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2/24/2017 Disclosure Diagnosis and No financial conflicts treatment of alcohol use disorder in primary care Trade names may be used for clarity Scott Steiger, MD, FACP, FASAM HS Associate Clinical Professor of Medicine and Psychiatry

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Diagnosis and treatment of alcohol use disorder in primary care

Scott Steiger, MD, FACP, FASAM HS Associate Clinical Professor

  • f Medicine and Psychiatry

UCSF-ZSFG

Disclosure

No financial conflicts Trade names may be used for clarity

Learning Objectives

You should be able to:

  • Screen for alcohol use disorder
  • Diagnose alcohol use disorder
  • ID multiple peer support options for AUD
  • ID multiple medication options for AUD

Cases…

On list for clinic this afternoon:

  • 44 yo F smoker c/o insomnia to NAL
  • 55 yo F hospital DC for hip fx
  • 56 yo M with HTN, DM, GERD, anxiety,

hypertriglyceridemia, chronic pain

  • 62 yo M homeless M with ESLD
  • 29 yo F new patient here to establish care

Who should be screened for alcohol use?

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Comorbidities with Alcohol use

Hypertension GERD Obesity Trauma DM Anemia Liver disease Depression Anxiety PTSD Insomnia **If one of above not controlled on max therapy, or you see 3-4

  • n problem list, ask about alcohol!

Screen for Alcohol Use Disorder

  • USPSTF recommends universal (category

B)

  • “Single” question 82% sensitive, 79%

specific*

– “Do you ever drink alcohol?” – “How many times in the past year have you had ___ or more drinks in a day?”

  • 4 for women or men > 65 yo
  • 5 for men < 65 yo

Smith PC, et al. J Gen Intern Med. 2009

Some stats

  • 87.6% lifetime prevalence of alcohol use

– 56.9% drank in the last month

  • ~25% binge in the last month
  • 9.2% men, 4.6% women with AUD
  • 88,000 die annually in US from alcohol

SAMHSA 2014 data. See “Alcohol Facts and Statistics” from NIAAA: http://pubs.niaaa.nih.gov/publications/AlcoholFacts&Stats/AlcoholFacts& Stats.htm http://www.nhtsa.gov/people/injury/research/pub/impaired_driving/triangle.gif

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Diagnosis of Alcohol Use Disorder

1 Had times when you ended up drinking more, or longer, than you intended? 2 More than once wanted to cut down or stop drinking, or tried to, but couldn't? 3 A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects. (See DSM-IV, criterion 9.) 4 Spent a lot of time drinking? Or being sick or getting over other aftereffects? 5 Found that drinking—or being sick from drinking—often interfered with taking care of your home or family? Or caused job troubles? Or school problems? 6 Continued to drink even though it was causing trouble with your family or friends?

NIAAA, 2016. Accessible at http://pubs.niaaa.nih.gov/publications/dsmfactsheet/dsmfact.htm

Diagnosis of Alcohol Use Disorder

7 Given up or cut back on activities that were important or interesting to you, or gave you pleasure, in order to drink? 8 More than once gotten into situations while or after drinking that increased your chances of getting hurt (such as driving, swimming, using machinery, walking in a dangerous area, or having unsafe sex)? 9 Continued to drink even though it was making you feel depressed or anxious or adding to another health problem? Or after having had a memory blackout? 10 Had to drink much more than you once did to get the effect you want? Or found that your usual number of drinks had much less effect than before? 11 Found that when the effects of alcohol were wearing off, you had withdrawal symptoms, such as trouble sleeping, shakiness, restlessness, nausea, sweating, a racing heart, or a seizure? Or sensed things that were not there?

