Medicine 5th year, 10th lecture (Dr. Mohammad Shaikhani)

ALCOHOL MISUSE AND DEPENDENCE

Dr. Mohammad Shaikhani

The CAGE Questionnaire

The problem:

•Alcohol consumption associated with social, psychological & physical problems constitutes harmful use. •1/4 of male patients in general hospital medical wards in the UK have a current or previous alcohol problem •Alcohol misuse definitions include:• “Risky/hazardous” • “Harmful” drinking. • Risky drinkers consume alcohol above levels considered moderate. •Harmful drinkers experience current harm associated with alcohol use but do not meet criteria for dependence. •The USPSTF recommends routine screening to identify persons whose alcohol use puts them at risk. •Although the optimal interval for screening is not known, persons more likely to be at risk are those with prior alcohol problems, young adults, smokers.• More frequent screening may be beneficial in these populations.


Categories and Definitions for Patterns of Alcohol Use

Category Organization Definition

Mod drink NIAAA Men,≤2 drinks / day

Women, ≤1 drink/day

>65 ys, ≤1 drink/day




At-risk drinking NIAAA Men, >14 drinks/week or >4 drinks/ occasion

Women, >7 drinks/week or >3 drinks/occasion




Hazardous drinking WHO At risk for adverse consequences from alcohol

Harmful drinking WHO Alcohol causing physical or psychological harm




Alcohol abuse (DSM-IV) APA 1 or more of the following events in a 12-month period: • Recurrent use resulting in failure to fulfill major role obligations • Recurrent use in hazardous situations • Recurrent alcohol-related legal problems • Continued use despite social or interpersonal problems caused or exacerbated by alcohol use




Alcohol dependance (DSM-IV) APA 3 or more of the following events in a 12-month period:• Tolerance (increased amounts to achieve effect or diminished effect from same amount)• Withdrawal• Great deal of time spent obtaining alcohol, using it, or recovering from its effects• Important activities given up or reduced because of alcohol• Drinking more or longer than intended• Persistent desire or unsuccessful efforts to cut down or control alcohol use• Use continued despite knowledge of having a psychological problem caused or exacerbated by alcohol


The problem:Diagnosis

•There are several screening instruments: •A single question, “How many times in the past have you had five or more drinks (for men) or four or more drinks (for women) in a day?” can be used to screen for at-risk drinkers. • The CAGE questionnaire is a commonly used instrument to identify alcohol problems: •C Have you ever felt you should cut down on your drinking? •A Have people annoyed you by criticizing your drinking? •G Have you ever felt bad or guilty about your drinking? •E Eye opener: Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover? •With a cutoff of two positive answers, the CAGE questionnaire is 77-94% sensitive& 79- 97% specific for detecting alcohol abuse or dependence in primary care settings& indicates that further assessment is warranted; the test may be less accurate in women & blacks. Other screening instruments are available at www.niaaa.nih.gov/Publications/AlcoholResearch/.


The problem:lab diagnosis

•Lab findings such as an elevated MCV (sensitivity 63%; specificity 48%) & elevated aspartate aminotransferase/alanine aminotransferase ratio (sensitivity 12%; specificity 91%) can be suggestive but are not diagnostic of alcohol abuse & dependence.


The problem: Management

• Referral for specialty treatment. •For alcohol misuse, brief behavioral counseling (such as the five A’s & the five R’s used for smoking quiting) may be useful. •Adjunctive drug therapy may be considered for patients who previously failed to benefit from psychosocial approaches alone &those who have recently stopped drinking but are experiencing cravings or relapses.


The problem:Management

• 3 oral medications are currently approved for treating alcohol dependence, but they are most effective when combined with some behavioral support.



• Disulfiram causes a reaction of flushing, sweating, nausea, and tachycardia when the patient ingests alcohol. It is most effective when medication compliance can be monitored. Contraindications are use of alcohol-containing preparations, metronidazole, severe cardiac disease& unwillingness to completely abstain from alcohol.



• Naltrexone reduces alcohol cravings & causes a lesser reward in response to drinking. It is contraindicated if a patient is dependent on or taking opioids or has liver disease.



• Acamprosate’s alcohol-related action is unclear, but it may reduce abstinence-related symptoms, such as anxiety, restlessness, and dysphoria. It is contraindicated in severe renal disease. •There is no proven benefit for combining these medications. •A reasonable minimum duration of adjunctive drug therapy is 3 months, with treatment continuing a year or longer if the patient responds.


•Have you ever felt you should CUT down on your drinking? •Have people ANNOYED you by criticizing your drinking? •Have you ever felt bad or GUILTY about your drinking? •Do you ever have a drink first thing in the morning to steady you or help a hangover? (an EYE opener)



Narrowing of drinking repertoire (restriction to 1 type of alcohol as spirits) Priority of drinking over other activities (salience) Tolerance of effects of alcohol Repeated withdrawal symptoms Relief of withdrawal symptoms by further drinking Subjective compulsion to drink Reinstatement of drinking behaviour after abstinence

CRITERIA FOR ALCOHOL DEPENDENCE :


Availability of alcohol & social patterns of use appear to be the most important factors. Genetic factors may play some part in predisposition to dependence. The majority of alcoholics do not have an associated psychiatric illness, but a few drink heavily in an attempt to relieve anxiety or depression.

