AUD in General Hospitals n High Prevalence n

AUD in General Hospitals n High Prevalence n 25% Lifetime abuse or dependence n 35% Trauma surgical patients n 20% Burn patients n Very costly n $166 Billion/yr: ↓work, ↑crime, ↓health n Comorbid AUD ↑ stay and cost © AMSP 2012 2

↑ Medical Complications n. Alcohol n↓ interacts with meds General health n. Poor nutrition © AMSP 2012 3

This Lecture Reviews: n Definitions n Screening/evaluation n Medical/psych complications, comorbidity and Rx n Interventions in the hospital © AMSP 2012 4

Definitions n Standard Drink (~10 grams alcohol) n 12 oz. Beer n 5 oz. Wine n 1. 5 oz. Hard liquor (80 proof) n Hazardous Drinking n Men: >14 drinks/wk or >4 drinks/sitting n Women: >7 drinks/wk or >3 drinks/sitting © AMSP 2012 5

Abuse & Dependence n Abuse 1+ of: Failure in roles n Hazardous use n Social/interpersonal problems n Legal problems n (Not alc dependent) © AMSP 2012 n Dependence 3+ of: Tolerance n Withdrawal n Unable to ↓ or quit n Longer than intended n ↑ Time find/use n ↓ Important activities n Despite consequences n 6

This Lecture Reviews n Definitions n Screening/evaluation n Medical/psych complications, comorbidity, and Rx n Interventions in the hospital © AMSP 2012 7

Screening/Evaluation n Often undetected by MDs n Reasons include: n. Inadequate training n. Misperceptions/stereotyping n. Uncertain about what to do © AMSP 2012 8

Psychiatric Consultation n Ask why refer n Review records/labs/etc. n Review all meds n Interview/examine patient © AMSP 2012 9

Psychiatric Consultation n Interview n Order collateral diagnostic tests n Formulate n Discuss assessment & plan w/ referring clinician © AMSP 2012 10

Taking AUD History n. Current/past patterns of use n. Usual drinks/day n. Binge pattern n. Periods of abstinence n. History of treatment n. Withdrawal n. Family history © AMSP 2012 11

Screening/Evaluation n Alc Use Disorders Identification Test n 10 questions, scored 0 -4 n≥ 8 = hazardous drinking (Sens=98%) n≥ 10 = alc dependence (Sens=99%) n Short Michigan Alcohol Screening Test n 13 questions, self-administered n. Accuracy=25 item MAST (Sens 90%) AMSP 2012 12

Screening/Evaluation n Lab markers n Gamma-glutamyltransferase n Aspartate & Alanine Aminotransferase n Carbohydrate n Mean deficient transferrin Corpuscular Volume © AMSP 2012 13

Lab Markers 1 (GGT) n Gamma-glutamyltransferase n n n ↑ With heavy drinking ↑ In: heart disease, kidney disease, preg GGT >35 -Heavy drinking -↑ Before liver damage -Sensitivity for heavy drinking ~75% GGT >50 may indicate liver damage Normalizes ~5 weeks of abstinence © AMSP 2012 14

Lab Markers 2 (LFT) n Liver enzymes: AST and ALT n ALT in liver, AST in many tissues n ↑ In high use AND liver damage n Absolute value &ratio important -AST (14 -38 U/L normal range) -ALT (15 -48 U/L normal range) -AST: ALT ratio >2 suggestive of alcohol n Less sensitive than GGT © AMSP 2012 15

Lab Markers 3 (CDT) n Carbohydrate deficient transferrin n Transferrin=protein; transports iron n Abnormal form produced in ↑ drinking n CDT >20 g/l indicates heavy drinking n Few other conditions ↑ n Sensitivity & specificity ~75% (=GGT) n Normalizes ~1 month of abstinence © AMSP 2012 16

Lab Markers 4 (MCV) n Mean n Corpuscular Volume Size of red cells (nl =80 -100 u) n↑ By heavy drinking n >90 u suggests heavy drinking n MCV ↑ in other conditions © AMSP 2012 17

Screening/Evaluation n Signs and symptoms n Irregular heart rhythm n Enlarged tender liver (alc hepatitis) n Hard small liver (cirrhosis- in 20% of AUD) n Ascites (abdom. cavity fluid in liver failure) n Jaundice (yellow skin/eyes in liver failure) n Tremor (hangover or withdrawal) n Hyperactive reflexes/↑ pulse/ etc. © AMSP 2012 18

This Lecture Reviews n Definitions n Screening/evaluation n Medical/psych complications, comorbidity, and Rx n Interventions in the hospital © AMSP 2012 19

Alcohol Withdrawal Cessation or ↓ heavy use n 2+ w/in hrs: n n Tremor n↑ (hands, arms, legs, tongue) Pulse n Insomnia n Agitation (restlessness/agitation/aggression) n Anxiety n Visual/tactile/auditory n Grand hallucinations (rare) mal seizure (rare) © AMSP 2012 20

Alcohol Withdrawal n 6 -8 hours after last drink n Declining BAC (not at zero) n Symptoms n R/O → distress/↓ functioning general medical or mental dx n Delirium Tremens (DT’s) (rare) © AMSP 2012 21

Delirium Tremens (DT’s) n Seen in ~5% AUD n Disorientation (confusion) n Fluctuating consciousness n Hyperactivity/excitation n ↑ Pulse, bp, temp, etc. © AMSP 2012 22

Delirium Tremens (DT’s) n Hallucinations n Can be fatal if med problems n Onset n↑ 48 -96 hours after last drink Risk prior episodes/med probs n R/ O other causes © AMSP 2012 23

