Learning Objectives At the end of this workshop you should be able - - PDF document

10/15/2018 1

Management of the Hospitalized Patient with an Alcohol Use Disorders: Case Workshop

Soraya Azari, MD

Learning Objectives

• At the end of this workshop you should be

able to…

• 1. Feel confident in how to do an effective screen

for alcohol use disorders

• 2. Be familiar with how to manage common

complications of the alcohol withdrawal syndrome (AWS)

• 3. Be able to counsel patients on a menu of

different treatment options for alcohol use disorder (besides just AA)

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Format

• Real cases
• Q&A design
• Learn from peers
• Practice skill

Case 1

• Mr. H is a 57yo M teacher with a history of HTN, obesity,

and diabetes presenting to the emergency department with epigastric pain and vomiting. ROS is notable for recent weight loss and occasional numbness in his feet.

• Meds: HCTZ‐lisinopril 12.5‐10mg, metformin 500mg BID
• Exam: well‐kempt withdrawn M, in distress from pain and

nausea w/TTP epigastric area w/no rebound or guarding

• FH: father with “cirrhosis”
• Labs are notable for:

– Hb 11.5, lipase 95, creat 1.4 (baseline normal), glu 252, Ca 9.0, BUN 58, Mg 1.3, AST 91, ALT 45

• Abdominal CT: stranding around pancreas c/w pancreatitis

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Question

• Q1: How do you screen for alcohol use

disorder?

• Q2: What are considered safe limits for

alcohol use?

• Q3: What is considered a standard drink?
• Q4: How good are providers at making the dx
• f use disorders in hospitalized adults?
• Q5: How prevalent are alcohol use disorders?

How to Screen

• Ask permission
• Single question screener (for primary care!):

– How many times in the past year have you had more than 5 (4) drinks in a day?

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What’s a Standard Drink?

In the U.S., a standard drink is any drink that contains about 14 grams of pure alcohol (about 0.6 fluid ounces or 1.2 tablespoons).

Rethinking Drinking: Alcohol and your health. Available at: www.niaaa.gov

What I hear:

Patient: “one 2‐11”… Me: 24 oz. of steel reserve = malt liquor (stronger!), so 12oz beer = 8 oz malt liquor, so 1 beer = 3 drinks Others: St. Ides, Colt 45, Old E *craft beers Patient: “just a pint a day” Me: 1 pint = ~13 oz 1.5 oz = 1 drink, so Just a pint = 8 ½ drinks

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Others

“fifth a day” “Handle a day”

Me = 17 drinks per day Me = 40 drinks per day

How to Screen

• Ask permission
• Single question screener:

– How many times in the past year have you had more than 5 (4) drinks in a day?

• NONE  reinforce safe drinking limits
• ≥1 

– What do you like to drink? – Assess amount: average drinks/day, average days/week

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• 4Rs

– Risk of bodily harm – Relationship trouble – Role Failure – Repeated attempts to cut back

• 4Cs

– Loss of Control – Continued use despite harm** – Compulsion – Craving

What if they screen positive?

Tolerance** Withdrawal

DSM-5 Criteria for Substance Use Disorders Recommendations and Rationale

Source: Am J Psychiatry. 2013;170(8):834-851.

a One or more abuse criteria within a 12-month period and no dependence diagnosis; applicable to all substances except

nicotine, for which DSM-IV abuse criteria were not given.

b Three or more dependence criteria within a 12-month period. c Two or more substance use disorder criteria within a 12-month period. d Withdrawal not included for cannabis, inhalant, and hallucinogen disorders in DSM-IV. Cannabis withdrawal added in DSM-5.

Loss of Control Compulsion

Consequences

Craving Compulsion

Risk bodily harm

Relationship trouble

Role Failure

Repeated try Cut back

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What are healthy limits?

• Men: 4 and 14
• Women, >65: 3 and 7

How Common?

30% risky

From Saitz NEJM; Holt et al Am J Addiction Mar 2012

6% alcohol abuse 4% alcohol Dependence (M>F)

Alcohol: 17% screen pos risky use  77% of those are dependent

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• In the hospital: 64% detected of the time
• In the clinic: <50% of patients screened
• Physicians are less likely to detect alcohol problems:
• When screening tools are not used universally
• In patients who they do not expect to have alcohol

problems (women, white, higher SES)

How good are we at detecting substance use in our patients?

