AUD in General Hospitals AUD in General Hospitals High PrevalenceHigh Prevalence

25% Lifetime abuse or dependence25% Lifetime abuse or dependence 35% Trauma surgical patients35% Trauma surgical patients 20% Burn patients20% Burn patients

Very costly Very costly $166 Billion/yr: ↓work, ↑crime, ↓health $166 Billion/yr: ↓work, ↑crime, ↓health Comorbid AUD ↑ stay and cost Comorbid AUD ↑ stay and cost

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↑ ↑ Medical ComplicationsMedical ComplicationsAlcohol interacts with medsAlcohol interacts with meds

↓ ↓ General healthGeneral health

Poor nutrition Poor nutrition

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This Lecture Reviews:This Lecture Reviews: DefinitionsDefinitions

Screening/evaluationScreening/evaluation

Medical/psych complications, Medical/psych complications, comorbidity and Rxcomorbidity and Rx

Interventions in the hospital Interventions in the hospital 4© AMSP 2012

DefinitionsDefinitions Standard Drink (~10 grams alcohol)Standard Drink (~10 grams alcohol)

12 oz. Beer12 oz. Beer5 oz. Wine5 oz. Wine1.5oz. Hard liquor (80 proof)1.5oz. Hard liquor (80 proof)

Hazardous Drinking Hazardous Drinking Men: >14 drinks/wk or >4 drinks/sitting Men: >14 drinks/wk or >4 drinks/sitting Women: >7 drinks/wk or >3 drinks/sitting Women: >7 drinks/wk or >3 drinks/sitting

5© AMSP 2012

Abuse & DependenceAbuse & Dependence

Abuse 1+ of:Abuse 1+ of: Failure in rolesFailure in roles Hazardous useHazardous use Social/interpersonal Social/interpersonal

problemsproblems Legal problemsLegal problems

(Not alc dependent)(Not alc dependent)

Dependence 3+ of:Dependence 3+ of: ToleranceTolerance WithdrawalWithdrawal Unable to ↓ or quitUnable to ↓ or quit Longer than intendedLonger than intended ↑ ↑ Time find/useTime find/use ↓ ↓ Important activitiesImportant activities Despite consequencesDespite consequences

6© AMSP 2012

This Lecture ReviewsThis Lecture Reviews DefinitionsDefinitions

Screening/evaluationScreening/evaluation

Medical/psych complications, Medical/psych complications, comorbidity, and Rxcomorbidity, and Rx

Interventions in the hospital Interventions in the hospital 7© AMSP 2012

Screening/EvaluationScreening/EvaluationOften undetected by MDsOften undetected by MDs

Reasons include:Reasons include:Inadequate trainingInadequate trainingMisperceptions/stereotypingMisperceptions/stereotypingUncertain about what to doUncertain about what to do

8© AMSP 2012

Psychiatric ConsultationPsychiatric Consultation Ask why referAsk why refer

Review records/labs/etc.Review records/labs/etc.

Review all medsReview all meds

Interview/examine patientInterview/examine patient9© AMSP 2012

Psychiatric ConsultationPsychiatric Consultation Interview collateralInterview collateral

Order diagnostic testsOrder diagnostic tests

Formulate assessment & planFormulate assessment & plan

Discuss w/ referring clinicianDiscuss w/ referring clinician10

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Taking AUD HistoryTaking AUD HistoryCurrent/past patterns of useCurrent/past patterns of use

Usual drinks/dayUsual drinks/dayBinge patternBinge patternPeriods of abstinencePeriods of abstinenceHistory of treatmentHistory of treatmentWithdrawalWithdrawalFamily historyFamily history

11© AMSP 2012

Screening/EvaluationScreening/Evaluation Alc Use Disorders Identification Test Alc Use Disorders Identification Test

10 questions, scored 0-410 questions, scored 0-4≥≥8 = hazardous drinking (Sens=98%)8 = hazardous drinking (Sens=98%)≥≥10 = alc dependence (Sens=99%)10 = alc dependence (Sens=99%)

