ALCOHOL USE DISORDER. Lada Alexeenko, MD

Transcription

1 ALCOHOL USE DISORDER Lada Alexeenko, MD

2 Grand Rounds: 4/12/2017 Please sign the attendance sheet in the room to claim your credit. Kaiser Permanente South San Francisco has determined that the speaker (Dr. Alexeenko) and the planning committee (Dr. Becker, Dr. Sheikh, Dr. Jones, Dr. Liu, Dr. Zheng, Rebecca Bayrer, and Heather Miller), for this activity do not have any relevant financial relationships. Kaiser Permanente South San Francisco takes responsibility for the content, quality, and scientific integrity of this CME Activity. Kaiser Permanente does not endorse any brand-name products.

3 Learning objectives Discuss the clinical presentation, prevalence, and diagnosis of spectrum of unhealthy alcohol use Develop follow up plan for patients who are at risk for alcohol use d/o Diagnose unhealthy alcohol use vs. alcohol use d/o Assess and treat patients with alcohol withdrawal

4 The patient is 65 yo male with a lifelong Hx of alcohol use, Hx of alcohol withdrawal, seizures, and multiple unsuccessful attempts to engage in outpatient programs. The patient was seen several times previously and you recommended he stop drinking due to multiple comorbid medical illnesses. The patient reports he is afraid to stop drinking because whenever he decreases his drinking he becomes very sick. He, however, understands your concerns, and given his family Hx of alcohol-related problems he expresses a desire to stop drinking and maybe even go into residential treatment.

5 What will you decide next? 1. Great, we can manage his symptoms as outpatient Lorazepam (Ativan) 1 mg q 4 hours, Thiamine 100 mg, Folic Acid 1mg 2. Refer to AA meetings in the area 3. He requires referral to CDRP 4. He requires referral to CDS 5. Send him to the ER 6. Tell him to go home and continue drinking, but in moderation Great, we can manage his s... Refer to AA meetings in the... 0% 0% 0% 0% 0% 0% He requires referral to CDRP He requires referral to CDS Send him to the ER Tell him to go home and con...

6 CDRP (Chemical Dependency Recovery Program) vs CDS (Chemical Dependency Service) Our SSF medical center ( 1001 Sneath Lane, Suite 204, San Bruno) offers CDS level of care only (up to 9 hours per week of psychosocial treatment). Open Mondays-Fridays only, closed on weekends and holidays. Limited medical and detox coverage. No referrals to residential treatment. We treat more "functional" patients, patients who are able to continue working while receiving treatment. Also we do more "harm reduction" treatment

7 CDRP (Chemical Dependency Recovery Program) vs CDS (Chemical Dependency Service) CDRP : >20 hours per week of psychosocial treatment per week, including referrals to residential treatment programs. Open all weekend days and all holidays. Patients attend treatment 7 days per week for 2-3 weeks initially (6-7 hours of treatment per day during the week), and then stop down to gradually lower levels of care. Full medical and detox coverage 365 days per year Treatment severely addicted patients with medical comorbidities, who are functioning poorly, need time off work, etc. Less "harm reduction" approach, more abstinence-based

8 CDRP (Chemical Dependency Recovery Program) vs CDS (Chemical Dependency Service) CDS clinics : SSF, Redwood City, San Rafael, Vacaville, South Sacramento, Santa Rosa CDRP: San Francisco, Oakland, Santa Clara, Vallejo, Sacramento, Walnut Creek

9 Alcohol Facts and Statistics According to the 2015 National Survey on Drug Use and Health (NSDUH) 86.4 percent of people ages 18 or older reported that they drank alcohol at some point in their lifetime; 70.1 percent reported that they drank in the past year; 56.0 percent reported that they drank in the past month million adults ages 18 and older (6.2 percent of this age group) had AUD. This includes 9.8 million men (8.4 percent of men in this age group) and 5.3 million women (4.2 percent of women in this age group). About 1.3 million adults received treatment for AUD at a specialized facility in 2015 (8.3 percent of adults who needed treatment). This included 898,000 men (8.8 percent of men who needed treatment) and 417,000 women (7.5 percent of women who needed treatment