Aetiology:


Alcohol misuse may emerge during the patient's history, although patients may minimise their intake. It may also present via its effects on one or more aspects of the patient's life. Alcohol dependence commonly presents with withdrawal in those admitted to hospital, as they can no longer maintain their high alcohol intake.

Diagnosis:


These are protean and virtually any organ can be involvedAlcohol has replaced syphilis as the great mimic of disease. Social problems include absenteeism from work, unemployment, marital tensions, child abuse, financial difficulties & problems with the law, such as violence/ traffic offences.

Complications:


Depression is common, usually reactive to the numerous social problems which heavy drinking creates. Alcohol also has a direct depressant effect. Attempted suicide & completed suicide are often associated with alcohol misuse. Anxiety is relieved by alcohol. People who are socially anxious may consequently use alcohol in this way & may develop dependence& Conversely, alcohol withdrawal increases anxiety. Alcoholic hallucinosis is a rare condition in which alcoholic individuals experience auditory hallucination in clear consciousness. Alcohol withdrawal: Symptoms usually become maximal about 2 days after the last drink& can include seizures ('rum fits'). Delirium tremens is a form of delirium associated with severe alcohol withdrawal with significant mortality& morbidity

Psychosocial problems:


The familiar features of drunkenness are ataxia, slurred speech, emotional incontinence & aggression. Very heavy drinkers may experience periods of amnesia for events which occurred during bouts of intoxication, termed 'alcoholic blackouts'. Established alcoholism may lead to alcoholic dementia, a global cognitive impairment resembling Alzheimer's disease, but which does not progress if the patient becomes abstinent. Indirect effects on behaviour can result from head injury, hypoglycaemia &portosystemic encephalopathy

Brain effects:


Acute intoxicationEmotional & behavioural disturbance Medical problems: hypoglycaemia, aspiration of vomit, respiratory depression Complicating other medical problems Accidents&injuries sustained in fights Withdrawal phenomenaPsychological symptoms: restlessness, anxiety, panic attacks Autonomic symptoms: tachycardia, sweating, pupil dilation, nausea, vomiting Delirium tremens: agitation, hallucinations, illusions, delusions Seizures

CONSEQUENCES OF CHRONIC ALCOHOL MISUSE :


NeurologicalPeripheral neuropathy Cerebellar degeneration Cerebral haemorrhage Dementia HepaticFatty change,hepatiti, & cirrhosis, Liver cancer GastrointestinalOesophagitis, gastritis Pancreatitis Oesophageal cancer Mallory-Weiss syndrome Malabsorption Oesophageal varices RespiratoryPulmonary TB ,Pneumonia

MEDICAL CONSEQUENCES :


SkinSpider naevi ,Palmar erythema Duypuytren's contractures ,Telangiectasiae CardiacCardiomyopathy Hypertension MusculoskeletalMyopathy Fractures Endocrine and metabolicPseudo-Cushing's syndrome Hypoglycaemia ,Gout ReproductiveHypogonadism Fetal alcohol syndrome Infertility

MEDICAL CONSEQUENCES :


Depression Alcoholic hallucinosis Alcoholic 'blackouts' Wernicke's encephalopathy: nystagmus, opthalmoplegia, ataxia, confusion Korsakoff's syndrome: short-term memory deficits, confabulation

PSYCHIATRIC &CEREBRAL CONSEQUENCES :


A rare but important effect of chronic alcohol misuse This organic brain disorder results from damage to the mamillary bodies, dorsomedial nuclei of the thalamus & adjacent areas of grey matter. It is caused by a deficiency of thiamin (vitamin B1), which is most commonly caused by long-standing heavy drinking & an inadequate diet. Without prompt treatment, the acute presentation of Wernicke's encephalopathy (nystagmus, ophthalmoplegia, ataxia & confusion) can progress to the irreversible deficits of Korsakoff's syndrome (severe short-term memory deficits & confabulation). In those who die in the acute stage, microscopic examination of the brain shows hyperaemia, petechial haemorrhages& astrocytic proliferation.

PSYCHIATRIC AND CEREBRAL CONSEQUENCES :Wernicke-Korsakoff syndrome.


Advice about the harmful effects of alcohol & safe levels of consumption is often all that is needed.In more serious cases, patients may have to be advised to alter leisure activities or change jobs if these are contributing to the problem. Supportive psychotherapy is often crucial in helping the patient make the necessary changes in lifestyle. Psychological treatment is used for patients who have recurrent relapses &is usually available at specialised centres. Support is also provided by voluntary organisations such as Alcoholics Anonymous (AA). If alcohol dependence is suspected, withdrawal syndromes can be prevented, or treated once established, with benzodiazepines. Large doses may be required (e.g. diazepam 20 mg 6-hourly), tailed off over a period of 5-7 days as symptoms subside.

