Alcohol Use Disorder AUD Introduction to Treatment Slides

Alcohol Use Disorder (AUD): Introduction to Treatment Slides adapted from Kathleen Broad, MD, FRCPC Alejandro D. Meruelo, MD, Ph. D Department of Psychiatry University of California, San Diego AMSP 2020 1

Alcohol Use Common Fluctuates on continuum of risk: 80% of US population ♂; 60% ♀ ever drank 30 -50% ever had alcohol problems Alcohol use disorder (defined later) = 12% AMSP 2020 2

Alcohol Use Costly AUD problems cost US $223. 5 billion/yr Linked to: Motor Vehicle Accidents Poor academic performance Suicide Violence, (e. g. , intimate partner) Overdose deaths Sexually transmitted infections (STIs) AMSP 2020 3

AUDs Under Recognized & Rxd Lifetime risk: ~15% ♂ & ~10% ♀ But only 25% with AUD ever seek help <10% of AUD receive treatment ID AUD helps Rx of other probs AMSP 2020 4

Lecture Covers AUD Dx Effects & how relates to treatment Course Treatment AMSP 2020 5

Clinical Case: Sally Works as waitress Heavy drinking during HS Drunk – argued with boss & boyfriend Fired due to drinking on job AMSP 2020 6

Alcohol Use Disorder Dx (Diag & Stat Manual Mental D/o-5) In same year 2+ of: Tolerance Withdrawal Hazardous use Social problems Failed roles Use longer/more Unable to ↓ Lots time use ↓ activities Use despite probs Craving

Alcohol Withdrawal (W/D) A. Stopping alcohol after heavy, prolonged use B. 2+ of Sweating or ↑pulse Hand tremor Insomnia Nausea/vomiting Hallucinations Agitation Anxiety Seizures C. Cause impairment or distress D. R/O med/psych Dx or another substance AMSP 2020 8

Clinical Case: Sally How Sally had AUD: ↑ Drinking despite problems Drinking → failure to fulfill life obligations For withdrawal: Sally lacked criteria AMSP 2020 9

Lecture Covers AUD Dx Effects & how relates to treatment Course Treatment AMSP 2020 10

Acute Alcohol Brain Effects (1) Slowed breathing Poor concentration Sleepiness AMSP 2020 11

Acute Alcohol Brain Effects (2) Poor decisions Slurred speech Poor coordination AMSP 2020 12

Acute Alcohol Brain Effects (3) Depression/Suicide/Homicide Forget most/all of drinking evening (blackout) Loss of consciousness AMSP 2020 13

Acute Alcohol Brain Effects (4) Acute alcohol → ↑ gamma-aminobutyric acid (GABA) GABA relaxation, intoxication Acute alcohol → ↓N-methyl-D-aspartate (NDMA( NMDA→ tremor, anxiety, insomnia Withdrawal: ↓GABA & ↑NMDA All drugs ↑dopamine, reward & craving AMSP 2020 14

Alcohol Metabolism 10% excreted via lungs/urine/sweat 90% metabolized by stomach & liver enzymes: Alcohol acetaldehyde Acetaldehyde → CO 2 and H 2 O (ALDH) AMSP 2020 15

Chronic Alcohol Effects (1) Acute inflamed pancreas Severe abdom pain, vomit, fever Ulcers Bleeding in stomach Weakened immune system Pneumonia, tuberculosis, HIV AMSP 2020 16

Chronic Alcohol Effects (2) Persistent memory difficulties Vitamin deficiencies (in some) Malnutrition (in some) AMSP 2020 17

Lecture Covers AUD Dx Effects & how relates to treatment Course Treatment AMSP 2020 18

AUD Course (1) Intensity fluctuates Heavy drinking & problems Stop drinking Temporary control drinking 20% long term remission w/out Rx <10% can drink without problems AMSP 2020 19

AUD Course (2) If heavy drinking continues: ↓ life ~15 years ↑ heart attacks and strokes ↑ cancer stomach/breast/head & neck, etc. Liver disease AMSP 2020 20

Alcohol-Induced Major Depression Can → suicide In 40% of AUD Improves w abstinence Looks ID to major depr Don’t need antidepressants Starts in heavy drinking AMSP 2020 21

Other Psychological Syndromes Begin in intoxication or w/d Temporary panic attacks (defined below) ~20% Alcoholic psychosis (defined below) ~3% AMSP 2020 22

Panic Attacks A. 4+ of, lasting 10 min: Palpitations Trembling Sweating Shortness of breath Choking Chest pain Nausea Lightheadedness Fear of losing control Fear of dying Numbness Chills Feelings of unreality or detachment B. Disappear within days to weeks AMSP 2020 23

Alcoholic Psychosis Paranoia ± hearing voices Fear of being watched/followed Believes are real AMSP 2020 24

Clinical Case: Sally Kicked out of apartment Loses support of family AMSP 2020 25

Lecture Covers AUD Dx Effects & how relates to treatment Course Treatment AMSP 2020 26

Treating Alcohol Withdrawal <50% AUD have withdrawal Begins at 8 h after ↓intake Peaks day 2 ↓↓ day 4 or 5 Most: moderate tremors/no confusion or seizures Rx with depressant meds (usually Bzs) ↓s high bld pressure, heart rate & tremor AMSP 2020 27

Rx AUD: Talk Therapy Cognitive behavioral Rx Change how person thinks Change how person behaves Motivational interviewing When ready, not from rebuke Helps to change Empathic approach AMSP 2020 28

Rx AUD: Ancillary Program Alcoholic Anonymous AKA “ 12 -step” Continuous support Spiritual framework Steps Powerless over alcohol Make amends with friends Reach out to help others Mentorship AMSP 2020 29

Rx AUD: Naltrexone (Trexan, Vivitrol) Mechanism Opioid receptor blocker ↓cravings Drink less if relapse Rx orally or monthly injection Ideal patient Takes consistently or visit clinic monthly Can self-administer non-injection AMSP 2020 30

Rx AUD: Acamprosate (Campral) Mechanism NMDA receptor blocker Stimulating via glutamate Helps prolong abstinence Not metabolized by liver Side effects: nausea and diarrhea Ideal patient Tolerates side effects Ok with liver dz Can take 3 x daily AMSP 2020 31

Rx AUD: Disulfuram (Antabuse; 1) Mechanism ALDH blocker Warn: if drink sick Supervised dosing best AMSP 2020 32

Rx AUD: Disulfuram (Antabuse; 2) Ideal patient No significant comorbidities Diabetes Heart disease Abstinent for 12 h Family member administers Can monitor toxic possible side effects No psychosis AMSP 2020 33

Alt Rx AUD: Topiramate (Topomax) Mechanism Anticonvulsant Side effects Weight loss, cognition, Acute closure glaucoma, kidney stones Gradual dose titration ↓ side effect risk Adjust dose if renal impairment Ideal patient Heavy drinker Intolerant of other Rx No contraindications AMSP 2020 34

Clinical Case: Sally’s Treatment CBT and MI Alcoholics Anonymous Naltrexone AMSP 2020 35

Lecture Covered AUD Dx Effects & how relates to treatment Course Treatment AMSP 2020 36

Takeaway Points AUD is under-recognized and under-treated Alcohol use is common and costly Treatment is effective includes talk therapy + medication Treatment is personalized AMSP 2020 37