10 E-consult

11 Diagnosis Please use non-hedis triggering diagnoses, such as Unhealthy Drinking Behavior Z72.89 Unhealthy Substance Use Behavior Z72.89 Alcohol Prevention Counseling, Z71.89 Drug Use Prevention Counseling Z71.89 Allow CDS and Psychiatry to make the formal diagnoses of substance use disorder for your patients Any substance use disorder diagnosis with in remission specifier does not trigger AOD: IET HEDIS measure and is OK to use

12 Diagnosis Many diagnoses that mention alcohol, drugs or secondary harm due to such use, e.g withdrawal will trigger the metric even if the diagnoses does not include words use disorder Alcohol withdrawal, uncomplicated Alcohol withdrawal, unspecified withdrawal symptoms

13 If you do make a Substance Use Disorder Diagnosis Alcohol Use Disorder, Alcohol Withdrawal, Cannabis Use Disorder, Polysubstance Abuse, etc. please remember that the patient needs face to face follow-up office or video visit within 14 days to address the same diagnosis Follow-up visit can be in Primary Care, CDS, or Psychiatry Telephone visits do not count This applies to index diagnoses made on/after January 1st of each calendar year

14 If you do make a Substance Use Disorder Diagnosis

15 Substance Use Disorder Diagnosis A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 2 (or more) of the following, occurring within a 12-month period

16 Substance Use Disorder Diagnosis Impaired control: (1) taking more or for longer than intended (2) unsuccessful efforts to stop or cut down use, (3) spending a great deal of time obtaining, using, or recovering from use (4) craving for substance

17 Substance Use Disorder Diagnosis Social impairment: (5) failure to fulfill major obligations due to use (6) continued use despite problems caused or exacerbated by use (7) important social, occupational, recreational activities given up or reduced because of substance use.

18 Substance Use Disorder Diagnosis Risky use: (8) recurrent use in hazardous situations (9) continued use despite physical or psychological problems that are caused or exacerbated by substance use. Pharmacologic dependence: (10) tolerance to effects of the substance (11) withdrawal symptoms when not using or using less

19 Substance Use Disorder Diagnosis Severity Mild is suggested by the presence of 2-3 symptoms Moderate by 4-5 symptoms, Severe by 6 or more symptoms.

20 E-consult to CDS

21 E-consult to CDS If you click the button that says, Pt is not willing to accept referral and does not want to be contacted by phone Please keep in mind that the patient will be sent an outreach letter by CDS. If you believe patient will be offended by receiving such a letter, then do not submit e-consult

22 E-consult to CDS Therapist will call twice within hours after receiving e-consult If patient doesn t call back, chart will be closed in 5 days

23 ALCOHOL ( ETHANOL)

24 Mechanism of action ( acute stages ) Ethanol is the allosteric modulator of g-aminobutyric acid A (GABAA) receptors. Alcohol renders its central effects (eg, anxiolytic, sedative, anticonvulsant, and motor coordination impairment) mainly through its agonistic effect on GABAA receptors primarily in the cerebral cortex, medial septal neurons, and hippocampal neurons. Direct inhibitory effect on N-methyl-Daspartate (NMDA) receptors, thus reducing excitatory glutamatergic transmission. It also disinhibits GABA-mediated dopaminergic-projections to the ventral tegmental area (VTA), leading to increases in extracellular dopamine (DA) in the nucleus accumbens (NA), which are likely responsible for the initially pleasurable effects of alcohol and for the impulse to drink more

25 Mechanism of action ( Late stages ) The development of alcohol tolerance with chronic ethanol use is a neuroadaptive process (to reduce the acute effects of alcohol and provide homeostasis)