NIAAA, 2016. Accessible at http://pubs.niaaa.nih.gov/publications/dsmfactsheet/dsmfact.htm

The 4C’s of Addiction

  • craving
  • loss of control of amount or frequency of

use

  • compulsion to use
  • use despite consequences

Diagnosis of Alcohol Use Disorder

2-3 symptoms: Mild 4-5 symptoms: Moderate 6+ symptoms: Severe Treatment Decisions Depend on Severity and patient goal

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Treatment options depend on severity

  • Mild (2-3 criteria)

– Trial of abstinence (TOA)

  • Diagnostic and therapeutic
  • Moderate (4-5 criteria)

– TOA – Peer support – Pharmacotherapy

  • Severe (6+ criteria)

– TOA medically supervised withdrawal – Peer support – pharmacotherapy

Treatment options depend on patient’s goal

  • Abstinence?
  • Reduction in # drinks?
  • Reduction in # drinking days?
  • Reduction in harm to pt from drinking?

Treatment options depend on comorbidities

  • Depression/anxiety?
  • ESLD?
  • Homeless?
  • Chronic pain on opioids?
  • Other substance use disorder?

The Case: 42 yo M +EtOH screen

42 yo M presents for txfer care HTN, insomnia. +needs 3-4 now to get “buzz” +hangovers led to missed work twice Doesn’t see EtOH as ongoing problem Any “tests” or treatment would you recommend?

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Diagnosis of Alcohol Use Disorder

1 Had times when you ended up drinking more, or longer, than you intended? 2 More than once wanted to cut down or stop drinking, or tried to, but couldn't? 3 A great deal of time is spent in activities necessary to

  • btain alcohol, use alcohol, or recover from its effects.

4 Spent a lot of time drinking? Or being sick or getting

  • ver other after effects?

5 Found that drinking—or being sick from drinking—often interfered with taking care of your home or family? Or caused job troubles? Or school problems? 6 Continued to drink even though it was causing trouble with your family or friends?

NIAAA, 2016. Accessible at http://pubs.niaaa.nih.gov/publications/dsmfactsheet/dsmfact.htm

Diagnosis of Alcohol Use Disorder

7 Given up or cut back on activities that were important or interesting to you, or gave you pleasure, in order to drink? 8 More than once gotten into situations while or after drinking that increased your chances of getting hurt (such as driving, swimming, using machinery, walking in a dangerous area, or having unsafe sex)? 9 Continued to drink even though it was making you feel depressed or anxious or adding to another health problem? Or after having had a memory blackout? 10 Had to drink much more than you once did to get the effect you want? Or found that your usual number of drinks had much less effect than before? 11 Found that when the effects of alcohol were wearing off, you had withdrawal symptoms, such as trouble sleeping, shakiness, restlessness, nausea, sweating, a racing heart, or a seizure? Or sensed things that were not there?

NIAAA, 2016. Accessible at http://pubs.niaaa.nih.gov/publications/dsmfactsheet/dsmfact.htm

42 yo M mild-moderate AUD

Mild-Moderate AUD, new to pt: Brief Intervention

  • Educate on alcohol effects

– “Can I tell you a little about how alcohol and sleep?”

  • Give the diagnosis

– “You meet criteria for Alcohol Use Disorder”

  • TOA

– Patient agrees to 2 week trial of abstinence: 8/10 confidence

  • Schedule follow-up

– made it 5 days without (“sleep was a little tough”), then family

  • reunion. 4 more nights since, 3 of them 5+ drinks.

42 yo M moderate AUD

  • Wants another TOA
  • “I’ll do it this time, doc, 10 out of 10”

Other next steps?

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PEER SUPPORT GROUPS

Something for everyone

www.aasf.org Do 12-step groups work?

  • Meta-analysis says no*
  • Project MATCH: AA as good as CBT if

facilitated to get there**

– 35% 3 y abstinence

*Ferri et al., Cochrane Syst Rev, 2006

www.smartrecovery.org

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www.refugerecovery.org

www.sfmindfulnessfoundation.org/eve nts

42 yo M moderate-severe AUD

  • 2 weeks f/u: drank again by day 3.