Short Michigan Alcohol Screening Test Short Michigan Alcohol Screening Test 13 questions, self-administered 13 questions, self-administered Accuracy=25 item MAST (Sens 90%)Accuracy=25 item MAST (Sens 90%)

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Screening/EvaluationScreening/Evaluation Lab markersLab markers

Gamma-glutamyltransferaseGamma-glutamyltransferase

Aspartate & Alanine AminotransferaseAspartate & Alanine Aminotransferase

Carbohydrate deficient transferrinCarbohydrate deficient transferrin

Mean Corpuscular VolumeMean Corpuscular Volume

13© AMSP 2012

Lab Markers 1 (GGT)Lab Markers 1 (GGT) Gamma-glutamyltransferase Gamma-glutamyltransferase

↑ ↑ With heavy drinking With heavy drinking ↑ ↑ In: heart disease, kidney disease, pregIn: heart disease, kidney disease, preg GGT >35 GGT >35

-Heavy drinking-Heavy drinking

-↑ Before liver damage-↑ Before liver damage

-Sensitivity for heavy drinking ~75%-Sensitivity for heavy drinking ~75% GGT >50 may indicate liver damageGGT >50 may indicate liver damage Normalizes ~5 weeks of abstinence Normalizes ~5 weeks of abstinence

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Lab Markers 2 (LFT)Lab Markers 2 (LFT) Liver enzymes: AST and ALTLiver enzymes: AST and ALT

ALT in liver, AST in many tissuesALT in liver, AST in many tissues ↑ ↑ In high use AND liver damageIn high use AND liver damage Absolute value &ratio importantAbsolute value &ratio important

-AST (14-38 U/L normal range)-AST (14-38 U/L normal range)

-ALT (15-48 U/L normal range)-ALT (15-48 U/L normal range)

-AST:ALT ratio >2 suggestive of alcohol -AST:ALT ratio >2 suggestive of alcohol Less sensitive than GGTLess sensitive than GGT

15© AMSP 2012

Lab Markers 3 (CDT)Lab Markers 3 (CDT) Carbohydrate deficient transferrin Carbohydrate deficient transferrin

Transferrin=protein; transports iron Transferrin=protein; transports iron Abnormal form produced in ↑ drinking Abnormal form produced in ↑ drinking CDT >20 g/l indicates heavy drinkingCDT >20 g/l indicates heavy drinking Few other conditions ↑ Few other conditions ↑ Sensitivity & specificity ~75% (=GGT)Sensitivity & specificity ~75% (=GGT) Normalizes ~1 month of abstinenceNormalizes ~1 month of abstinence

16© AMSP 2012

Lab Markers 4 (MCV)Lab Markers 4 (MCV)Mean Corpuscular VolumeMean Corpuscular Volume

Size of red cells (nl =80-100u)Size of red cells (nl =80-100u)

↑↑ By heavy drinkingBy heavy drinking

>90u suggests heavy drinking>90u suggests heavy drinking

MCV ↑ in other conditionsMCV ↑ in other conditions17© AMSP 2012

Screening/EvaluationScreening/Evaluation Signs and symptoms Signs and symptoms

Irregular heart rhythmIrregular heart rhythm Enlarged tender liver (alc hepatitis)Enlarged tender liver (alc hepatitis) Hard small liver (cirrhosis- in 20% of AUD)Hard small liver (cirrhosis- in 20% of AUD) Ascites (abdom. cavity fluid in liver failure)Ascites (abdom. cavity fluid in liver failure) Jaundice (yellow skin/eyes in liver failure)Jaundice (yellow skin/eyes in liver failure) Tremor (hangover or withdrawal)Tremor (hangover or withdrawal) Hyperactive reflexes/↑ pulse/ etc.Hyperactive reflexes/↑ pulse/ etc.

