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. I strongly recommend that you quit drinking and I’m willing to help.” • Relate drinking to patient’s concerns and medical findings. Patient meets criteria for AUD: • Advise & Assist: • Is patient willing to change drinking? • If not ready to abstain, many patients can be successful at cutting down. • Consider referral to specialist. • Consider medication treatment. • Educate/advise regarding 12-step or other mutual help group. Patient meets criteria for AUD: • Advise & Assist: • Consider need for medically-assisted detox. • If patient is a health-care provider, advise self-referral to monitored treatment program. • http://www.monitoredtreatment.com Patient meets criteria for AUD: • Arrange: • Set f/u appointments for medication f/u, review goals. • Coordinate referrals to specialists as needed. Treatments Treatments

• (Evidence-based) Treatment can and does work!

• One-third of people who are treated for alcohol problems have no further symptoms 1 year later.

• Many others significantly reduce drinking and report fewer alcohol-related problems. Treatments

• Evidence-based treatments

– Pharmacologic – Behavioral – Mutual-help groups (AA, etc)

• Combination may be most effective Pharmacologic Treatments Pharmacologic Treatments

• Detoxification vs. longer-term tx: – Detox should generally be in medically supervised setting. • Longer-term EtOH medications: – FDA approved: • Naltrexone (50 mg PO QD or 380 mg IM Q4weeks) • Acamprosate (666 mg TID) • Disulfiram (250 – 500 mg QPM) – Non-FDA approved: • Topiramate (100 mg BID) • Baclofen (10 mg TID) • Gabapentin (300 – 600 mg TID) Pharmacologic Treatments

• Naltrexone – Consider as 1st line Tx for most patients. – Usually 50 mg daily (can be up to 100 mg) – Very effective: • Cochrane meta-analysis: risk of heavy drinking was decreased by 83% compared to placebo. – Safe if patient continues to drink. – Caution in liver disease, d/c if sig LFT elevation. – Side effects: nausea, headache, abdominal pain. – Antagonist at opioid receptor – contraindicated if taking opioids. – Reduces craving/reward of alcohol. Pharmacologic Treatments

• Naltrexone – Depot (Vivitrol) – 380 mg IM Q4 weeks. – Less robust data with depot form (25% decrease in heavy drinking vs. placebo), but no head-to-head with oral. – Good for patients who may have compliance issues with oral med. Pharmacologic Treatments

• Acamprosate – Safe in liver failure, acute hepatitis. – Caution in renal disease – renally metabolized. – Evidence mixed on efficacy – may be best in patients already abstinent to maintain sobriety. – glutamate antagonist (helps hyper- glutaminergic state) - Targets protracted sx/ craving for relief from symptoms. Pharmacologic Treatments

• Acamprosate – Must be sober 1-2 weeks to begin treatment. – 666 mg three times a day may be compliance problem. – No Serious side effects. Pharmacologic Treatments

• Disulfiram (Antabuse) – oldest ETOH drug (1951). – Inhibits aldehyde dehydrogenase leading to build up of acetaldehyde (Flushing, tachycardia, hypotension, N/V). – Mixed results in studies - compliance issues. – Works best when observed treatment. – May elevate liver functions. – Inhibits P450 - watch drug interactions. – Need extensive education: effects of drug may last as long as 14 days; reaction can occur with mouthwash, cold meds, etc. Pharmacologic Treatments

• Disulfiram – No alcohol for 12 hrs prior to start. – If pt reports no “antabuse reaction” at 250 mg, increase to 500 mg daily. – Discontinue if pregnancy – unknown effects on fetus or in breast-feeding. Pharmacologic Treatments – off-label: • Topiramate – Studies show significant decrease in alcohol use vs. placebo. – Some small studies compare with naltrexone suggest may be as effective. – Titrate slowly from 25 mg daily to max of 150 mg BID. – Significant SE: cognitive impairment, fatigue, depression, dizziness, paresthesias, depression, headache, weight loss. Pharmacologic Treatments – off label: • Baclofen

– GABAB Agonist. – Pre-clinical (animal studies) showed benefit. – Mixed efficacy compared to placebo. – Several studies: increased abstinence, decreased craving. – 30 – 80 mg daily (single or divided doses), some used up to 300 mg/day. – Reports of misuse, overdose, and severe withdrawal reactions. Pharmacologic Treatments – off label: • Gabapentin – Several small studies suggest decreased drinking with gabapentin 900 – 1800 mg daily. – Few side effects, none serious. – May also help with insomnia, anxiety, mild withdrawal sx. Behavioral Treatments

