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Assessment, Management & Referral of Patients with Alcohol Use Disorders

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Assessment, Management & Referral of Patients with Alcohol Use Disorders Assessment, management & referral of patients with alcohol use disorders NM Nurse Practitioners Council April, 2016 Karen Cardon, MD, ADAAPM, FASAM Did you know… • April is alcohol awareness month! • Ready to become REALLY aware? The average largest number of drinks consumed by binge drinkers on an occasion Objectives • Recognize criteria for alcohol use disorder and severity. • Identify methods for screening patients in clinic for alcohol use disorders. • List medications for treatment of alcohol use disorder and discuss risks/benefits of each. List other types of tx for AUD. • Determine appropriateness of patients for referral and identify referral resources in New Mexico. Outline • Terminology/Definitions • Epidemiology of AUD • Screening for AUD • Treatments for AUD • When/Where to refer • Clinical issues and lab abnormalities in AUD • Prevention/follow-up for patients with AUD Terminology/Definitions Terminology/Definitions • Standard Drink: – About 14 grams pure alcohol – 12 oz regular beer – 8-9 oz malt liquor – 5 oz table wine – 1.5 oz (1 shot) 80 proof distilled spirits (vodka, gin, rum, tequila, whiskey) Terminology/Definitions • Low-risk drinking: – Women: no more than 3 drinks on any single day and no more than 7 drinks per week. – Men: no more than 4 drinks on any single day and no more than 14 drinks per week. (Men > age 65: same as women) Terminology/Definitions • Moderate drinking: – up to 1 drink per day for women and up to 2 drinks per day for men. • Heavy Drinking: – 5 or more drinks on the same occasion on each of 5 or more days in the past 30 days. Terminology/Definitions • Binge Drinking: – NIAAA: a pattern of drinking that brings BAC levels to 0.08 g/dL. • ~4 drinks for women and 5 drinks for men—in about 2 hours. – SAMHSA: 5 or more alcoholic drinks on the same occasion on at least 1 day in the past 30 days. Terminology/Definitions Alcohol Use Disorder • Defined now by DSM V – Changed terminology (DSM IV: ”abuse” and “dependence;” DSM V: “Alcohol use disorder” with mild, moderate, severe – Eliminated legal problems, added craving – Changed dx thresholds Terminology/Definitions Consensus Statement of The American Academy of Pain Medicine, the American Pain Society, and the American Society of Addiction Medicine (2001): Addiction: “Addiction is a primary, chronic, neurobiological disease, with genetic, psychosocial, and environmental factors influencing its development and manifestations. It is characterized by behaviors that include one or more of the following: – impaired control over drug use, – compulsive use, – continued use despite harm, – and craving.” (Above sometimes referred to as “the 4 C’s”) DSM V Criteria for AUD • In the past year, have you… 1. Had times when you ended up drinking more or longer than you intended? 2. More than once wanted to cut down or stop drinking or tried to, but couldn’t? 3. Spent a lot of time drinking? Or being sick or recovering from the after-effects? 4. Wanted a drink so badly you couldn’t think of anything else? 5. Found that drinking - or being sick from drinking - interfered with taking care of your home or family? Or caused job troubles? Or school problems? 6. Continued to drink even though it was causing trouble with your family or friends? 7. Given up or cut back on activities that were important or interesting to you, or gave you pleasure, in order to drink? 8. More than once gotten into situations while or after drinking that increased your chances of getting hurt (such as driving, swimming, using machinery, walking in an unsafe area, or having unsafe sex)? 9. Continued to drink even though it was making you feel depressed or anxious or adding to another health problem? Or after having had a memory blackout? 10. Had to drink much more than you once did to get the effect you want? Or found that your usual number of drinks had much less effect than before? 11. Found that when the effects of alcohol were wearing off, you had withdrawal symptoms, such as trouble sleeping, shakiness, restlessness, nausea, a racing heart, or a seizure? Or sensed things that weren’t there? http://pubs.niaaa.nih.gov/publications/dsmfactsheet/dsmfact.htm accessed 3/21/16 DSM V Criteria for AUD • The presence of at least 2 of the previous symptoms indicates an alcohol use disorder. • The severity of AUD is defined as: – Mild: the presence of 2-3 symptoms – Moderate: the presence of 4-5 symptoms – Severe: the presence of 6 or more symptoms. Epidemiology Epidemiology • The majority of American adults DO drink alcohol (~73%), but most do not develop AUD. • More are drinking and more are binge drinking than 10 years ago. Source: