besides just AA) 1
10/15/2018 Format • Real cases • Q&A design • Learn from peers • Practice skill Case 1 • Mr. H is a 57yo M teacher with a history of HTN, obesity, and diabetes presenting to the emergency department with epigastric pain and vomiting. ROS is notable for recent weight loss and occasional numbness in his feet. • Meds: HCTZ ‐ lisinopril 12.5 ‐ 10mg, metformin 500mg BID • Exam: well ‐ kempt withdrawn M, in distress from pain and nausea w/TTP epigastric area w/no rebound or guarding • FH: father with “cirrhosis” • Labs are notable for: – Hb 11.5, lipase 95, creat 1.4 (baseline normal), glu 252, Ca 9.0, BUN 58, Mg 1.3, AST 91, ALT 45 • Abdominal CT: stranding around pancreas c/w pancreatitis 2
10/15/2018 Question • Q1: How do you screen for alcohol use disorder? • Q2: What are considered safe limits for alcohol use? • Q3: What is considered a standard drink? • Q4: How good are providers at making the dx of use disorders in hospitalized adults? • Q5: How prevalent are alcohol use disorders? How to Screen • Ask permission • Single question screener (for primary care!): – How many times in the past year have you had more than 5 (4) drinks in a day? 3
10/15/2018 What’s a Standard Drink? In the U.S., a standard drink is any drink that contains about 14 grams of pure alcohol (about 0.6 fluid ounces or 1.2 tablespoons) . Rethinking Drinking: Alcohol and your health. Available at: www.niaaa.gov What I hear: Patient: “one 2 ‐ 11”… Me: 24 oz. of steel reserve = malt liquor (stronger!), so 12oz beer = 8 oz malt liquor, so 1 beer = 3 drinks Others: St. Ides, Colt 45, Old E *craft beers Patient: “just a pint a day” Me: 1 pint = ~13 oz 1.5 oz = 1 drink, so Just a pint = 8 ½ drinks 4
10/15/2018 Others “fifth a day” Me = 17 drinks per day “Handle a day” Me = 40 drinks per day How to Screen • Ask permission • Single question screener: – How many times in the past year have you had more than 5 (4) drinks in a day? • NONE reinforce safe drinking limits • ≥ 1 – What do you like to drink? – Assess amount: average drinks/day, average days/week 5
10/15/2018 What if they screen positive? • 4Rs • 4Cs – Risk of bodily harm – Loss of Control – Relationship trouble – Continued use despite harm** – Role Failure – Compulsion – Repeated attempts to cut back – Craving Tolerance** Withdrawal DSM-5 Criteria for Substance Use Disorders Recommendations and Rationale R isk bodily harm R elationship trouble R ole Failure C ompulsion Repeated try Cut back C ompulsion C onsequences Loss of C ontrol C raving a One or more abuse criteria within a 12-month period and no dependence diagnosis; applicable to all substances except nicotine, for which DSM-IV abuse criteria were not given. b Three or more dependence criteria within a 12-month period. c Two or more substance use disorder criteria within a 12-month period. d Withdrawal not included for cannabis, inhalant, and hallucinogen disorders in DSM-IV. Cannabis withdrawal added in DSM-5. Source: Am J Psychiatry. 2013;170(8):834-851. 6
10/15/2018 What are healthy limits? • Men: 4 and 14 • Women, >65: 3 and 7 How Common? 4% alcohol Dependence (M>F ) 6% alcohol abuse 30% risky Alcohol: 17% screen pos risky use From Saitz NEJM; Holt et al Am J Addiction Mar 2012 77% of those are dependent 7
10/15/2018 How good are we at detecting substance use in our patients? • In the hospital: 64% detected of the time • In the clinic: <50% of patients screened • Physicians are less likely to detect alcohol problems: When screening tools are not used universally In patients who they do not expect to have alcohol problems (women, white, higher SES) Holt et al Am J Addiction Mar 2012. Fleming MF Alcohol Health Res World 1997. Screening & Stigma • People with alcohol use disorders (AUD) are highly stigmatized – Systematic review of extent of stigma for alcohol use disorder compared to other mental illnesses • Blame : ~60% people say the person is to blame for the AUD v. 33% in eating disorders and 4 ‐ 13% w/ depression • Danger : 71% of people consider it likely for an alcohol ‐ dependent person to hurt others v. 33% w/depression • Social distance : not my neighbor AUD >> schizophrenia >> depression • How to uproot stigma – Language: person with alcohol use disorder – Education: learn from your patients (humbly); encourage equality between physical and mental illness; educ care team – Compassion: walk in their shoes; focus on the positive – Support/offer treatment for ALL patients • Now: 8% of 15million needing treatment got it Schomerus G et al. 2010 Alcohol and Alcoholism;46(2):105 ‐ 12. NAMI website. 8