Holt et al Am J Addiction Mar 2012. Fleming MF Alcohol Health Res World 1997.

Screening & Stigma

• People with alcohol use disorders (AUD) are highly

stigmatized

– Systematic review of extent of stigma for alcohol use disorder compared to other mental illnesses

• Blame: ~60% people say the person is to blame for the AUD v. 33% in

eating disorders and 4‐13% w/ depression

• Danger: 71% of people consider it likely for an alcohol‐dependent

person to hurt others v. 33% w/depression

• Social distance: not my neighbor AUD >> schizophrenia >> depression
• How to uproot stigma

– Language: person with alcohol use disorder – Education: learn from your patients (humbly); encourage equality between physical and mental illness; educ care team – Compassion: walk in their shoes; focus on the positive – Support/offer treatment for ALL patients

• Now: 8% of 15million needing treatment got it

Schomerus G et al. 2010 Alcohol and Alcoholism;46(2):105‐12. NAMI website.

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Question

• Q1: How do you screen for alcohol use disorder?

Single question screener, though hospitalized population has high prevalence use disorders

• Q2: What are considered safe limits for alcohol use?

4/d and 14/wk (men), 3/d and 7/wk (women, persons >65)

• Q3: What is considered a standard drink? Drink

containing 14g alcohol

• Q4: How good are providers at making the dx of use

disorders in hospitalized adults? Generally poor

• Q5: How prevalent are alcohol use disorders? 5‐10%

general population; ~15% of hospitalized patients

Case Continued

• Mr. H feels so ashamed that he’s in the hospital. He just got

his job back as an english teacher and he’s really been enjoying it, but his divorce proceedings have been extremely difficult for him.

• He says that after work he drinks 1‐2 bottles of wine per

night, but this past week (school recess), he had 2‐3 bottles per night, which is more than his usual amount. He has been drinking heavily since age 40.

• He has been drinking more than usual over time, it is part
• f the reason for his divorce, he has tried to quit multiple

times, and overall says he’s been doing well until this

• episode. He says he used to drink a fifth of vodka per day,

but then when his wife left him (8 mos ago), he went to a “detox program.” He was abstinent of alcohol, but in the past 2‐3 mos has resumed drinking wine only.

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Case Continued

• Mr. H feels so ashamed that he’s in the hospital. He

just got his job back as an English teacher and he’s really been enjoying it, but his divorce proceedings have been extremely difficult for him.

• He says that after work he drinks 1‐2 bottles of wine

per night, but this past week (school recess), he had 2‐3 bottles per night, which is more than his usual amount.

• He has been drinking more than usual over time, it is

part of the reason for his divorce, he has tried to cut back multiple times, and overall says he’s been doing well until this episode. He says he used to drink a fifth of vodka per day, but then when his wife left him (8 mos ago), he went to a “detox program.” He was abstinent of alcohol, but in the past 2‐3 mos has resumed drinking wine only.

Risk of bodily harm Relationship trouble Role Failure Repeated attempts to cut Back Loss of Control Continued use despite harm** Compulsion Craving Tolerance** Withdrawal

Case Continued

• The patient is admitted to your medicine

service for pancreatitis. He is admitted to your medicine service and given: IVF, bowel rest, analgesics, and was put on “observation” for the alcohol withdrawal syndrome.

• HD 2 he seemed more tremulous and anxious,

but said that was due to ongoing nausea and headache from his pancreatitis. VS were notable for BP 185/92 and HR 105.

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Question

• Q1. What are the primary risk factors for

developing the alcohol withdrawal syndrome (AWS)?

• Q2. Are you concerned about AWS in this

patient? Why?

• Q3. What patients and what dose do you use for

prevention of Wernicke’s encephalopathy?

• Q4. What medications represent standard of care

for AWS?

• Q5. What is the “time course” for the alcohol

withdrawal syndrome?