Increased arguments with GF. “I think I need some more help” What pharmacotherapy might you offer?

PHARMACOTHERAPY FOR AUD

There’s a pill (or a shot) for that

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Meds to treat alcohol use disorder

Maintain abstinence

  • Acamprosate
  • ?naltrexone
  • Gabapentin*
  • ?Baclofen*
  • Disulfiram**

Decrease binges

  • Naltrexone
  • Gabapentin*
  • Topiramate*
  • Baclofen*
  • Ondansetron*
  • Varenicline*

*not FDA-approved **in highly structured environment only

Maintain abstinence: acamprosate

Pro

  • Well studied: MA (n=

6915)

– NNT 9 to prevent one relapse within 8-24 wks*

  • Safe in liver dz
  • FDA-approved

Con

  • 6 pills per day
  • Contraindicated in ESRD
  • SE: diarrhea in 10-15%
  • ?mechanism
  • No help with active

drinker cutting down

*Rosner S, et al., Cochrane Database Syst Rev, 2010 Ideal candidates: post-medically supervised withdrawal, no ESRD, able to manage pills Rx: 666 mg po tid

Decrease binges: naltrexone

Pro

  • Mu-opioid antagonist

reduces endogenous reward from EtOH

– Pt “learns” not to drink too much

  • Well-studied for preventing

return to heavy drinking:

– MA (n=7793) RR 0.83* – MA (n=2875) NNT 12**

  • Safe to take with EtOH

Con

  • ?improvement in abstinence

– MA (n=2347): risk reduction 0.05 (0.1 – 0.002)

  • SE: transaminitis
  • Contraindications: opioids,

LFTs > 5x ULN

Ideal candidate: actively drinking patient not on opioids who wants help to “cut down” Rx: 50 mg po qday or 380 mg IM q4wks *Rosner S, et al., Cochrane Database Syst Rev, 2010 **Jonas DE, et al., JAMA, 2014

Maintain abstinence: disulfiram

Pro

  • Inhibits aldehyde

dehydrogenase effectively punishing EtOH intake

  • FDA-approved

Con

  • MA: n=492 no diff

placebo*

  • SE: severe hepatitis

(rare), reaction with “hidden” EtOH (mouthwash, sauce)

Ideal candidate: patient in methadone maintenance (or other clinic with DOT capability) Rx: 250 mg po qday *Jonas DE, et al., JAMA, 2014

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Decrease use OR maintain abstinence: gabapentin

Pro

  • Can be used for “detox” as well

as maintenance*

  • RCT showed incr abstinence

and reduced binge with dose- related response; NNT 8**

  • Treats common sx in patients

trying to reduce or quit drinking (anxiety, insomnia, craving)

  • Naltrexone combo works***

Con

  • Off-label for AUD
  • Abuse potential?
  • CI for RCT overlapped

placebo

  • Dose adjust for CKD

Ideal candidate: active drinker no hx seizures goal of abstinence Rx: titrate up to target dose 600 mg tid *Myrick H et al. Alcohol Clin Exp Res, 2009 **Mason BJ et al. JAMA Int Med, 2014 ***Anton RF et al. Am J Psychiatry, 2011

Decrease use OR maintain abstinence: baclofen

Pro

  • GABA-ergic
  • 2 of 3 RCT showed

improvement in achieving and maintaining abstinence in active drinkers*

  • Anti-cravings

Con

  • Off-label for AUD
  • SE: Drowsiness,

confusion?

