9/22/2015. Timothy W. Lineberry, MD Chief Medical Officer Greater Green Bay Aurora Health Care

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1 Timothy W. Lineberry, MD Chief Medical Officer Greater Green Bay Aurora Health Care Differentiate between hazardous drinking and alcohol use disorders Recognize issues associated with comorbidity between substance use and other psychiatric disorders Describe evidence based approaches for initial management and treatment 2014 MFMER Honorarium None Stock or Patents None Consulting None Publishing/Royalti None es Organization 1-Board member of Institute for Clinical Systems Improvement (not-for-profit) Government Subject Matter Expert Military Suicide Prevention Department of Defense 52 year old female presents with concerns related to depressive symptoms, positive neurovegetative profile, reports intermittent use of marijuana (twice monthly with husband) and drinks socially. Has been on multiple antidepressants without good response. Stressor recently has been arrest for DUI. Labs show slight anemia, slight elevation of MCV, normal AST and ALT, GGT of 75 1

2 1. Patient has hazardous drinking 2. Patient has alcohol use disorder 3. Patient has alcohol use disorder and marijuana use disorder 4. Patient has marijuana use disorder 5. Can t determine diagnosis 1. Referral to psychiatrist 2. Referral to Alcoholics Anonymous 3. Referral to a dual diagnosis treatment group 4. Treatment with antidipsotropic (e.g. acamprosate, naltrexone) 5. All of the above 1. Abnormal GGT indicates it is substance induced 2. It is substance induced until proven otherwise 3. This requires obtaining time course history of depressive symptoms and substance history 4. Family history of depression is not helpful 2

3 Men 5 drinks/day or 15 drinks/week Women 4 drinks/day or 8 drinks/week At risk for alcohol related problems NOT alcohol abuse or dependence/alcohol use disorder (AUD) AMSP BRFSSData reported in MMWR Jan 2012 AUDs by Substate Region based on NSDUH Age group with most binge drinkers: years Age group that binge drinks most often: 65+ years Income group with most binge drinkers: more than $75,000 Most alcohol impaired drivers binge drink Most people who binge drink are not alcohol dependent or alcoholics More than half of the alcohol adults drink is while binge drinking More than 90% of the alcohol youth drink is while binge drinking NSDUH Report 18 Sep

4 Alcohol Use Disorder Previous terminology to classify alcohol abuse and dependence combined Pulls together previous symptoms of both along with additional 12 month prevalence 13.9%; lifetime 29.1% (Grant et al JAMA Psych 2015) 10 item survey Developed by W.H.O. Score of > 8 = positive test for hazardous drinking/ chance of alc. dx Sensitivity ~70% Specificity 80% AUDIT-C 3 item survey Sensitivity/specificity = to 10 item AUDIT Positive score Men > 4 Women 3 Cut down, Annoyed, Guilt, Eyeopener Positive test >2 yes answers Sensitivity 50 80% Specificity ~ 80% Doesn t screen for hazardous drinking Blood tests Change with heavy sustained alcohol use Gamma glutamyl transferase (GGT) Carbohydrate Deficient Transferrin (CDT) CBC w/mean Corpuscular Volume (MCV) Aspartate transaminase (AST) 4

5 NSDUH Reports (SAMHSA) General understanding of telescoping women with later age of use but more rapid development of dependence More recent larger population data doesn t support as much (Keyes et al AJP 2009) Question of relation to childhood maltreatment and particular groups (Oberleitner et al Childhood Mal 2015) Abuse/maltreatment is independent risk factor for AUDs Women more likely to have abuse history Abuse associated with higher rates of suicidality and psychiatric diagnoses NSDUH Reports (SAMHSA) 5

6 NSDUH Reports (SAMHSA) Mood Disorders Major Depressive Disorder Bipolar Disorder Antisocial and Borderline Personality Disorder PTSD Substance Use Disorders Nicotine Anxiety Disorders Social Anxiety Panic Disorder Timeline interview Carefully assess lifetime MDD sxs Sxs present w/sustained abstinence? Family history of depression? 6

7 Clinically recommendations for treatment often not made (McGlynn 2003 NEJM) by clinicians Patient specific only 20% receive treatment in lifetime (Grant et al JAMA Psych 2015) Issues with treatment availability Challenges with carve out Perception of treatment being stigmatized, notefficacious Need for more systematic screening and treatment and population health strategies Motivational Interviewing/SBIRT Cognitive Behavioral Therapy Disulfiram Naltrexone Acamprosate 7

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