© Copyright Annals of Internal Medicine, 2016Ann Int Med. 164 (1): ITC1-1.

In the Clinic

Alcohol Use

© Copyright Annals of Internal Medicine, 2016Ann Int Med. 164 (1): ITC1-1.

Hypertension, stroke, cardiomyopathy, arrhythmias Cirrhosis, acute and chronic pancreatitis Brain atrophy Hypogonadism with osteoporosis, sexual dysfunction Various types of cancer GERD, esophagitis, peptic ulcers Seizures Acute alcohol poisoning from heavy episodic drinking Increased incidence chronic diseases Poor nutrition Mental health and social consequences Drinking during pregnancy may harm the fetus

Which health conditions have definite links to alcohol use?

© Copyright Annals of Internal Medicine, 2016Ann Int Med. 164 (1): ITC1-1.

Common alcohol-prescription medication interactions by class Cardiovascular agents: ACE inhibitors, beta-blockers,

diuretics Central nervous system agents: anticonvulsants,

anxiolytic/sedative/hypnotics, opioids Coagulation modifiers: anticoagulants Metabolic agents: antidiabetic, antihyperlipidemic Psychotherapeutic agents: antidepressant Respiratory agents: antihistamines Other: antibiotics, NSAIDs

© Copyright Annals of Internal Medicine, 2016Ann Int Med. 164 (1): ITC1-1.

Does alcohol use have positive health effects?

Unhealthy alcohol use increases the risk of CVD but moderate alcohol use appears to be protective in some studies Underlying mechanisms may include: development of

favorable lipid profiles, inhibition of platelet activation, decreased fibrinogen levels, and anti-inflammatory effects

Because of the lack of data from randomized clinical trials at this time, clinicians should not recommend initiation of low-level alcohol use for cardioprotective effects

© Copyright Annals of Internal Medicine, 2016Ann Int Med. 164 (1): ITC1-1.

Which groups are at particularly high risk for adverse health outcomes from alcohol use?

Individuals < 21 years old and college-aged Individuals > 65 years old, especially with:

Chronic medical conditions Taking medications that may interact with alcohol and

those with polypharmacy

Women Minorities and underserved populations People with certain chronic medical conditions that

make them more sensitive to alcohol

© Copyright Annals of Internal Medicine, 2016Ann Int Med. 164 (1): ITC1-1.

CLINICAL BOTTOM LINE: Health effects... Unhealthy alcohol use is associated with adverse medical,

psychiatric, and behavior-related outcomes Special caution with alcohol use is appropriate among:

Young adults and older adults Women and minorities Underserved populations Those with chronic medical conditions Those taking prescribed medications

© Copyright Annals of Internal Medicine, 2016Ann Int Med. 164 (1): ITC1-1.

Unhealthy alcohol use has negative consequences and often goes unrecognized

NIAAA, USPSTF, and CDC recommend routine screening of adults for unhealthy alcohol use

Potentially effective treatments for unhealthy alcohol use are available

When should clinicians screen for unhealthy alcohol use?

© Copyright Annals of Internal Medicine, 2016Ann Int Med. 164 (1): ITC1-1.

NIAAA recommended screening opportunities

During routine examinations Before prescribing a medication with potential

interactions with alcohol In the emergency department or urgent care center When seeing patient who:

Is pregnant or planning conception Has risk factors for unhealthy alcohol use Has potentially alcohol-related health problems Has a chronic condition resistance to usual treatment

© Copyright Annals of Internal Medicine, 2016Ann Int Med. 164 (1): ITC1-1.

Single-Item Screening Question (SISQ) “How many times in the past year have you had ≥4 drinks

(women) or ≥5 drinks (men) in a day?” Positive screen: ask about frequency and quantity of use

CAGE questionnaire (4 questions) AUDIT (10-item screening tool) or AUDIT-C (3-item) Michigan Alcohol Screening Test (25 questions)

For screening lifetime alcohol use disorders more than lower levels of problem drinking or binge drinking

What are effective self-report-based methods to screen for unhealthy alcohol use in clinical settings?

© Copyright Annals of Internal Medicine, 2016Ann Int Med. 164 (1): ITC1-1.

CLINICAL BOTTOM LINE: Prevention and screening... Incorporate standardized processes to facilitate routine

screening of all patients for unhealthy alcohol use

Counsel patients with negative screening results on maintaining lower-risk alcohol use or abstinence

Evaluate those with positive results for alcohol use disorders and alcohol-related consequences

Provide appropriate treatment

© Copyright Annals of Internal Medicine, 2016Ann Int Med. 164 (1): ITC1-1.

