Alcoholism and Unhealthy Alcohol Use – 2013Information by Johns Hopkins Medicine Internet Learning CenterArranged By: Benjamin Tabibian DO

Why this module?

Health Effects of Alcohol Question 1 Mr. Stubbs is a 50 year-old executive

who is brought to the emergency department after his car hit a tree. He says he was on his way home from a party where he had two glasses of wine with dinner. He is awake, alert and oriented, but somewhat irritable. His blood alcohol level is 112 mg/dL

Health Effects of Alcohol

a).His blood alcohol level is consistent with drinking two glasses of wine.

b).He is not legally intoxicated.

c).His blood alcohol level is equivalent to a BAC of 1.12%.

d).His blood alcohol level would cause a significant impairment in reflexes and reaction time.

Health Effects of Alcohol ETOH is the most common substance of

abuse 1 unit is commonly thought of as

12oz beer 5oz wine 1.5oz shot

Health Effects of Alcohol The acute effect of a given amount of alcohol on an

individual will vary depending on a number of factors: Weight (higher weight, less impact). Gender (women tend to be affected more). Genetics (variations in absorption and metabolism). Rapidity of consumption (faster consumption leads to

higher levels). Presence of food in the stomach (slows absorption). Tolerance (those who consume alcohol regularly

develop a tolerance to the effects and metabolize alcohol more rapidly).

BAC of 0.08% (80 mg/dL) or higher is considered intoxicated (in the USA)

general rule of thumb is that two standard drinks will increase the average person's blood alcohol concentration by roughly 50 mg/dL (0.05%), therefore one would generally need to consume at least 3 drinks to be over this threshold.

10-15 mg/dL per hour; those who abuse alcohol chronically generally metabolize it at a higher rate of about 20-30 mg/dL per hour

risk of death with blood alcohol concentrations over 300 mg/dL

The Abuser Signs of a pt presenting

Odor of etoh Slurred speech Having just consumed prior to visit Having signs of withdrawal because they chose to

obtain Multiple traumatic injuries work or family problems, depression, anxiety, sleep

disorders, gastrointestinal problems, sexual dysfunction, heavy cigarette smoking and family history of alcoholism

Blood test abnormalities

Withdrawal

However… moderate alcohol consumption has not

been shown to have deleterious health effects; in fact, it is associated with a reduced risk of a number of medical problems, including heart disease (5), type II diabetes (6), and dementia

Diagnosis Mr. Stubbs, our 50 year-old executive, sees you for a

routine physical exam after his car accident when he was legally intoxicated. He has no current complaints. Past medical history is notable for an episode of paroxysmal atrial fibrillation four years ago, which has not since recurred. Family history is notable for a mother with hypertension; his father died of liver failure. When you question him about his alcohol use, he tells you he has "a few drinks" each night, typically vodka martinis. When you try to quantify this further, the patient states that he does not feel that this is a problem and changes the subject.

a).Men typically under report their quantity of alcohol intake.

b).The diagnosis of "alcoholism" requires that an individual has developed some level of tolerance to alcohol.

c).Denial is a characteristic of alcoholism.

d).Someone who has driven while intoxicated meets the criteria for unhealthy alcohol use.

According to the 2010 National Survey on Drug Use and Health (NSDUH), among Americans aged 12 and older, about half are current alcohol users (drank in the last month), 23% reported binge drinking (more than 5 drinks on one occasion in the last month), and 7% reported heavy alcohol use (binge drinking at least 5 of the last 30 days). An estimated 11% drove under the influence of alcohol at least once in the previous year; this rate was highest among those in the 21-25 years age group (23%)

No clear line between healthy and unhealthy use… but we can approximate

This is per NIAA recommendations Men over 65 should follow women parameters

Alcoholism "primary, chronic disease with genetic,

psychosocial, and environmental factors influencing its development and manifestations. The disease is often progressive and fatal. It is characterized by impaired control over drinking, preoccupation with the drug alcohol despite adverse consequences, and distortions in thinking, most notably denial. Each of these symptoms may be continuous or periodic”

DSM IV creiteria must have 3/7

Question 3 You continue to evaluate the business

executive presenting for a routine evaluation. You are intrigued by his history of atrial fibrillation in the past, and wonder if that was related to alcohol ingestion. Knowing that patients do not do well at assessing the impact of alcohol on their life, you decide to screen him with a set of specific questions on his drinking.

a).His wife complains about his drinking.

b).He has recently cut down on his drinking.

c).He has an eye-opener in the morning.

d).He feels he should drink less.

AUDIT and CAGE 10-item Alcohol Use Disorders

Identification Test (AUDIT) 4-item CAGE questionnaire AUDIT is designed to detect unhealthy

alcohol use as well as alcoholism, while the CAGE is designed to screen for alcohol dependence

AUDIT-C AUDIT-C; a score of 3 or more has a

sensitivity of 98% for heavy drinking and 90% for alcohol abuse or dependence, but a specificity of only 60% (i.e., 40% false-positive rate).