• Motivational Enhancement • Cognitive-Behavioral • Individual drug counseling • Contingency management • Case management/integrated services • Family therapy • Community Reinforcement and Family Training (CRAFT) Mutual-Help Groups Recommending Mutual Help/12-step Programs • Cochrane systematic review shows that AA and TSF are as effective as any of the comparison tx (such as CBT, MET). • Some studies show linear dose-response between AA and improved drinking outcomes (min 1 mtg/week). • Participation decreases healthcare costs while improving outcomes. • AA/TSF provides long-term recovery support. Recommending Mutual Help/12-step Programs • Be able to direct patient to meetings in their area. • Consider giving patient a “prescription” to attend meeting. • Be able to describe to the patient how meetings are structured and what will happen. • Talk about fears/concerns about meetings. Recommending Mutual Help/12-step Programs • 12-step programs are not right for everyone. • Other mutual help groups exist, such as: – SMART recovery: based on self-reliance, coping with urges, behavioral approach. – SOS (Secular Organizations for Sobriety) – LifeRing – Women For Sobriety – Moderation Management • Religious/church-based programs. Recommending 12-step Programs • http://www.nm-aa.org Recommending 12-step Programs • http://www.albuquerqueaa.org When/Where to Refer When/Where to Refer

• First, remember addiction/alcoholism is a chronic disease. • Patients will present in various stages of disease. – At-risk pts need prevention! – Dx and Tx early in disease may prevent complications and worsened course. – If sober, need continuing relapse prevention. – Like any other chronic disease: needs continuous evaluation/monitoring and adjustment of care plans. When/Where to refer

• Consider the severity of AUD and patient preferences/needs/comorbidities. • Least restrictive means that will meet patient’s goals. • Many patients can do well with 12-step program, individual treatment, or low- intensity outpatient tx. When/Where to refer

• Natural hx of AUD: – Lifetime remission rates for AUD are > 90%! – 72% of U.S. adults with AUD dx have single episode lasting 3-4 years. – Contrast with the very small group of chronic, severe, persistent AUD that we often see. • More than 40% of daily or near-daily heavy drinkers do not meet any criteria for AUD. • Harms are often in pts without AUD: trauma often occurs in occasional heavy drinkers. When/Where to refer

• Consider the severity of AUD and patient preferences/needs/comorbidities. • Levels of treatment (actually a spectrum): – Detox (3-5 days), early intervention, brief tx (MET) – Individual/outpatient – Intensive outpatient Tx (9+ hours/week) – Partial hospitalization (day-treatment: 5 days/week, 6 hrs/day, ~ 2 weeks) – Residential Rehab (30 day programs) – Long-term residential (6-12 months) – Hospitalization (variable) When/Where to refer

• ASAM criteria – Placement based on 6 dimensions: 1. Acute intoxication or withdrawal potential 2. Medical conditions/complications 3. Emotional/behavioral/cognitive conditions 4. Readiness to change 5. Relapse, continued use, continued problem potential 6. Recovery/Living environment When/Where to refer

• Low risk: – Minimal clinical supervision • Moderate risk: – May need services 2-3 days/week • High risk: – May need residential/intensive tx

• Patients with complicating psychiatric disorders, medical issues, or social barriers may need higher level of care. When/Where to refer

• Wide variety of approaches and programs. • Many for-profit (and non-profit) addiction tx centers do not follow evidence-based methods. – Often no doctor or nurse on site. – Group counseling sessions may be bulk of tx: • Studies do NOT show positive effect with group drug counseling!! – Group counseling often run by low-skill addiction counselors: • In 13 states you don’t need a high school education or even a GED to be an addiction counselor. When/Where to refer

• Major providers in many programs: Addiction Counselors – Research shows their training, licensure, and certification do not require proficiency or even understanding of therapies, medications, or biological facts of addiction. – Little investment in training due to high turnover up to 50% per year. – They are poorly paid for this difficult job: salaries around $18,000/year. When/Where to refer

• National Drug and Alcohol Treatment Referral Routing Service • HHS & SAMHSA toll-free telephone number for alcohol and drug information/ treatment referral assistance:

• Telephone: 1-800-662-HELP (4357) When/Where to refer https://findtreatment.samhsa.gov