Moderate alcohol use Men ≤65: ≤4 drinks on single day and ≤14 drinks/wk Men >65, women: ≤3 drinks on single day and ≤7 drinks/wk

At-risk drinking Use that increases risk for alcohol-related consequences When lower-risk alcohol use thresholds exceeded When drinking in lower amounts increases risk

Alcohol use disorder Individual meets ≥2 DSM-5 criteria

How should clinicians distinguish between “moderate” alcohol consumption, at-risk drinking, and alcohol use disorders?

© Copyright Annals of Internal Medicine, 2016Ann Int Med. 164 (1): ITC1-1.

DSM-5 criteria for alcohol use disorderMild 2-4 symptoms; Moderate 4-5; Severe 6+ Alcohol taken in larger amounts or for longer than intended Persistent desire / unsuccessful efforts to cut down or control use Great deal of time spent obtaining, using, or recovering from use Craving or strong desire to use alcohol Failure to fulfill major obligations due to alcohol use Continued use despite problems caused or exacerbated by use Important activities given up or reduced because of alcohol use Recurrent alcohol use in physically hazardous situations Continued use despite knowledge of physical or psychological

problems that are caused or exacerbated by alcohol Tolerance Withdrawal

© Copyright Annals of Internal Medicine, 2016Ann Int Med. 164 (1): ITC1-1.

Exam: Helps identify, evaluate unhealthy alcohol use Patients with worsening hypertension or tachycardia may

be manifesting withdrawal Liver, cardiac, or neurocognitive disease may signal

longer-term consequences of alcohol use

Labs: May signal unhealthy alcohol use Increased mean corpuscular volume of RBCs Elevated gamma-glutamyl transferase Increased aspartate to alanine aminotransferase ratio Under investigation: markers related to ethanol metabolism

What is the role of the physical exam and lab testing in the evaluation of patients with unhealthy alcohol use?

© Copyright Annals of Internal Medicine, 2016Ann Int Med. 164 (1): ITC1-1.

Findings that May Indicate Unhealthy Alcohol Use Hypertension Jaundice Spider angiomata Cardiomyopathy Atrial fibrillation Gynecomastia Hepatosplenomegaly Ascites Testicular atrophy Palmar erythema, plethoric facies Peripheral neuropathy Cognitive abnormalities

© Copyright Annals of Internal Medicine, 2016Ann Int Med. 164 (1): ITC1-1.

Conditions that often co-occur with unhealthy alcohol use Substance use disorders Mental illness Chronic pain Sexual risk behaviors

Underlying conditions can affect treatment decisions and response

Which other conditions should clinicians be alert for in patients with unhealthy alcohol use?

© Copyright Annals of Internal Medicine, 2016Ann Int Med. 164 (1): ITC1-1.

CLINICAL BOTTOM LINE: Diagnosis... Diagnosis relies on a comprehensive evaluation

History and physical exam Supporting labs: various markers can detect alcohol use

and measure impact on health Patient self-reported information

Screen for prevalent comorbid conditions Substance use Mental illness Chronic pain Sexual risk behaviors

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Avoid imprecise and stigmatizing language Use “people-first” language Focus on medical aspects of condition and treatment Avoid using slang and idioms (alcoholic, alcohol

abuser) Compare unhealthy alcohol use to another chronic

medical condition Where the cause is also based on genetic and

behavioral factors and treatment is comprehensive

What is appropriate language to use when treating patients with unhealthy alcohol use?

© Copyright Annals of Internal Medicine, 2016Ann Int Med. 164 (1): ITC1-1.

What should clinicians do if they identify patients with hazardous or at-risk alcohol use?

Provide brief, empathic interventions Provide specific advice on recommended alcohol use Give feedback on impact of alcohol on the patient’s health Empathize with patient’s responsibility to make a change List options for facilitating change Discuss situations likely to trigger excessive use Establish drinking agreement and follow-up

Brief, multi-contact interventions are most effective

© Copyright Annals of Internal Medicine, 2016Ann Int Med. 164 (1): ITC1-1.

How should care of patients with an alcohol use disorder be prioritized?