http://www.spectrum.niaaa.nih.gov/news-from-the-field/ news-from-the-field-01.html. Accessed 4/2/16 Epidemiology of Alcohol Use Disorder • Data from 2013: – 7% adults age 18+ had an AUD. – 2.8% adolescents (ages 12–17) had an AUD. – 24.6% of adults reported that they engaged in binge drinking in the past month. – 6.8% of adults reported that they engaged in heavy drinking in the past month. • Cost to U.S. society of ETOH estimated at $223.5 billion annually (data from NIAAA 2006). – 75% of cost is related to binge drinking. http://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/alcohol-facts-and-statistics Epidemiology of Alcohol Use Disorder • About 6% of all global deaths attributable to alcohol consumption. • Alcohol contributes to > 200 health conditions. • Fifth leading risk factor for premature death and disability. First risk factor among people between ages 15 and 49. • Nearly 88,000 people die from alcohol-related causes annually, making it the 3rd leading preventable cause of death in the United States. • In 2013, alcohol-impaired driving fatalities accounted for 10,076 deaths (30.8 percent of overall driving fatalities). Screening for Alcohol Use Disorder Screening for Alcohol Use Disorder • Ask • Assess • Advise • Assist • Arrange Screening for Alcohol Use Disorder • ASK: Single screening question: • Do you sometimes drink beer, wine, or other alcoholic beverages? • If no, screening complete. • If yes… Screening for Alcohol Use Disorder • “How many times in the past year have you had...” – 5 or more drinks in a day? (men) – 4 or more drinks in a day? (women) • 1 or more heavy drinking days is a positive screen. Screening Tools • AUDIT, AUDIT-C • CAGE, CAGE-AID • Libraries of screening tools – SAMHSA: • http://www.integration.samhsa.gov/clinical- practice/screening-tools#drugs – UW: • http://lib.adai.washington.edu/dbtw-wpd/exec/ dbtwpub.dll Screening Tools: CAGE-AID The Modified CAGE for All Addictions • Have you ever thought you should Cut down your drinking or drug use? • Have people Annoyed you by criticizing your drinking or drug use? • Have you ever felt bad or Guilty about your drinking or drug use? • Have you ever had a drink or used drugs first thing in the morning (Eye-opener) to steady your nerves, get rid of a hangover, or get the day started? Screening Tools: CAGE-AID Scoring • Regard one or more positive responses to the CAGE- AID as a positive screen. (~80% sensitive/specific) Screening Tools: AUDIT-C 1. How often do you have a drink containing alcohol? a. Never b. Monthly or less c. 2-4 times a month d. 2-3 times a week e. 4 or more times a week 2. How many standard drinks containing alcohol do you have on a typical day? a. 1 or 2 b. 3 or 4 c. 5 or 6 d. 7 to 9 e. 10 or more 3. How often do you have six or more drinks on one occasion? a. Never b. Less than monthly c. Monthly d. Weekly e. Daily or almost daily Screening Tools: AUDIT-C Scoring • Points: a = 0 points, b = 1 point, c = 2 points, d = 3 points, e = 4 points • In men, a score of 4 or more is considered positive, optimal for identifying hazardous drinking or active alcohol use disorders. • In women, a score of 3 or more is considered positive. • Generally, the higher the score, the more likely it is that the patient’s drinking is affecting his or her safety. Negative screen? • Advise to stay within recommended limits: – For healthy men up to age 65: • no more than 4 drinks in a day AND • no more than 14 drinks in a week – For healthy women (and healthy men over age 65): • no more than 3 drinks in a day AND • no more than 7 drinks in a week • Advise less/abstinence if: pregnant, planning pregnancy, have health issues or medications affected by alcohol. Screening for Alcohol Use Disorder • Ask • Assess • Advise • Assist • Arrange Positive screen? • Assess: • Determine number of heavy drinking days in past year and weekly average. • Review all alcohol-related sx. • Does the pt meet DSM-V criteria for AUD? • At-risk drinking or Alcohol Use Disorder? At-Risk drinking, but not meeting criteria for AUD: • Advise: • “You are drinking more than is medically safe.” • “I strongly recommend that you cut down (or quit), and I’m willing to help.” • “Are you willing to consider making changes in your drinking?” At-Risk drinking, but not meeting criteria for AUD: • Advise & Assist: • If patient is not ready to change drinking: – Acknowledge patient not ready – Restate concern for patient’s health – Ask about barriers to change – Reaffirm willingness to help when ready – Screen again at next visit At-Risk drinking, but not meeting criteria for AUD: • Advise & Assist: • If patient is open to changing drinking: – Help set a goal – Agree on a plan – Provide information – Review goals/progress at each visit Patient meets criteria for AUD: • Advise: • “I believe that you have an alcohol use disorder.
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