26 Kattimani S, Bharadwaj B. Clinical management of alcohol withdrawal: A systematic review (07/2013)

27 Alcohol withdrawal syndromes

28 Early Alcohol Withdrawal Starts in 6-24 hours after last use of alcohol SYMPTOMS Tremor ( usually generalized, coarse ) the earliest and most common sign, worsen with motor activity or emotional stress Irritability Nausea Anorexia Increased reflexes

29 Alcohol withdrawal seizures (Rum Fits ) Withdrawal seizures begin on the first day. Seizures typically occur between 12 and 36 hours after the last drink When a patient in withdrawal has a seizure, other causes of seizures, such as head injuries, bleeding should be ruled out before the diagnosis of withdrawal seizures is made Seizures during alcohol withdrawal are primarily generalized, with fewer than three seizures occurring per withdrawal episode

30 Alcohol withdrawal seizures Usually generalized major motor (grand mal) 25% are multiple 2-3% go onto status epilepticus Heightened sensitivity to photic (light) stimulation during period of seizure vulnerability 30% of patients having withdrawal seizures go onto DT s

31 Markers associated with withdrawal seizures Low Mg++ Respiratory alkalosis Hypoglycemia High Na+

32 Alcoholic Hallucinosis Begin on the first day, peaking about hours afterhours after the last drink Usually primary auditory, less frequent visual Sensorium is clear and VS are stable Some signs of early withdrawal might present

33 Late Withdrawal ( Delirium Tremens, DT) hours after drinking has stopped Profound confusion and misperceptions Disorientation Hallucinations: auditory, visual and tactile Paranoid delusions Motor hyperactivity Tremor, restless, agitated, increased reflexes Autonomic hyperactivity Tachycardia, profuse sweating, dilated pupils Mortality is 10-15% if untreated, 1-2% if treated

34 Kindling Becker HC. Kindling in alcohol withdrawal ( 1998)

35 Predictors of complicated withdrawal Previous episodes of alcohol withdrawal, regardless of severity Previous episodes of alcohol withdrawal seizures Previous episodes of Delirium Tremens(DT) Previous admissions for Alcohol Detox/Rehab treatment Previous episodes of blackouts Use of other downers ( benzodiazepines or barbiturates) during the last 90 days Use any other substance of abuse during the last 90 days BAL>200 Evidence of increased autonomic instability ( HR>120,tremor, sweating, agitation, nausea)

36 Markers associated with complicated withdrawal Low platelets count Low level of potassium High blood level of homocysteine

37 The patient is a 65 yo male with a long Hx of alcohol use. He is a treatment-adherent patient and usually follows your recommendations. He is receptive to your suggestion that he decrease his alcohol consumption; however he still drinks 5-6 drinks daily. He mentioned that recently he increased his alcohol use due to his upcoming retirement and concerns about his life. He understands that his alcohol use is becoming more problematic and he would like to stop at least for some time, to see if he feels any differently. He insists that he will do whatever you tell him, and he will follow all your recommendations but he is not willing to go to any outpatient treatment program. His last drink was last night about 6 beers... BP: 140/95 HR: 105 He is anxious, and fidgety, with some beads of sweat obvious on his forehead, and an intention tremor. He is alert, oriented x3, denies HA, nausea, auditory, visual, or tactile hallucinations.

38 What will you decide next? 1. Great, we can manage his symptoms as outpatient Lorazepam (Ativan) 1 mg q 4 hours, Thiamine 100 mg, Folic Acid 1mg 2. Refer to AA meetings in the area 3. He requires referral to CDRP 4. He requires referral to CDS 5. Send him to the ER 6. Tell him to go home and continue drinking, but in moderation Great, we can manage his s... Refer to AA meetings in the... 0% 0% 0% 0% 0% 0% He requires referral to CDRP He requires referral to CDS Send him to the ER Tell him to go home and con...