Patients may have a ranging set of treatment needs Promote patient safety and stabilization first Initial goal is reduction in alcohol consumption

But few are able to maintain controlled drinking So abstinence is typically the goal of therapy

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How should alcohol withdrawal be addressed in the primary care setting? Withdrawal may manifest with range of signs and symptoms

Some patients can safely be managed as outpatients Patients at greater risk for harm or unlikely to follow-up

should be referred to an inpatient setting Use standardized instruments to guide treatment

Clinical Inst. Withdrawal Assessment for Alcohol, revised Multiple dosing strategies and medication regimens may be

used to treat withdrawal symptoms, prevent seizure Benzodiazepines safest and most effective

Monitor closely: withdrawal begins as early as 5-8 h and up to 72 h after last drink

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Indications for referral for inpatient detoxification Reasons for immediate referral for inpatient detoxification

Moderate to severe withdrawal History of seizures or delirium tremens Unable to adhere to daily follow-up Comorbid psychiatric or medical complications requiring

hospitalization Unable to take oral medication Unsuccessful outpatient detoxification Pregnancy

Reasons to strongly consider inpatient detoxification Coexisting benzodiazepine use High risk for severe alcohol withdrawal

© Copyright Annals of Internal Medicine, 2016Ann Int Med. 164 (1): ITC1-1.

What is the role of psychotherapeutic interventions for alcohol use disorder? Cognitive behavioral therapy

Patients identify thoughts, feelings, circumstances that occur before and after alcohol use

New behaviors and techniques help patients cope with these triggers

Motivational enhancement therapy Increases internal motivation to change alcohol use

Twelve-step facilitation Underlying premise that alcohol use disorders are

secondary to medical and spiritual disease Community reinforcement and behavioral couples therapy

© Copyright Annals of Internal Medicine, 2016Ann Int Med. 164 (1): ITC1-1.

When should clinicians consider pharmacotherapy for relapse prevention? Consider for for all patients with alcohol use disorder Disulfiram

Appropriate when abstinence is the initial goal Nausea, flushing, palpitations associated with alcohol use

Acamprosate Dosed 3x/d and commonly leads to diarrhea, vomiting Dose adjustment needed with renal insufficiency

Naltrexone Once daily oral or long-acting injectable Decreases the reward pathways associated with alcohol use Opioids contraindicated

© Copyright Annals of Internal Medicine, 2016Ann Int Med. 164 (1): ITC1-1.

When should clinicians consider antidepressants or anxiolytics in treating patients with unhealthy alcohol use?

Antidepressants treat depressive symptoms but not alcohol use disorders 

Benzodiazepines Standard treatment for managing acute withdrawal phase Ineffective for treating alcohol use disorder Poses risk of creating additional substance use disorder

Consider delaying treatment of co-occurring mental illness until abstinence achieved for at least several weeks

© Copyright Annals of Internal Medicine, 2016Ann Int Med. 164 (1): ITC1-1.

Are any medications of particular concern in the setting of unhealthy alcohol use? Cardiovascular agents Ace-inhibitors Beta-blockers Diuretics Central nervous system

agents Anticonvulsants Anxiolytic/sedative/

hypnotics Opioids

Anticoagulants Metabolic agents Antidiabetic Antihyperlipidemic Antidepressants Antihistamines Other Antibiotics NSAIDS

© Copyright Annals of Internal Medicine, 2016Ann Int Med. 164 (1): ITC1-1.

What additional care should be considered for patients with unhealthy alcohol use to promote health?

Comorbid conditions Other substance use (tobacco, drug use disorders) Mental health disorders (anxiety, mood, personality disorders) For those with longstanding alcohol use disorder: specific

cognitive and neurologic deficits Also: insomnia, anemia, osteoporosis, and liver disease

Hepatitis B and C vaccinations for those with established liver disease

Screening for STIs

© Copyright Annals of Internal Medicine, 2016Ann Int Med. 164 (1): ITC1-1.

What type of follow-up care and referrals should clinicians provide for patients with unhealthy alcohol use? Patients need regular, ongoing monitoring for:

Alcohol use Associated medical, psychiatric and behavioral-related AEs Treatment effects

Refer patients to specialty care for: At-risk alcohol use that doesn’t respond to brief intervention Alcohol use disorder and/or significant comorbid medical or

psychiatric condition, if office-based treatments ineffective

Use American Society of Addiction Medicine criteria

© Copyright Annals of Internal Medicine, 2016Ann Int Med. 164 (1): ITC1-1.

CLINICAL BOTTOM LINE: Treatment… For at-risk drinking, brief interventions can be effective For alcohol use disorder, treatment hinges on patient safety

and stabilization Benzodiazepines: decrease withdrawal symptoms, seizures Hospitalization: indicated for patients with moderate to

severe withdrawal and high risk for complications Prevent relapse with psychotherapeutic interventions,

pharmacotherapy, self-help groups Comprehensive care includes optimizing medication regimens Refer to specialty services

Patients who don’t respond to treatment Patients who show evidence of alcohol use disorder or

significant comorbidity