  • Dose adjust for CKD

Ideal Candidate: active drinker with goal of reducing use open to abstinence Rx: 10 mg po tid, can titrate to 20 mg po tid (…or higher?) *Pos: Addolorato G, et al. Lancet, 2007; Addolorato G, et al. Alcohol Alcohol, 2002 Neg: Garbutt JC, et al. Alcohol Clin Exp Res, 2010

Pro

  • 12 week RCT (n=93)
  • 68% total abstinence (vs

22%)

  • Mean dose 180 mg

Muller CA, et al. Eur Neuropsychopharmacol, 2015

Con

  • 16 week RCT (n=151)
  • No diff in time to relapse

placebo, low, or high (150 mg) dose

Beraha EM, et al. Eur Neuropsychopharm, 2016

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Decrease use: topiramate

Pro

  • MA (n=691) 9% decr in

heavy drinking days and -1 drink per average day*

  • RCT: helps AUD+PTSD**
  • AED: safe in pt with sz
  • Appetite-suppression?

Con

  • Off-label for AUD
  • SE: cognitive (“Dope-

amax”)

  • Appetite suppression?

Ideal candidate: Overweight patient on chronic opioids with seizure disorder Rx: 50 mg po qhs, titrating up slowly to max of 150 mg bid *Jonas DE, et al., JAMA, 2014. **Batki SL, et al., Alcohol Clin Exp Res, 2014

Decrease use: ondansetron

Pro

  • RCT: appears to work in

certain sub-pop (“early-

  • nset” AUD, genotype)*

– Reduced 1.5 drinks per day – Reduced # drinking episodes ~10%

Con

  • Off-label for AUD
  • Can’t ID genetics
  • QT prolongation

*Johnson BA, Am J Psychiatry, 2011 Ideal candidate: young healthy pt normal QT already failed other meds

Targeting symptoms to choose meds

Anxiety: gabapentin, ?baclofen Insomnia: gabapentin, topiramate Cravings: gabapentin, baclofen, ?ondansetron, ?varenicline “I want to drink like a normal person”: naltrexone

Acute alcohol withdrawal

Benzos > placebo for seizure ppx*

  • RR 0.16
  • Symptom-triggered > fixed schedule

Phenobarbital = placebo for seizure ppx*

  • Carbamazepine > placebo, = benzos for seizure ppx in

mild to moderate + LESS DRINKING AFTER*

  • Gabapentin = benzo for seizure ppx in mild to moderate +

less drinking in RCT**

*Amato L, Cochr ane Syst Rev, 2010 **Myrick H, Alcohol Clin Exp Res, 2009

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42 yo M mod-severe AUD

  • Trial naltrexone – didn’t tolerate (mood and HA)
  • Trial gabapentin 300 mg tid – still drinking at 1

mo

  • Gabapentin 600 mg tid – 3 drinking episodes @

1 mo – SMART recovery

  • 100% Abstinent at 1 mo f/u
  • 100% Abstinent at 3 mo f/u
  • 100% Abstinent at 6 mo f/u -- +GF sign

Take home messages

  • Universal screening!
  • Diagnose before physically dependent
  • AA is not the only game in town
  • Make it a medical—not a moral—problem

Final exam

  • 56 yo homeless M with HTN, HCV, opioid

use disorder in remission on methadone with AUD in early remission after completing medically-assisted withdrawal.

Final exam

  • 56 yo homeless M with HTN, HCV, opioid use disorder in remission on

methadone with AUD in early remission after completing medically-assisted withdrawal.

  • Evidence supports which of the following

medications to increase abstinence from alcohol in this patient?

a) Topiramate b) Naltrexone c) Acamprosate d) All of the above

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Full citations for references cited (1/2)

  • Addolorato G, Caputo F, Capristo E, Domenicali M, Bernardi M, Janiri L, Agabio R, Colombo G,

Gessa GL, Gasbarrini G. Baclofen efficacy in reducing alcohol craving and intake: a preliminary double-blind randomized controlled study. Alcohol and Alcoholism Sep 2002, 37 (5) 504-508; DOI: 10.1093/alcalc/37.5.504

  • Addolorato G, L Leggio, A Ferrulli, Cardone S, Vonghia L, Mirijello A, Abenavoli L, D’angelo C,

Caputo F, Zambon A, Haber PS, Gasbarrini G. Effectiveness and safety of baclofen for maintenance of alcohol abstinence in alcohol-dependent patients with liver cirrhosis: randomised, double-blind controlled study. Lancet. 370 (2007), pp. 1915–1922

  • Anton RF, Myrick H, Wright TM, et al. Gabapentin Combined with Naltrexone for the Treatment of

Alcohol Dependence. The American journal of psychiatry. 2011;168(7):709-717. doi:10.1176/appi.ajp.2011.10101436.

