Family Physicians’Encounter with Patients Having Alcohol Use Disorder

Dr. Mohammad MataroR4, Family MedicineAga Khan Univeristy Karachi Sindh.

Objectives

• To know the primary care approach to a patient with AUD

• To review different screening tools used at primary care level for AUD

• To review the simple approaches and interventions applicable for AUD patients in primary care setting

• To learn how to manage frontline encounter of Alcohol related emergencies

• A 45-year-old man presents to the CHC after falling off a some height while repairing something

• He sprained both ankles

• The assessment nurse smells alcohol on his breath • The patient admits to having had "a couple of beers" but denies

being intoxicated • He states that he drinks 6-drinks of beer daily, after work, and

more on weekends. • He denies that alcohol is a problem for him

• History of being arrested by Police while driving one month back• History of frequent falls

Alcohol Use Disorder

• Common psychiatric disorder– Multifactorial in etiology, – Chronic in nature– Associated with a wide variety of medical and

psychiatric sequelaee

• Approx.40 % develop their first symptoms between 15 and 19 years of age

• Screening for alcohol consumption in health care settings remains lower than 50 %

• Approximately 70 % of alcoholics are heavy smokers

Risk factors

Extent of Influence

Initiation of

Drinking

Progression

Alcoholic Drinking

Environmental (familial and non familial)Personality/Temperament)

Pharmacological effects of ethanol

Initiation and Continuation of Drinking

Situation at Pakistan

The Pakistan penal code, under the Prohibition (Enforcement of Had)

Order of 1979, awards 80 lashes to those convicted

of consuming alcohol.

• Back to our patient• Approach?

Diagnostic Approach

• Diagnostic interview/examination• Screening• Behavioral assessment/Motivation

Cues From Clinical Encounter

Lab Investigations

• Breath Alcohol Concentration/BAC:  > 200 = Diagnostic ,> 400=lethal

• Gamma-GT, ALT, AST• CBC, high-density lipoprotein

cholesterol and triglyceride levels• Urinary ethyl glucuronide

Definitions

• Safe Drinking: 01 /day for women and 02 standard drinks per day for men

• Problem drinking: >07/week Or >03 per occasion for women; and >14 /week or> 04/ occasion for men

• Heavy drinking: >03 to 04 /day for women and > 05 to 06 drinks /day for men

DSM5: Alcohol Use Disorder

• Alcohol use in larger quantities or over a longer period of time than intended• Persistent desire or unsuccessful attempts to decrease or control alcohol use• Significant time spent in activities needed to obtain or use alcohol or to

recover from its effects• Cravings to use alcohol• Recurrent use that results in failure to fulfill major role obligations at home,

work, or school• Continued alcohol use despite social or interpersonal problems caused or

worsened by alcohol• Decreasing or forgoing important social, occupational, or recreational

activities due to alcohol use• Recurrent use of alcohol in hazardous situations• Use of alcohol, despite knowing that alcohol is likely causing or worsening

chronic physical or psychological problems• Physiological tolerance • Withdrawal

2 to 3 criteria for mild, 4 to 5 for

moderate, and 6 or more for severe

Screening Instruments

• The alcohol use disorders identification test (AUDIT)

• Audit C• Screen: CAGE

• Back to our patient• What is your management plan?

Management

Factors to consider– The severity of the alcohol problem– Comorbid medical and psychosocial

problems– Patient’s motivation to change

Management

• Medical assessment and advice• Realistic goals• Detoxification & withdrawal

symptom management• Rehabilitation and aftercare• Relapse prevention/ abstinence

enhancement with pharmacotherapy

Key points :Mild to Moderate AUD

1. Review quantity and frequency of current drinking2. Review personal drinking cues3. Give feedback of personal risk for alcohol-related problems4. Give explicit advice to reduce or stop drinking5. Discuss patient’s personal responsibility and choice for reducingor stopping drinking6. Find appropriate personal timing for change7. Establish a drinking goal and agree on a contract8. Set up a drinking diary9. Suggest ways for behavior modification, coping techniques, and self-help materials.10. Encourage self-motivation and optimism

• Consecutive three sessions with two weeks intervals are mandatory for maintenance and reinforcement

• No pharmacotherapy at this stage

Key points: Moderate to Severe AUD

• 02 stages:– Withdrawal, detoxification,

Complications– Interventions to maintain abstinence

Alcohol Overdose

• ABC’s• Oxygen• Glucose, Thiamine• IV, infuse fluid to support perfusion• Lavage if within 2 hours• Reffer to ER for Intubation

Acute Alcohol Withdrawal

• ABCs• Glucose• Fluids• Benzodiazepines• Diazepam: 5-10 mg PO/I/V/I/M every 6-

8 hours• B-Complex• Refer for detoxification to inpatient

settings

Long Term management

• Behavioral• Pharmacological

Treatment Intervention Primary Target Population(s)

High-risk

Alcohol Use

disorderAt risk drinking

Brief intervention

Motivational enhancement therapy

Cognitive behavioral therapy

Couples (marital) and family therapies

Community reinforcement

Behavioral Therapies

Selected References: Moyer et al. (2002) Addiction, 97: 279-292; Miller et al. (2002) Addiction, 97: 265-277; O’Farrell et al. (2000) J. Sub.Abuse Treat., 18: 51-54

Medication Target Year Approved

Disulfiram Aldehyde Dehydrogenase 1949

Research from animal models over the past 25 years has provided promising targets for pharmacotherapy

Naltrexone Mu Opioid Receptor 1994

Acamprosate Glutamate and GABA-Related

2004

Naltrexone Depot Mu Opioid Receptor 2006

Abstinence Enhancement With Pharmacotherapy

Medication Target

Topiramate GABA/Glutamate

Valproate GABA/Glutamate

Ondansetron 5-HT3 Receptor

Nalmefene Mu Opioid Receptor

Baclofen

Antidepressants

GABAB Receptor

Emerging Therapies To Prevent Relapse

Patients With Comorbid Conditions

Co-morbidities Medication(s)

AD/Depression naltrexone; sertraline

AD/Bipolar valproate; naltrexone

AUD/anxiety disorders venlafaxine (Effexor)

AD/schizophrenia clozapine (Clozaril)

AD/tobacco dependence bupropion (Zyban)

AD/cocaine dependence topiramate (Topamax)

Follow up

• Weekly or every 2 weeks for patients attempting to cut down alcohol use

• Sobriety tests: – Liver function tests, including gamma-

gt, ALT, AST.

Prevention

• Public / Institutional• Education/Awareness/Mass-Media

campaign• Reducing availability• Increasing Prices/Taxes• Legislation & Implementation• Ban on Alcohol use on public places• Proper screening during doctor Visits• Avoid Triggers

References

• BMJ 2014• AFP 2003,2014• Uptodate• Book: Clincal Guidelines in Familly

Medicine 2014

Thanks for Everything