Alcohol Withdrawal Syndrome

• 1024 ambulatory patients undergoing detoxification  3.7%

hallucinosis, 1.2% seizures, 1% DTs

• Admitted etoh‐dependent hosp patients: 5‐20% require meds
• Risk factors for severe AWS or DTs:

– Age >40 – Heavy drinking >8 years – Drinking >100g etoh daily (i.e., 1 pint) – Symptoms/signs of withdrawal when not drinking – Random BAC >200mg/dL – Elevated MCV – Elevated BUN – Cirrhosis

• No predictors perform well; assessing signs, symptoms, and using

clinical judgment is best

Whitfield CL, et al. JAMA. 1978;239:1409‐10. Blondell, R. Am Fam Physician 2005;71(3):495‐502. Saitz JAMA IM 2018.

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Risk Factors for AWS

• Prediction of Alcohol Withdrawal Severity

Scale (PAWSS)

• AUDIT‐PC

– Retrosp case control – 239 developed withdrawal – Score ≥4 – 91% sens, 89% spec for AWS – +LR 9

Pecoraro A et al. JGIM 2014

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AWS

5‐10%

“Complicated AWS:” withdrawal seizures, alcoholic hallucinosis, DTs

Ohio State University Protocol. Available at: https://evidencebasedpractice.osumc.edu/Documents/Guidelines/AlcoholWithdrawal.pdf

DSM‐5: Cessation or reduction alcohol + 2 or more: autonomic hyperactivity, inc hand tremor, Insomnia, n/v, transient hallucinations (aud, vis, tactile), psychomotor agitation, anxiety, GTC seizures

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Fuster and Samet. 2018 NEJM

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Other Complications

• Wernicke’s Encephalopathy

– UNDER‐recognized disease

• 80% of cases not found prior to autopsy
• 16% of patients have classic “triad” of oculomotor abnormalities,

cerebellar dysfunction, and confusion

• Suggestion to use 2 of the following:

– Dietary deficiencies – Oculomotor abnormalities – Cerebellar dysfunction – Altered mental state or impaired memory

– Common

• Found in 20‐35% of patients with “alcoholism”
• At risk: recent weight loss, other nutritionally‐related conditions,

recurrent vomiting past month, high carb intake

Thompson, Guerrini, and Marshall. Practical Gastroenterology 2009 Thompson, Guerrini, and Marshall. Practical Gastroenterology 2009

Patients at risk for WE: thiamine 250‐500mg IM x3‐5d [recommended for use in Europe]

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Other Complications

• Med Toxicity

Long et al. Am J of Emergency Medicine 2017;35:1005‐1011

Phenobarbital 5min (peak 20) 3‐4 days 65, 130 or 260mg IV boluses (or infusion)

Other Complications: Adjunctive Meds

• Dexmedetomidine

– Centrally‐acting alpha‐2 agonist – Use: adjunct to BZDs for treatment of alcohol withdrawal. Never used as monotherapy. Observed to dec BZD use, dec intubation, dec LOS – Cons: hypotension, bradycardia

• Phenobarbital

– Increases frequency of GABA channel opening and duration AND inhibits glutamate receptor activity – Use: BZD‐resistant withdrawal or DTs – Cons: hypotension, respiratory depression

• Propofol

– Potentiates GABA receptor, NMDA receptor antagonist – Use: refractory DT with withdrawal, especially if intubation is required – Cons: ICU LOC

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Question

• Q1. What are the primary risk factors for developing the

alcohol withdrawal syndrome (AWS)? Age, hx detoxification, large quantity and duration of use

• Q2. Are you concerned about AWS in this patient? Why? He

meets DSM‐criteria for AWS

• Q3. What patients and what dose do you use for

prevention of Wernicke’s encephalopathy? Given his high risk features (neuropathy, recent wt loss, would give high dose parenteral dose for prevention (250 or 500mg IV/IM x3d)

• Q4. What medications represent standard of care for AWS?

Benzodiazepines

• Q5. What is the “time course” for the alcohol withdrawal

syndrome? Hallucinations (12‐24h), Seizures (12‐48h), DTs (starts 3d)

Case Continued

• Mr. H is diagnosed with alcohol withdrawal

syndrome and started on a symptom‐driven CIWA protocol.

• He receives ~10mg lorazepam the first day with

good response in terms of his symptoms.