  • Batki SL, Pennington DL, Lasher B, et al. Topiramate Treatment of Alcohol Use Disorder in

Veterans with PTSD: A Randomized Controlled Pilot Trial. Alcoholism, clinical and experimental

  • research. 2014;38(8):2169-2177. doi:10.1111/acer.12496.
  • Beraha EM, Salemink E, Goudriaan AE, Bakker A, de Jong D, Smits N, Zwart JW, Geest DV,

Bodewits P, Schiphof T, Defourny H, van Tricht M, van den Brink W, Wiers RW. Efficacy and safety of high-dose baclofen for the treatment of alcohol dependence: a multicentre, randomized, double-blind controlled trial. Eur Neuropsychopharmacol. 2016 Dec;26(12):1950-1959. doi: 10.1016/j.euroneuro.2016.10.006.

  • De Beaurepaire R. The use of very high-doses of baclofen for the treatment of alcohol-

dependence: a case series. Front Psychiatry October 2014. Dx.doi.org/10.3389/fpsyt.2014.00143

  • Johnson BA, Ait-Daoud N, Seneviratne C, et al. Pharmacogenetic Approach at the Serotonin

Transporter Gene as a Method of Reducing the Severity of Alcohol Drinking. The American journal

  • f psychiatry. 2011;168(3):265-275. doi:10.1176/appi.ajp.2010.10050755.

Full citations for references cited (2/2)

  • Jonas DE, Amick HR, Feltner C, Bobashev G, Thomas K, Wines R, Kim MM, Shanahan E, Gass

CE, Rowe CJ, Garbutt JC. Pharmacotherapy for Adults With Alcohol Use Disorders in Outpatient SettingsA Systematic Review and Meta-analysis. JAMA. 2014;311(18):1889-1900. doi:10.1001/jama.2014.3628

  • Mason BJ, Quello S, Goodell V, Shadan F, Kyle M, Begovic A. Gabapentin Treatment for Alcohol

Dependence: A Randomized Controlled Trial. JAMA internal medicine. 2014;174(1):70-77. doi:10.1001/jamainternmed.2013.11950.

  • Müller CA, Geisel O, Pelz P, Higl V, Kruger J, Stickel A, Beck A, Wernecke K-D, Hellweg R, Heinz
  • A. High-dose baclofen for the treatment of alcohol dependence (BACLAD study): a randomized,

placebo-controlled trial. Eur Neuropsychopharmacol, 2015. 25:1167–1177. http://dx.doi.org/10.1016/j.euroneuro.2015.04.002

  • Myrick H, Malcolm R, Randall PK, et al. A double blind trial of gabapentin vs. lorazepam in the

treatment of alcohol withdrawal. Alcoholism, clinical and experimental research. 2009;33(9):1582-

  • 1588. doi:10.1111/j.1530-0277.2009.00986.x.
  • Rösner S, Hackl-Herrwerth A, Leucht S, Vecchi S, Srisurapanont M, Soyka M. Opioid antagonists

for alcohol dependence. Cochrane Database of Systematic Reviews 2010, Issue 12. Art. No.:

  • CD001867. DOI: 10.1002/14651858.CD001867.pub3.
  • Smith PC, Schmidt SM, Allensworth-Davies D, Saitz R. Primary Care Validation of a Single-

Question Alcohol Screening Test. Journal of General Internal Medicine. 2009;24(7):783-788. doi:10.1007/s11606-009-0928-6.