18© AMSP 2012

This Lecture ReviewsThis Lecture Reviews DefinitionsDefinitions

Screening/evaluationScreening/evaluation

Medical/psych complications, Medical/psych complications, comorbidity, and Rxcomorbidity, and Rx

Interventions in the hospital Interventions in the hospital 19© AMSP 2012

Alcohol WithdrawalAlcohol Withdrawal Cessation or ↓ heavy useCessation or ↓ heavy use 2+ w/in hrs:2+ w/in hrs:

Tremor (hands, arms, legs, tongue)Tremor (hands, arms, legs, tongue)

↑ ↑ PulsePulse

InsomniaInsomnia

Agitation (restlessness/agitation/aggression)Agitation (restlessness/agitation/aggression)

AnxietyAnxiety

Visual/tactile/auditory hallucinations (rare)Visual/tactile/auditory hallucinations (rare)

Grand mal seizure (rare)Grand mal seizure (rare)

20© AMSP 2012

Alcohol WithdrawalAlcohol Withdrawal

6-8 hours after last drink6-8 hours after last drink

Declining BAC (not at zero)Declining BAC (not at zero)

Symptoms → distress/↓ functioningSymptoms → distress/↓ functioning

R/O general medical or mental dxR/O general medical or mental dx

Delirium Tremens (DTDelirium Tremens (DT’’s) (rare)s) (rare)21© AMSP 2012

Delirium Tremens (DT’s)Delirium Tremens (DT’s) Seen in ~5% AUD Seen in ~5% AUD

Disorientation (confusion)Disorientation (confusion)

Fluctuating consciousnessFluctuating consciousness

Hyperactivity/excitationHyperactivity/excitation

↑ ↑ Pulse, bp, temp, etc.Pulse, bp, temp, etc.22© AMSP 2012

Delirium Tremens (DT’s)Delirium Tremens (DT’s) HallucinationsHallucinations

Can be fatal if med problemsCan be fatal if med problems

Onset 48-96 hours after last drinkOnset 48-96 hours after last drink

↑ ↑ Risk prior episodes/med probs Risk prior episodes/med probs

R/O other causesR/O other causes

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Withdrawal TxWithdrawal Tx Benzodiazepines (e.g. diazepam [Valium])Benzodiazepines (e.g. diazepam [Valium])

Correct transmitter problems Correct transmitter problems Day 1: give enough to ↓ symptomsDay 1: give enough to ↓ symptoms↓ ↓ Dose ~20% day 1 dose each dayDose ~20% day 1 dose each day↑ ↑ Dose if symp ↑; ↓ dose next dayDose if symp ↑; ↓ dose next day

Anticonvulsants not neededAnticonvulsants not needed24© AMSP 2012

Clinical CaseClinical Case80 y/o female 80 y/o female ↑↑BPBP, 3 days s/p hip surgery, 3 days s/p hip surgeryKeeps trying to get out of bedKeeps trying to get out of bedConfused Confused AgitatedAgitated↑ ↑ BP and bilateral hand tremorBP and bilateral hand tremorDx: EtOH withdrawal delirium (DT)Dx: EtOH withdrawal delirium (DT)

25© AMSP 2012

Clinical CaseClinical CaseReview criteria for DT’sReview criteria for DT’s

Symptom onset at 72 hoursSymptom onset at 72 hours

ConfusionConfusion

Psychomotor agitationPsychomotor agitation

↑ ↑ Blood pressure/pulse/etc.Blood pressure/pulse/etc.26© AMSP 2012

Clinical CaseClinical CaseRx recommendations:Rx recommendations:

1:1 observation1:1 observation

Folate 1mg/d, thiamine 100mg/dFolate 1mg/d, thiamine 100mg/d

R/O other causesR/O other causes

BenzodiazepineBenzodiazepine27

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Benzodiazepine Rx Benzodiazepine Rx Chlordiazepoxide (Librium);diazepam (Valium)Chlordiazepoxide (Librium);diazepam (Valium)