39 Clinical Institute Withdrawal Assessment of Alcohol Scale (CIWA)

40 Clinical Institute Withdrawal Assessment of Alcohol Scale (CIWA) This 10 item scale scores the severity of a patient s Nausea and vomiting, paroxysmal sweats, agitation, headache, anxiety, tremor, sensory disturbances(visual, tactile, auditory) and orientation. Scores: 0-7, except orientation: 0-4 Maximum score : 67

41 Clinical Institute Withdrawal Assessment of Alcohol Scale (CIWA) Mild: < 8, no medication required Moderate: 8-15 can be managed as outpatient Severe: > 15 or history of complicated withdrawal, active suicidal ideation, unstable medical conditions: inpatient treatment

42 Nausea Vomiting "Do you feel sick to your stomach? Have you vomited?" Observation. 0 no nausea with no vomiting 1 mild nausea with no vomiting intermittent nausea with dry heaves constant nausea, frequent dry heaves and vomiting

43 Tremor Arms extended and fingers spread apart. Observation. 0 no tremor 1 not visible, but can be felt fingertip to fingertip moderate, with patient's arms extended severe, even with arms not extended

44 Paroxysmal sweats Observation. 0 no sweat visible 1 barely perceptible sweating, palms moist beads of sweat obvious on forehead drenching sweats

45 Anxiety "Do you feel nervous?" Observation. 0 no anxiety, at ease 1 mild anxious moderately anxious, or guarded, so anxiety is inferred equivalent to acute panic states as seen in severe delirium or acute schizophrenic reactions

46 Agitation Observation. 0 normal activity 1 somewhat more than normal activity moderately fidgety and restless paces back and forth during most of the interview, or constantly thrashes about

47 Tactile Hallucinations "Have you any itching, pins and needles sensations, any burning, any numbness, or do you feel bugs crawling on or under your skin?" Observation 0 none 1 very mild itching, pins and needles, burning or numbness 2 mild itching, pins and needles, burning or numbness 3 moderate itching, pins and needles, burning or numbness 4 moderately severe hallucinations 5 severe hallucinations 6 extremely severe hallucinations 7 continuous hallucinations

48 Auditory Hallucinations "Are you more aware of sounds around you? Are they harsh? Do they frighten you? Are you hearing anything that is disturbing to you? Are you hearing things you know are not there?" Observation 0 not present 1 very mild harshness or ability to frighten 2 mild harshness or ability to frighten 3 moderate harshness or ability to frighten 4 moderately severe hallucinations 5 severe hallucinations 6 extremely severe hallucinations 7 continuous hallucinations

49 Visual Hallucinations Does the light appear to be too bright? Is its color different? Does it hurt your eyes? Are you seeing anything that is disturbing to you? Are you seeing things you know are not there?" Observation. 0 not present 1 very mild sensitivity 2 mild sensitivity 3 moderate sensitivity 4 moderately severe hallucinations 5 severe hallucinations 6 extremely severe hallucinations 7 continuous hallucinations

50 Headache, fullness in head "Does your head feel different? Does it feel like there is a band around your head?" Do not rate for dizziness or lightheadedness. Otherwise, rate severity. 0 not present 1 very mild 2 mild 3 moderate 4 moderately severe 5 severe 6 very severe 7 extremely severe

51 Orientation "What day is this? Where are you? Who am I?" 0 oriented and can do serial additions 1 cannot do serial additions or is uncertain about date 2 disoriented for date by no more than 2 calendar days 3 disoriented for date by more than 2 calendar days 4 disoriented for place/or person

52 The patient is 50 yo male, with a long Hx of alcohol use. The patient came today for scheduled follow up. However he reports that he left work early because he had a seizure. The patient denies any previous episodes of seizures. He mentioned that it looks like I fell maybe once recently I got some bruises, but he is vague about details. BP: 165/120, HR: 125 He insists he forgot to take his blood pressure medication today. He reports having nausea, and HA, his hands are tremulous, he looks uncomfortable, is covered with sweat, and is asking for you to close the shades in the office because light is too bright. He is scanning the room suspiciously.