10/15/2018 Question • Q1: How do you screen for alcohol use disorder? Single question screener, though hospitalized population has high prevalence use disorders • Q2: What are considered safe limits for alcohol use? 4/d and 14/wk (men), 3/d and 7/wk (women, persons >65) • Q3: What is considered a standard drink? Drink containing 14g alcohol • Q4: How good are providers at making the dx of use disorders in hospitalized adults? Generally poor • Q5: How prevalent are alcohol use disorders? 5 ‐ 10% general population; ~15% of hospitalized patients Case Continued • Mr. H feels so ashamed that he’s in the hospital. He just got his job back as an english teacher and he’s really been enjoying it, but his divorce proceedings have been extremely difficult for him. • He says that after work he drinks 1 ‐ 2 bottles of wine per night, but this past week (school recess), he had 2 ‐ 3 bottles per night, which is more than his usual amount. He has been drinking heavily since age 40. • He has been drinking more than usual over time, it is part of the reason for his divorce, he has tried to quit multiple times, and overall says he’s been doing well until this episode. He says he used to drink a fifth of vodka per day, but then when his wife left him (8 mos ago), he went to a “detox program.” He was abstinent of alcohol, but in the past 2 ‐ 3 mos has resumed drinking wine only. 9
10/15/2018 Case Continued • Mr. H feels so ashamed that he’s in the hospital. He Risk of bodily harm just got his job back as an English teacher and he’s Relationship trouble really been enjoying it, but his divorce proceedings Role Failure have been extremely difficult for him. Repeated attempts to cut • He says that after work he drinks 1 ‐ 2 bottles of wine Back per night, but this past week (school recess), he had Loss of Control 2 ‐ 3 bottles per night, which is more than his usual amount. Continued use despite • He has been drinking more than usual over time, it is harm** part of the reason for his divorce, he has tried to cut Compulsion back multiple times, and overall says he’s been doing Craving well until this episode. He says he used to drink a Tolerance** fifth of vodka per day, but then when his wife left Withdrawal him (8 mos ago), he went to a “detox program.” He was abstinent of alcohol, but in the past 2 ‐ 3 mos has resumed drinking wine only. Case Continued • The patient is admitted to your medicine service for pancreatitis. He is admitted to your medicine service and given: IVF, bowel rest, analgesics, and was put on “observation” for the alcohol withdrawal syndrome. • HD 2 he seemed more tremulous and anxious, but said that was due to ongoing nausea and headache from his pancreatitis. VS were notable for BP 185/92 and HR 105. 10
10/15/2018 Question • Q1. What are the primary risk factors for developing the alcohol withdrawal syndrome (AWS)? • Q2. Are you concerned about AWS in this patient? Why? • Q3. What patients and what dose do you use for prevention of Wernicke’s encephalopathy? • Q4. What medications represent standard of care for AWS? • Q5. What is the “time course” for the alcohol withdrawal syndrome? Alcohol Withdrawal Syndrome 1024 ambulatory patients undergoing detoxification 3.7% • hallucinosis, 1.2% seizures, 1% DTs • Admitted etoh ‐ dependent hosp patients: 5 ‐ 20% require meds • Risk factors for severe AWS or DTs: – Age >40 – Heavy drinking >8 years – Drinking >100g etoh daily (i.e., 1 pint) – Symptoms/signs of withdrawal when not drinking – Random BAC >200mg/dL – Elevated MCV – Elevated BUN – Cirrhosis No predictors perform well; assessing signs, symptoms, and using • clinical judgment is best Whitfield CL, et al. JAMA . 1978;239:1409 ‐ 10. Blondell, R. Am Fam Physician 2005;71(3):495 ‐ 502. Saitz JAMA IM 2018. 11
10/15/2018 Risk Factors for AWS • Prediction of Alcohol Withdrawal Severity Scale (PAWSS) • AUDIT ‐ PC – Retrosp case control – 239 developed withdrawal – Score ≥ 4 – 91% sens, 89% spec for AWS – +LR 9 Pecoraro A et al. JGIM 2014 12
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