Alcoholism in Primary Care

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Alcoholism in Primary Care

• Brad Shapiro, M.D.
• Billy Etzler
• February 4, 2005

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Overview

• Definitions and Diagnosis
• Epidemiology Basics
• Screening in Primary Care
• Interventions
• Wernicke-Korsakoff
• Open Discussion

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Risky/Hazardous Drinking

• More than 7 drinks/week or 3 drinks/occasion for
  women
• More than 14 drinks/week or 4 drinks/occasion for
  men

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Harmful Drinking

• Currently experiencing physical, social or
  psychological harm from alcohol
• Do not meet DSM criteria for abuse or dependence

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Epidemiology Prevalence in Primary Care

• Young Adults 18-25 are highest prevalence
• Risky Drinking 4-29
• Harmful Drinking 0.3-10
• Alcohol Dependence 2-9

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Epidemiology Associated Health Problems

• Cirrhosis
• CNS disease
• Hypertension!
• Cancers (head/neck, digestive tract, liver,
  breast)
• Fetal Alcohol Syndrome

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Alcohol Doses Understanding Your Patient
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Servings Equal To 0.5 Ounces Absolute Alcohol

• 12 oz. 4 beer (1 can)
• 5 oz. 10 wine
• 1.25 oz. 40 vodka (80 proof)
• 1.25 oz. 43 whiskey (86 proof)
• This are all slightly more than a standard shot
  (1 oz.)

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Non-Equivalent Serving Sizes
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Alcohol Beverage Caloric Content

• 200 calories/oz. absolute alcohol
• 100 calories/drink equivalent
• 12 oz. regular beer150 calories
• Typical light beer100 calories (less alcohol
  and less carbohydrate)

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Nutritional Supplementation

• Multivitamin
• Folate 1 mg/day
• Thiamine 100 mg oral unless you suspect
  Wernicke-Korsakoff
• Treat 1-2 weeks

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Wernickes Syndrome

• Acute Encephalopathy
• Confusion
• Ataxia
• Ophthalmoplegia
• Disorientation
• Treat with Parenteral Thiamine

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Korsakoffs Syndrome

• Psychosis
• Anterograde/Retrograde Amnesia with Confabulation
• Delirium and Insomnia
• Painful Extremities

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Screening for Alcoholism

• Questionaire
• Physician or allied professional
• Laboratory testing

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Provider Screening

• Alcohol Use Disorders Identification Test (AUDIT)
  is most studiedboth sensitive and specific
• CAGE questions is most popular in primary care
• Other scales available (pregnancy, adolescent,
  etc.) from NIAAA Website
• Optimal screening interval unknown

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Screen for Comorbid Conditions

• Depression, Anxiety and Bipolar disorder
• Other Psychiatric conditions
• Chronic Pain
• Associated Medical Conditions HTN,
  Hyperlipidemia, Liver Disease, Anemia, etc.

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Screening Lab Tests

• Carbohydrate Deficient Transferrin (CDT) and
  Gamma-Glutamyltransferase (GGT)
• MCV, ALT/AST not specific or sensitive
• May help with screening
• Elevated CDT and GGT correlate with specific
  alcohol-sensitive diseases
• May help with monitoring drinking

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GGT

• Protein elevated by chronic heavy drinking
• gt54 U/I considered abnormally elevated
• Other causes of elevation include non-alcoholic
  liver disease, obesity, meds (hormones,
  anticonvulsants)
• Sensitivity 70, Specificity 75

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CDT

• Chronic heavy alcohol use causes a higher
  percentage of transferrin to lack its normal
  carbohydrate content
• Few other causes of this ESLD, biliary
  cirrhosis, and rare genetic variability
• Sensitivity 65-73, Specificity 90
• Combining CDT, GGT and provider screening
  increases sensitivity/specificity

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Primary Care Interventions
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Pharmacotherapy

• Disulfiram
• Naltrexone
• Acamprosate

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Disulfiram

• Aversive drug therapy
• Inhibits alcohol dehydrogenase
• Limited Effectiveness
• Works better when given by spouse/partner/housemat
  e
• Also a dopamine-beta-hydroxylase
  inhibitorincreases CNS dopamine

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Naltrexone

• Opiate Antagonist
• Typical dose 50 mg daily
• FDA approved for maintenance therapy
• Apparently decreases pleasurable effects of
  alcohol
• Can be used during periods of active drinking

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Naltrexone 2 Contraindications

• Chronic opiate therapy (MMT, opioids for chronic
  pain)
• Liver disease

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Acamprosate

• Multiple mechanisms of action involving GABA,
  Glutamate, and NMDA systems
• Described as an anti-craving agent
• Increases continuous abstinence rate
• Probably best for patients trying to maintain
  abstinence, rather than currently drinking

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Acamprosate 2

• Newly FDA approved
• Not on CHN/SFGH formulary (expensive)
• TID dosing
• Not shown to be superior to naltrexone
• Probably niche is patients with contraindication
  to naltrexone

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Behavioral Interventions

• Behavioral Counseling Interventions for adults
  are recommended by USPSTF
• Good evidence suggests these can reduce alcohol
  consumption
• These reductions are sustained over 12 months
• Insufficient evidence in adolescents

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Behavioral Interventions 2

• Many different brief interventions have been
  shown to be effective
• Most include follow up
• Can (should!) include other members of the health
  care team
• Providing clinic level system supports is helpful
  (prompts, reminders, etc.)

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Traditional Approaches 5 As

• Assess Alcohol consumption
• Advise Patients to reduce alcohol consumption to
  moderate level
• Agree on individual goals
• Assist patients with acquiring motivation,
  skills, supports
• Arrange follow-up support/counselling

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