When/Where to refer https://findtreatment.samhsa.gov

When/Where to refer: Turquoise Lodge http://nmhealth.org/about/ofm/ltcf/tlh/ When/Where to Refer: ASAP http://hospitals.unm.edu/bh/asap/adult.shtml When/Where to Refer: MATS

• http://www.bernco.gov/substance-abuse-programs/detoxification- from-alcohol-substance-abuse.aspx • MATS DETOX: 5901 Zuni, SE; 468-1555. • Free of charge • First come - first served – 32 M and 16 F beds • Usual stay 3-5 days When/Where to Refer: Military Veterans

• http://www.albuquerque.va.gov/index.asp

New Mexico VA provides the full range of addiction treatments for veterans: - Outpatient - Intensive Outpatient - Residential - Medication + Behavioral - On-campus AA meetings When/Where to Refer: Pregnant women: Milagro http://hospitals.unm.edu/bh/milagro_program.shtml When/Where to Refer:

CONSIDER: • Does the program provide evidence-based treatments? • Does the program tailor the treatment plan for each individual patient? – Is there integrated psychiatric and medical care? – Are psychosocial issues/barriers addressed? • Does the program adapt the treatment plan when the patient’s needs change? • Is the duration of treatment sufficient? Medical Comorbidities

“Scoring drugs", The Economist, data from "Drug harms in the UK: a multi-criteria decision analysis", by David Nutt, Leslie King and Lawrence Phillips, on behalf of the Independent Scientific Committee on Drugs. The Lancet. 2010 Nov 6;376(9752):1558-65. doi:10.1016/S0140-6736(10)61462-6 PMID:21036393 http://www.addictions.com/alcohol/long-term-effects-of-alcohol-abuse/ Medical comorbidities • Cardiovascular: – HTN, cardiomyopathy, atrial Fib, CAD, CVA. • Endo/reproductive: – Gynecomastia/testicular atrophy, reversible hypoparathyroidism, osteopenia, hypertriglyceridemia, hyperuricemia/gout, diabetes, obesity. • GI: – Gastritis, pancreatitis, GERD, hepatic steatosis, hepatitis, cirrhosis, portal HTN, varices, GIB, ascites/SBP. Medical comorbidities continued • Hematologic: – Macrocytic anemia, pancytopenia, thrombocytopenia, coagulopathy, iron deficiency, folate deficiency. • Neurologic: – Peripheral neuropathy, seizures, hepatic encephalopathy, Wernicke syndrome, Korsakoff dementia, cerebellar dysfunction, alcoholic myopathy, delirium; falls. Medical comorbidities continued • Pulmonary: – Aspiration/pneumonia/pneumonitis, OSA, respiratory depression. • Renal: – Dehydration, AKI/CKD, hepatorenal, rhabdo • Musculoskeletal: – Rhabdo, compartment syndromes, gout, osteopenia/osteonecrosis (hip/shoulder), traumatic fractures/injuries. • HCC, aerodigestive CA, sexual abuse, STDs, HepC, TB, fetal alcohol syndrome. Laboratory abnormalities

• Anemia, thrombocytopenia, elevated INR, elevated MCV. • Transaminitis, often 2:1 AST/ALT. (AST/ ALT may be normal or low in cirrhosis). Elevated GGT. • Hypomagnesemia, hypocalcemia, other electrolyte disturbances. Clinical Issues & Follow- up of patients with AUD Prevention/follow-up

• Regular/frequent follow-up. • Expect relapses – prepare. • Remember that adherence to any medical tx may be even more difficult in patients with AUD. • Older adults may have poorer nutrition, falls, self-care issues. Clinical Issues - Women

• Women are more likely than men to develop complications of AUD. – Alcoholic hepatitis – Alcohol-related heart disease – Breast cancer • 10% higher risk than women who do not drink at all, increases by additional 10% for every additional drink per day. – Increased risk of violence/sexual assault. Clinical Issues - Women