CAGE Looking for 2 or more positive answers when using a cutoff of two or more

positive answers, the sensitivity was 74% and specificity 91%; using a cutoff of one or more positive answers increased the sensitivity to 89% while lowering the specificity to 81%

Question 4 While your patient offers negative

answers for all four of the CAGE questions, he does admit to having more than 5 drinks at a party a few weeks ago.

a).Counseling alone is not effective.

b).Counseling unhealthy alcohol users is effective, but the effect disappears after a few months.

c).In order to be effective, counseling must be delivered by trained mental health professionals.

d).Brief counseling has been shown to reduce unhealthy alcohol use for up to 4 years.

Counseling for Unhealthy Use brief counseling for unhealthy alcohol

use is effective at reducing alcohol consumption Studies on people who were not alcoholics

be empathic and non-judgmental, while clearly stating your concerns and recommendations

the goal for unhealthy drinkers is not necessarily abstinence, but limiting alcohol consumption to healthy levels

For Alcoholics brief advice alone has not been shown

to be effective for alcoholics The first step is confrontation: telling a

patient that you believe they have a problem in an empathic manner, while offering hope and help. The alcoholic's initial response to confrontation is often denial and it may take time for this to break down

Question 5 You see the business executive back, and

after a few visits and further discussion, your patient states that his problem with alcohol is more serious than he previously acknowledged. He now admits that he has been secretly drinking an "eye opener" to prevent "the shakes". The patient is concerned about suddenly stopping alcohol, as he has heard stories about people dying from "the DTs", although he has never experienced them himself.

a).If untreated, most alcoholics will have seizures or develop delirium tremens during withdrawal.

b).Phenothiazines are an effective alternative to benzodiazepines for alcohol withdrawal.

c).Alcoholics can be safely detoxified as outpatients.

d).He should be started on phenytoin to prevent seizures while going through withdrawal.

Detoxification withdrawal is an important barrier to

sobriety and can, at times, be life-threatening

the most dangerous complications are seizures and delirium tremens

mild-moderate withdrawal symptoms, detoxification can be done in an outpatient setting

Delirium Tremens Risk factors

Previous episodes of DT’s High bp or hr on presentation Older age comorbidities

Recommended indications for inpatient therapy Moderate to severe withdrawal. Previous seizures or delirium tremens. Inability to cooperate with daily follow-up. Comorbid medical or psychiatric illness that requires

hospitalization. Inability to take medications by mouth/persistent

nausea and vomiting. Unsuccessful previous attempts at outpatient

detoxification.

Treatment Benzodiazepine taper

no evidence that any particular benzodiazepine is better than any other, but most studies utilized diazepam, lorazepam or chlordiazepoxide

Lorazepam may be a better choice for severe liver disease

No real difference between fixed dose and as needed regements

patients with severe alcohol withdrawal may initially require much higher dosage for treatment of their withdrawal

For seizures phenytoin has not been shown to be effective (36).

Question 6 After successfully completing

detoxification, your patient comes to see you and asks you what he should do to prevent a relapse

a).Attendance at self-help groups like AA is associated with improved outcomes.

b).Disulfiram (antabuse) is the best drug to prevent relapse.

c).Benzodiazepines have been shown to reduce the risk of relapse.

d).Topiramate is effective for preventing alcohol-related seizures, but not decreasing alcohol consumption.

Staying Sober Self-help groups, such as

Alcoholics Anonymous (AA) and other rehabilitation programs have traditionally been the mainstay of maintenance of sobriety.

counseling (individual or group) psychotherapy (especially

cognitive behavioral therapy), residential treatment programs

Pharmacotherapy disulfiram (Antabuse)

inhibits the metabolism of alcohol and results in a buildup of acetaldehyde when alcohol is consumed, leading to nausea, vomiting and flushing

Studies of alcoholics prescribed this agent have failed to show lasting benefit in preventing relapse or reducing consumption of alcohol

associated with hepatitis and liver failure and should not be used in patients with pre-existing chronic liver disease

Naltrexone (Revia) thought to attenuate craving for alcohol by blocking

endogenous opioids Short term studies showed moderate decrease in

consumption but questionable long term benefit FDA approved for treatment of alcoholism

Acamprosate GABA analogue and studies suggest that it may

have modest benefit May be used alone or with naltrexone Very questionable benefit FDA approved for treatment of alcoholism

topiramate (Topamax) effects on GABA transmission Two randomized-controlled study of this antiseizure

medication have reported a significant reduction in alcohol consumption and increase in abstinence over a 12-14 week period

Not FDA approved for treatment of alcoholism Studies excluded cirrhotics

Baclofen Effects on GABA transmission Only one trial but showed some promise placebo-controlled trial, among 84 alcoholics with

cirrhosis, those who received baclofen (10 mg three times daily) were significantly more likely to achieve and maintain abstinence at 12 weeks (71 vs. 29%)

Not FDA approved