53 What will you decide next? 1. Great, we can manage his symptoms as outpatient Lorazepam (Ativan) 1 mg q 4 hours, Thiamine 100 mg, Folic Acid 1mg 2. Refer to AA meetings in the area 3. He requires referral to CDRP 4. He requires referral to CDS 5. Send him to the ER 6. Tell him to go home and continue drinking, but in moderation

54 Send patient to ER SBP > 160 or Pulse > 120 RR > 35 or < 10 Temp > degrees or 38C

55 TREATMENT ALCOHOL WITHDRAWAL

56 Treatment : Benzodiazepines The Gold Standard in the treatment of alcohol withdrawal syndromes Excellent cross-coverage with all CNS-depressant agents (i.e., alcohol, barbiturates, benzodiazepines). Effective in ALL facets and degrees of alcohol withdrawal syndromes (e.g., decreases the frequency and intensity of seizures, tremors, and DTs).

57 Treatment : Benzodiazepines Chlordiazepoxide (Librium) (taking into account active metabolites). In cases of severe liver disease, and in the elderly, consider intermediate agents,either Lorazepam (Ativan) or Oxazepam (Serax). These two agents are recommended given they are metabolized via glucuronidation (usually unaffected by hepatic failure), and have no active metabolites.

58 Chlordiazepoxide ( Librium ) taper Day 1-2 : 25 mg every 6 hours, may use additional 1 capsule as needed every 6 hours for withdrawal symptoms not adequately treated by above Day 3: 25 mg every 8 hours Day 4: 25 mg every 12 hours Day 5: 25 mg daily Additional dose might be needed at bed time to treat insomnia Day 6: d/c

59 Lorazepam ( Ativan ) taper Day 1-2 : 1 mg every 6 hours, may use additional 1 tab as needed every 6 hours for withdrawal symptoms not adequately treated by above Day 3: 1 mg every 8 hours Day 4: 1 mg every 12 hours Day 5: 1 mg daily Additional dose might be needed at bed time to treat insomnia Day 6: d/c

60 Stop Medication If patient becomes Hyper somnolent Difficult to arouse Shows signs of respiratory depression Confused and disoriented

61 Vitamin Supplementation Thiamine 100 mg PO daily Folate 1 mg PO daily Multivitamin, 1 tab PO daily

62 BRIEF INTERVENTION (BI)

63 US Adults Drinking patterns NIH : national Institute on alcoholism and alcohol abuse. Helping patients who drink too much. A clinician s guide

64 State your conclusion and recommendation clearly: You are drinking more than is medically safe. Relate to patient s concerns and medical findings, if present. I strongly recommend that you cut down (or quit). Are you willing to consider making changes in your drinking? Is the patient ready to commit to change at this time? YES NO

65 NO. Do not be discouraged ambivalence is common. Your advice has likely prompted a change in your patient s thinking, a positive change in itself. With continued reinforcement, your patient may decide to take action. For now, Restate your concern about his or her health. Encourage reflection: Ask patients to weigh what they like about drinking versus their reasons for cutting down. What are the major barriers to change? Reaffirm your willingness to help when he or she is ready.

66 YES Help set a goal: Cut down to within maximum limits or abstain for a period of time. Agree on a plan: what specific steps the patient will take (e.g., not go to a bar after work, measure all drinks at home, alternate alcoholic and nonalcoholic beverages, include food ) how drinking will be tracked (diary, kitchen calendar) how the patient will manage high-risk situations who might be willing to help, such as a spouse or nondrinking friends Joining Alcoholics Anonymous(AA) or another mutual support group is a way to acquire a network of friends who have found ways to live with-out alcohol

67 Alcoholics Anonymous(AA) 2 meetings a week at SSF, Thursday, Friday, 8pm-9pm Women AA meeting at CDS, every Thursday at 12-1 pm

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71 BI STEPS 3. Enhance motivation to change Ask readiness and confidence scales DIALOGUE/PROCEDURES Confidence Scale On a scale from 0-10, how confident do you feel to make these changes? A 10 would mean total confidence and a 0 means no confidence at all. What needs to happen for you to feel more confident? What have you successfully changed in the past? How? Could you use these methods to help you with the challenges of this change?