• Fetal Alcohol Syndrome – 20-30% of women drink at some time during pregnancy. 8% report binge drinking. Follow up of patients with Alcohol Use Disorder • Heavy drinkers/AUD: should be prescribed folate and thiamine supplementation. • Frequency of alcoholic neuropathy varies from 20% to 66%. – Direct toxic effect of alcohol – Thiamine deficiency • Risk of Wernicke/Korsakoff. • Risk of FAS. Vitamin/Mineral Deficiencies in AUD • Women of childbearing age: supplement folate 0.4 to 0.8 mg daily. • Risk of thiamine, vitamin D, pyridoxine, niacin, riboflavin, zinc, and folic acid deficiency in people with AUD: – Supplement daily multivitamin including 400- IU vitamin D, 100-mg thiamine, and 1-mg folic acid. • High dose Vitamin D if low, mag if low. Vitamin/Mineral Deficiencies in AUD • adequate calcium intake in diet or supplement (1-g elemental calcium daily for all but postmenopausal women, who should receive 1.5 g). Prevention/follow-up

• Alcoholism is a specific indication for pneumococcal vaccine. • HepA vaccine if chronic liver disease. • Flu vaccine yearly. Prevention/follow-up

• ASA if benefits outweigh risks for CV • Many with AUD are also smokers – screen and advise on smoking cessation. Protracted Withdrawal

• May last more than a year. • Changes in sleep latency, frequency of awakening. • Variations in autonomic activity. • Spontaneous anxiety/depression. • May involve 5-HT and CRF systems. Long-term Monitoring

• Lab Monitoring: – Why? • Verify abstinence/intake in those who may not provide accurate reports. • Guide treatment decisions • Provide feedback that can motivate change • Monitor for physiological changes – Blood tests: • BAL, GGT, AST/ALT, MCV • Phophatidyl Ethanol • Carbohydrate deficient Transferrin (CDT) Long-term Monitoring

• Lab Monitoring: – Urine tests • Ethyl Glucuronide/Ethyl Sulfate • Direct alcohol metabolites • Detectable in urine for ~2 days • Highly sensitive • No direct correlation with alcohol intake Long-term Monitoring

• Lab Monitoring: – Urine Ethyl Glucuronide/Ethyl Sulfate • A “high” positive (e.g.,>1,000 ng/mL) may indicate: – Heavy drinking on the same day or previous day or two. – Light drinking the same day. • A “low” positive (e.g.,500–1,000 ng/mL) may indicate: – Previous heavy drinking (previous 1–3 days). – Recent light drinking (e.g., past 24 hours). – Recent intense “extraneous exposure” (last 24 hrs). • A “very low” positive (100–500 ng/mL) may indicate: – Previous heavy drinking (1–3 days). – Previous light drinking (12–36 hours). – Recent “extraneous” exposure. Long-term Monitoring

• Lab Monitoring:

The Role of Biomarkers in the Treatment of Alcohol Use Disorders, 2012 Revision SAMHSA Advisory, Spring 2012

Long-term Monitoring

• Lab Monitoring: References

• NIAAA: National Institute on Alcohol Abuse and Alcoholism: http:// pubs.niaaa.nih.gov • NIDA: National Institute on Drug Abuse: https:// www.drugabuse.gov • CDC: Centers for Disease Control and Prevention: http:// www.cdc.gov • SAMHSA: Substance Abuse and Mental Health Services Administration: http://www.samhsa.gov • SAMHSA’s library of Evidence Based Practices: http:// nrepp.samhsa.gov/01_landing.aspx. • The Role of Biomarkers in the Treatment of Alcohol Use Disorders, 2012 Revision, SAMHSA Advisory, Spring 2012. References

• ASAM: American Society of Addiction Medicine: http:// www.asam.org. • The ASAM Criteria: Treatment Criteria for Addictive, Substance- Related, and Co-Occurring Conditions, David Mee-Lee, MD, editor; October 24, 2013. • The Carlat Report – Addiction Treatment, Daniel Carlat, MD, Editor-in-Chief, Vol. 3, Issues 5&6, July/August 2015. • The Carlat Report – Addiction Treatment, Daniel Carlat, MD, Editor-in-Chief, Self-Help Programs, Vol 2, Issue 4, June 2014. • The Carlat Report – Addiction treatment Online: http:// www.carlataddictiontreatment.com/free_articles/pharmacotherapy- alcohol-dependence-free-article. References

• The ASAM Principles of Addiction Medicine, Fifth Edition. Richard K. Ries, MD, FAPA, FASAM, David A. Fiellin, MD, Shannon C. Miller, MD, FASAM, DFAPA, Richard Saitz, MD, MPH, FACP, FASAM, editors; 2014. • UK National Health Service Alcohol Information: http://www.nhs.uk/ livewell/alcohol/Pages/Alcoholhome.aspx • For Patients: http://rethinkingdrinking.niaaa.nih.gov