Longer half-life=smoother withdrawal Longer half-life=smoother withdrawal

Better seizure protectionBetter seizure protection

But can over-sedate elderly and liver impairedBut can over-sedate elderly and liver impaired Lorazepam (Ativan)=better choice in this ptLorazepam (Ativan)=better choice in this pt

Shorter half-life = ↓ risk of oversedation Shorter half-life = ↓ risk of oversedation

↓ ↓ Risk if liver prob; not metabolized in liver Risk if liver prob; not metabolized in liver 28© AMSP 2012

Wernicke EncephalopathyWernicke Encephalopathy

Cause: ↓ thiamine (Vit B1) Cause: ↓ thiamine (Vit B1)

Emergency: untreated →20% deathEmergency: untreated →20% death

Triad: Confusion, ataxia (incoordination), Triad: Confusion, ataxia (incoordination), ophthalmoplegia (eye muscle paralysis)ophthalmoplegia (eye muscle paralysis)

Rx: IV thiamine (to optimize absorption)Rx: IV thiamine (to optimize absorption)29

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Korsakoff’s SyndromeKorsakoff’s Syndrome

Impaired memory in alert, responsive ptImpaired memory in alert, responsive pt

Limited insight to memory lossLimited insight to memory loss

Confabulation -- makes up storiesConfabulation -- makes up stories

Retrograde & anterograde memory lossRetrograde & anterograde memory loss30© AMSP 2012

Psychiatric Disorders: MDEPsychiatric Disorders: MDE

Co-morbid major depressionCo-morbid major depression

Gen pop major depressive episode (MDE) ~15%Gen pop major depressive episode (MDE) ~15%

AUD slightly ↑ even when not drinkingAUD slightly ↑ even when not drinking

MDE unrelated to drinking MDE unrelated to drinking

-Alcohol ↑ depressive symptoms-Alcohol ↑ depressive symptoms

-Alcohol intoxication/withdrawal ↑ suicidal ideation-Alcohol intoxication/withdrawal ↑ suicidal ideation31© AMSP 2012

Psychiatric Disorders: AIDPsychiatric Disorders: AID

Alcohol induced: severe intoxication → Alcohol induced: severe intoxication →

temporary MDE in ~30%temporary MDE in ~30%

Causal relationship--psychiatric disorder Causal relationship--psychiatric disorder

not predating AUDnot predating AUD

Treatment = abstinence (≠ meds)Treatment = abstinence (≠ meds)

Depression ↓↓ in 2 d to 4 wks abstinence Depression ↓↓ in 2 d to 4 wks abstinence 32

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Psychiatric Disorders: PsychosisPsychiatric Disorders: Psychosis Psychosis – HallucinationsPsychosis – Hallucinations

Delirium (e.g. post surgery, DT’s) --usually Delirium (e.g. post surgery, DT’s) --usually

disappear as delirium resolvesdisappear as delirium resolves

~3% AUD during severe intoxication~3% AUD during severe intoxication

-No delirium -No delirium

-Alcohol-induced psychosis-Alcohol-induced psychosis

-Disappears 2 d to 4 wks without meds-Disappears 2 d to 4 wks without meds

-Antipsychotics (e.g. risperidone) control symp-Antipsychotics (e.g. risperidone) control symp33

© AMSP 2012

This Lecture ReviewsThis Lecture Reviews DefinitionsDefinitions

Screening/evaluationScreening/evaluation

Medical/psych complications, Medical/psych complications, comorbidity, and Rxcomorbidity, and Rx

Interventions in the hospital Interventions in the hospital 34© AMSP 2012

InterventionsInterventions

35© AMSP 2012

Motivational Interviewing (MI)Motivational Interviewing (MI)

Behavior change (e.g. taking meds)Behavior change (e.g. taking meds)Change: process with multiple stepsChange: process with multiple stepsStage of change model Stage of change model Collaboration (not confrontation)Collaboration (not confrontation)↑ ↑ Pt’s motivationPt’s motivationRespect pt’s own decision Respect pt’s own decision