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74 MEDICATION FOR ALCOHOL USE D/O

75 Naltrexone (Depade, ReVia, Vivitrol) Opioid antagonist that reduces heavy drinking and craving, may improve abstinence from alcohol. Contraindications : current opioid medication, positive urine opioid screen, acute opioid withdrawal, acute hepatitis, liver failure. Dose : mg daily, might consider 25 mg BID with meals to avoid nausea during fist week. Common AE: Nausea, Vomiting, HA, Fatigue, Insomnia, Somnolence

76 Disulfiram (Antabuse) Interferes with degradation of alcohol, resulting in accumulation of acetaldehyde, which, in turn, produces a very unpleasant reaction including flushing, nausea, and palpitations if the patient drinks alcohol. Abstinence is the treatment goal Abstinence >24 hours, or blood or breath alcohol level is zero Capacity to appreciate risks and benefits Most effective with monitored administration Contraindications : Severe cardiovascular, respiratory or renal disease, severe hepatic dysfunction, transaminase >5 times upper limits, severe psychiatrist disorders, cognitive d/o, poor impulse control, use of metronidazole, ketoconazole

77 Disulfiram (Antabuse) Dose : 250 mg once daily (125 mg initially to reduce adverse effects ) Major AE: Hepatotoxicity, Peripheral neuropathy, Psychosis, Delirium, Severe Disulfiram Ethanol reaction Common AE: Somnolence, Metallic taste, HA

78 Acamprosate (Campral) Acts on the GABA and glutamate neurotransmitter systems First line for patients with liver disease Contraindication : severe renal impairment (CrCl<30 ml/min) Dose : 666 mg TID ( two 333 mg tab) Major AE: Suicidality Common AE: Diarrhea, Anxiety, Insomnia

79 Topiramate Works by increasing inhibitory (GABA) neurotransmission and reducing stimulatory (glutamate) neurotransmission. Can reduce drinking and increase abstinence Dose : mg daily, start with 25 mg daily AE: Paresthesia, Anorexia, Difficulties concentrating, Dizziness, Psychomotor and Cognitive slowing

80 Monitoring GGT ( gamma glutamyl trabsferase ) AST, ALT Serum CrCl, Bicarbonate CDT ( Carbohydrate Deficient Transferrin )

81 References : Maldonado JR, Sher Y, Das S, Hills-Evans K. Prospective Validation Study of the Prediction of Alcohol Withdrawal Severity Scale (PAWSS) in Medically Ill Inpatients: A New Scale for the Prediction of Complicated Alcohol Withdrawal Syndrome. Alcohol and Alcoholism, 2015, 50(5) Maldonado JR. An approach to the patient with substance use and abuse. Medical Clinics of North America Volume 94, Issue 6, November 2010, Stephens JR, Liles EA, Dancel R, Gilchrist M, Kirsch J, DeWalt DA. Who needs inpatient detox? Development and implementation of a hospitalist protocol for the evaluation of patients for alcohol detoxification. J Gen Intern Med Apr;29(4): Lee J, Kresina TF, Campopiano M, Lubran R, Clark HW. Use of pharmacotherapies in the treatment of alcohol use disorders and opioid dependence in primary care. BioMed Research International, Volume Becker HC. Kindling in alcohol withdrawal. Alcohol Health Res World. 1998; 22(1): Kattimani S, Bharadwaj B. Clinical management of alcohol withdrawal: A systematic review. Industrial Psychiatry J Jul;22(2): NIH, National Institute on Alcohol and Alcoholism. Module 10H: Ethnicity, Culture and Alcohol. Retrieved 02/21/17 Helping patients who drink too much. A clinician s guide. NIH : national Institute on alcoholism and alcohol abuse. Retrieved 03/10/17.

82 QUESTIONS?

83 Please sign the attendance sheet in the room to claim your credit. Please complete the Online Survey: This survey will be ed to participants and will close within 10 days of the date the was sent.