Management :


Prevention of the Wernicke-Korsakoff complex requires the immediate use of high doses of thiamin, which may be given parenterally There is no treatment for Korsakoff's syndrome once it has arisen. The risk of side-effects, such as respiratory depression with benzodiazepines & anaphylaxis with B1, is small when weighed against the risks of no treatment. Disulfiram (200-400 mg daily) can be given as a deterrent to patients who have difficulty resisting the impulse to drink after becoming abstinent. It blocks the metabolism of alcohol, causing acetaldehyde to accumulate. When alcohol is consumed, an unpleasant reaction follows with headache, flushing and nausea. Disulfiram always an adjunct to other treatments,esp psychotherapy. Acamprosate (666 mg 8-hourly) maintain abstinence by reducing the craving for alcohol. Only rarely are antidepressants required; depressive symptoms, if present, usually resolve with abstinence. Antipsychotics as chlorpromazine required for alcoholic hallucinosis.

Management :

Unhealthy Alcohol Use Is a Significant Public Health Problem

• 85,000 alcohol-related deaths

• Substantial disability from consequences of alcohol use

In the United States (per year)

Abstinent - 30%

Low-risk - 30%

Abusive or dependent 10%

Risky - 30%

Alcohol Use Among Americans

What is the Difference Between Risky Alcohol Use and Alcohol Abuse?

7+ drinks/week3 drinks/occasion

Risky Alcohol Use

14+ drinks/week4 drinks/occasion

Women

Men

No Alcohol Related Consequences – YET!

Alcohol Abuse

Recurrences in the last 12 months of:

• Failure to fulfill major obligations

• Alcohol use in hazardous situations

• Related legal problems

• Related social or interpersonal problems

Source: Saitz R. Unhealthy Alcohol Use. NEJM. 2005;352:596-607.

What Determines Alcohol Dependency?

1. Tolerance

2. Withdrawal

3. Significant time spent obtaining/using alcohol, or recovering from its effects

4. Reducing or giving up important activities because of alcohol

5. Drinking more or longer than intended

6. Persistent desire or unsuccessful efforts to cut down or control use

7. Continued use despite problems caused or exacerbated by alcohol

Those with alcohol dependency suffer clinically significant impairment or distress in the presence of three or more of the following:


Moderate Alcohol Use Has Some Health Benefits, But It Affects People

DifferentlyPossible Benefits Possible Harmful Effects

(Varied based on age, sex, genetics) Risk of ischemic heart disease Risk of ischemic stroke

Liver diseasePancreatitisMotor vehicle accidentsGun-related traumaHypertensionHemorrhagic strokeCancer

Abstinence Low-Risk Use

Men <34Women <45

Men >35Women >45

<5 drinks/week<2 drinks/week

Lowest Mortality Rates


How Does A Person Know If His/Her Alcohol Use is Unhealthy?

1. Have you felt you should cut down?

2. Have people annoyed you by criticizing your drinking?

3. Have you felt bad or guilty?

4. Do you drink first think in the morning?

CAGE (4 questions)

Unhealthy Use

1 or 2 Positives

Sources: Saitz R. Unhealthy Alcohol Use. NEJM. 2005;352:596-607. Fiellin DA, Reid MC, O’Connor PG. Screening for alcohol problems in primary care: a systematic review. Arch Intern Med. 2000;160:1977-1989. Cited in Saitz R.

The AUDIT Test Includes 10 Questions with Multiple Choice

Answers Scaled 0 to 4

How often do you have a drink containing alcohol?

How many drinks do you have in one day?

How often do you have six or more drinks?

How often during the past year were you unable to stop drinking?

How often during the past year have you failed to do what was normally expected from you?

Has a relative, friend, doctor, or health care worker been concerned and suggested you cut down?

Score of 8 or more

AUDIT

Unhealthy Use

Sources: Saitz R. Unhealthy Alcohol Use. NEJM. 2005;352:596-607. Fiellin DA, Reid MC, O’Connor PG. Screening for alcohol problems in primary care: a systematic review. Arch Intern Med. 2000;160:1977-1989. Cited in Saitz R.

Nine Steps to Help Prevent Long-Term Disability from Unhealthy

Alcohol Use

1. Gather information

2. Express concern

3. Provide feedback

4. Express empathy

5. Offer help

Prevention requires:

• Intervention • Tailored treatment plans • Supportive follow-up

6. Know local referral options

7. Reinforce self worth

8. Assist with a plan

9. Follow up

Sources: Helping patients with alcohol problems: a health practitioner’s guide. Rockville, Md.: National Institute on Alcohol Abuse and Alcoholism, January 2003. (NIH publication no. 03-3769.) Cited in Saitz R.Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: recommendation statement. Ann Intern Med. 2004;140:554-556. Cited in Saitz R.

Medicine 5th year, 10th lecture (Dr. Mohammad Shaikhani)

Health & Medicine

Transcript of Medicine 5th year, 10th lecture (Dr. Mohammad Shaikhani)