Withdrawal Tx n Benzodiazepines (e. g. diazepam [Valium]) n. Correct transmitter problems n. Day 1: give enough to ↓ symptoms n↓ Dose ~20% day 1 dose each day n↑ Dose if symp ↑; ↓ dose next day n Anticonvulsants not needed © AMSP 2012 24

Clinical Case n 80 y/o female n ↑BP, 3 days s/p hip surgery n Keeps trying to get out of bed n Confused n Agitated n ↑ BP and bilateral hand tremor n Dx: Et. OH withdrawal delirium (DT) © AMSP 2012 25

Clinical Case n Review criteria for DT’s n Symptom onset at 72 hours n Confusion n Psychomotor n↑ agitation Blood pressure/pulse/etc. © AMSP 2012 26

Clinical Case n Rx recommendations: n 1: 1 observation n. Folate n R/O 1 mg/d, thiamine 100 mg/d other causes n Benzodiazepine © AMSP 2012 27

Benzodiazepine Rx n n Chlordiazepoxide (Librium); diazepam (Valium) n Longer half-life=smoother withdrawal n Better seizure protection n But can over-sedate elderly and liver impaired Lorazepam (Ativan)=better choice in this pt n Shorter half-life = ↓ risk of oversedation n ↓ Risk if liver prob; not metabolized in liver © AMSP 2012 28

Wernicke Encephalopathy n Cause: ↓ thiamine (Vit B 1) n Emergency: untreated → 20% death n Triad: Confusion, ataxia (incoordination), ophthalmoplegia (eye muscle paralysis) n Rx: IV thiamine (to optimize absorption) © AMSP 2012 29

Korsakoff’s Syndrome n Impaired n Limited memory in alert, responsive pt insight to memory loss n Confabulation n Retrograde -- makes up stories & anterograde memory loss © AMSP 2012 30

Psychiatric Disorders: MDE n Co-morbid n Gen major depression pop major depressive episode (MDE) ~15% n AUD slightly ↑ even when not drinking n MDE unrelated to drinking -Alcohol ↑ depressive symptoms -Alcohol intoxication/withdrawal ↑ suicidal ideation © AMSP 2012 31

Psychiatric Disorders: AID n Alcohol induced: severe intoxication → temporary MDE in ~30% n Causal relationship--psychiatric disorder not predating AUD n Treatment = abstinence (≠ meds) n Depression ↓↓ in 2 d to 4 wks abstinence © AMSP 2012 32

Psychiatric Disorders: Psychosis n Psychosis – Hallucinations n Delirium (e. g. post surgery, DT’s) --usually disappear as delirium resolves n ~3% AUD during severe intoxication -No delirium -Alcohol-induced psychosis -Disappears 2 d to 4 wks without meds -Antipsychotics (e. g. risperidone) control symp © AMSP 2012 33

This Lecture Reviews n Definitions n Screening/evaluation n Medical/psych complications, comorbidity, and Rx n Interventions in the hospital © AMSP 2012 34

n Brief Interventions intervention for heavy drinkers n Non-dependent n Goal: n ~10 (e. g. regular >3 drks/d) early intervention & prevention min educ. or Motivationa. I Interviewing n Delivered by MD/staff © AMSP 2012 35

Motivational Interviewing (MI) n Behavior change (e. g. taking meds) n Change: process with multiple steps n Stage of change model n Collaboration (not confrontation) n ↑ Pt’s motivation n Respect pt’s own decision © AMSP 2012 36

Stages of Change Model n Precontemplativen Contemplative n Preparation n Action not a problem – considers change - makes plans - changes behavior n Maintenance - sustains change © AMSP 2012 37

Motivational Interviewing n General principles: n. Empathy n. Discuss ambivalence to change n. Skillful listening n. Point out behavior contrast to goals n. Roll with resistance n. Support self-efficacy © AMSP 2012 38

Clinical Case n 45 year old male high school principal n 3 rd admission for alcoholic pancreatitis n Given AUD treatment options in past n No follow up n Now: marital discord, job lay-off, etc. n Admits alcohol a problem © AMSP 2012 39

Clinical Case n Stage of change: contemplative n Express empathy for situation/stressors n Discuss barriers to change n Discuss goals vs behavior n Support ability to change if desired n Result: pt takes initiative n Stage : contemplation→preparation © AMSP 2012 40

n All Treatment options work to: n. Change thinking about AUD -Chronic disorder -Can be managed n. Help prevent relapse -Recognize triggers -Avoid high risk situations -Cope with cravings © AMSP 2012 41

Referral Option 1 n Inpatient/residential rehabilitation n Lessons/support in 24 hr milieu n Typically 14 -28 days n Learn through group discussions n Intensive Outpatient Treatment (IOP) n Groups multiple days of week n Provided in “real world” setting © AMSP 2012 42

Referral Option 2 n Outpatient treatment n Substance or mental health Rx provider n Provided in variety of settings n Self-help groups (AA) n Introduced in rehab or IOP n Requires only desire to stop drinking n Change through working “ 12 steps” © AMSP 2012 43

Medications n Naltrexone (Re. Via or Vivitrol) n Oral (50 mg/d) or injectable (380 mg/mo) n Opioid receptor antagonist n ↓Cravings n Acamprosate (Campral) n Oral (~2 g/d) n NMDA receptor antagonist n ↓ Post-withdrawal symptoms n Rx 3 -6 months n ~15% improvement © AMSP 2012 44

Conclusions n AUD important issue in general hospital n Effective n Multiple screening and evaluation medical/psychiatric complications n Effective interventions for Rx and referral © AMSP 2012 45