36© AMSP 2012

Stages of Change ModelStages of Change ModelPrecontemplative- not a problemPrecontemplative- not a problem

Contemplative – considers changeContemplative – considers change

Preparation - makes plansPreparation - makes plans

Action - changes behaviorAction - changes behavior

Maintenance - sustains changeMaintenance - sustains change37

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Motivational InterviewingMotivational InterviewingGeneral principles:General principles:

EmpathyEmpathyDiscuss ambivalence to changeDiscuss ambivalence to changeSkillful listeningSkillful listeningPoint out behavior contrast to goalsPoint out behavior contrast to goalsRoll with resistanceRoll with resistanceSupport self-efficacySupport self-efficacy

38© AMSP 2012

Clinical CaseClinical Case 45 year old male high school principal45 year old male high school principal 33rdrd admission for alcoholic pancreatitis admission for alcoholic pancreatitis Given AUD treatment options in past Given AUD treatment options in past No follow up No follow up Now: marital discord, job lay-off, etc.Now: marital discord, job lay-off, etc. Admits alcohol a problem Admits alcohol a problem

39© AMSP 2012

Clinical CaseClinical Case Stage of change: contemplativeStage of change: contemplative Express empathy for situation/stressorsExpress empathy for situation/stressors Discuss barriers to changeDiscuss barriers to change Discuss goals vs behavior Discuss goals vs behavior Support ability to change if desiredSupport ability to change if desired Result: pt takes initiative Result: pt takes initiative Stage : contemplation→preparation Stage : contemplation→preparation

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TreatmentTreatmentAll options work to:All options work to:

Change thinking about AUDChange thinking about AUD-Chronic disorder -Chronic disorder

-Can be managed -Can be managed

Help prevent relapseHelp prevent relapse-Recognize triggers-Recognize triggers

-Avoid high risk situations-Avoid high risk situations

-Cope with cravings-Cope with cravings

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Referral Option 1 Referral Option 1 Inpatient/residential rehabilitationInpatient/residential rehabilitation

Lessons/support in 24 hr milieuLessons/support in 24 hr milieu Typically 14-28 daysTypically 14-28 days Learn through group discussionsLearn through group discussions

Intensive Outpatient Treatment (IOP)Intensive Outpatient Treatment (IOP) Groups multiple days of weekGroups multiple days of week Provided in Provided in ““real worldreal world”” setting setting

42© AMSP 2012

Referral Option 2Referral Option 2 Outpatient treatmentOutpatient treatment

Substance or mental health Rx provider Substance or mental health Rx provider Provided in variety of settingsProvided in variety of settings

Self-help groups (AA)Self-help groups (AA) Introduced in rehab or IOPIntroduced in rehab or IOP Requires only desire to stop drinkingRequires only desire to stop drinking Change through working Change through working ““12 steps12 steps””

43© AMSP 2012

MedicationsMedications Naltrexone (ReVia or Vivitrol) Naltrexone (ReVia or Vivitrol)

Oral (50mg/d) or injectable (380mg/mo)Oral (50mg/d) or injectable (380mg/mo) Opioid receptor antagonistOpioid receptor antagonist↓↓Cravings Cravings

Acamprosate (Campral)Acamprosate (Campral) Oral (~2g/d)Oral (~2g/d) NMDA receptor antagonistNMDA receptor antagonist↓↓ Post-withdrawal symptomsPost-withdrawal symptoms

Rx 3-6 monthsRx 3-6 months ~15% improvement ~15% improvement

44© AMSP 2012

ConclusionsConclusions AUD important issue in general hospitalAUD important issue in general hospital

Effective screening and evaluationEffective screening and evaluation

Multiple medical/psychiatric complicationsMultiple medical/psychiatric complications

Effective interventions for Rx and referralEffective interventions for Rx and referral

45© AMSP 2012