• He continues to receive supportive care for his

pancreatitis and gradually has improved and challenged with a PO diet.

• He receives a decreasing dose of lorazepam while

hospitalized with you.

• You begin discharge planning.

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Referral to Treatment: Levels of Care

Detox

Hospital MAD Ambulatory MAD Residential MAD Social Model

Relapse Prevention

Residential Intensive Outpatient Outpatient with MAT (i.e. methadone) 12 Step/ Peer Office- Based, including Medication Mgmt

MAD = Medically Assisted Detoxification MAT = Medication Assisted Treatment

Outpatient w/o MAT

Can it work?

• Psychosocial treatments

– 482 patients with AUD, survey to those in public/private treatment (371) v. not (111)

• 30d abstinent (1yr): 57% (v. 12%)
• No binge drinking, psychosocial problems, or alcohol

dependence symptoms: 40% in treated group v. 23% in untreated group

– Lots of options for relapse prevention – not once‐ size‐fits‐all

Weisner et al. 2003 Addiction;98(7):901‐11

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Meds to treat alcohol use disorder

Increase abstinence

• Acamprosate
• Gabapentin*
• Baclofen*

Decrease binges

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

*not FDA‐approved

Med Options: FDA Approved

• Disulfiram

– Who: increase abstinence; high incentive for abstinence – Dose: 250‐500mg daily, best if observed dosing – Side‐effects: sedation (8%), disulfiram reaction

• Naltrexone (PO or IM)

– Who: decrease binge drinking & increase abstinence. NOT on opioids. LFTs <3‐ 4x ULN – Dose: 25mg PO x3d, then 50mg PO x3d, then 100mg (if needed). IM injection is 380mg q mo. – Outcomes:

• PO: dec return to drinking (NNT=20) and dec binge drinking (NNT = 12)
• IM: 1 RCT showing dec in binge drinking days from 13/mo  3/mo in naltrexone arm

(6/mo in placebo arm)

• Acamprosate:

– Who: increase abstinence; safe in liver dz – Dose: 1998mg/day (TID dosing) – Side effects: diarrhea (1/3) Kranzler and Soyka. JAMA 2018;320(8):815

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Med Options: NOT FDA Approved

• Baclofen

– Who: increase abstinence, esp good for those drinking heavily – Dose: 30‐180mg/d (divided 4 doses) – Side effects: (many) drowsiness, h/a, confusion, stiff muscles, sweating – Outcomes: delay in return to heavy drinking

• Gabapentin

– Who: inc abstinence, and dec heavy drinking – Dose: 900‐1800mg/day, divided – Side effects: dizziness, somnolence, ataxia, and edema – Outcomes: abstinence in gaba 900 (11%), gaba 1800 (17%) v. placebo (4%)

• Topiramate

– Who: inc abstinence, and dec heavy drinking – Dose: start 25mg/day and titrate up to 100mg BID (over 5‐6 weeks) – Side‐effects: dysgeusia, paresthesias, weight loss, cognitive impairment (NNH 12) – Outcomes: 9% absolute risk reduction heavy drinking days Kranzler and Soyka. JAMA 2018;320(8):815. Saitz JAMA IM. 2018

Fuster and Samet. 2018 NEJM

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Meds for AUD

• Who gets MAT:

– <9% of patients with AUD got one of 4 meds approved by FDA for AUD – VA system: 3.4% get meds

• Stigma & Treatment

– Increased stigma: male, non‐white, lower income, education, and previous marriage. Associated w/not accessing treatment

Kranzler and Soyka. JAMA 2018;320(8):815

Final Exercise

• Role play exercise: Counseling a patient about

medication options

– Patient: contemplative of treatments – Provider:

• Open‐ended questions: Can you tell me about

treatment experiences you’ve had in the past?

• Affirmations: It sounds like you’ve tried a lot of things
• Options: Describe the menu of options for treatment of

alcohol use disorders

– Ask – tell – Ask

• Summarize

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Summary

• Alcohol use disorders are common in patients that are

hospitalized; make sure you do universal screening of all patients

• For patients with an alcohol use disorder, the

MAJORITY will not develop the alcohol withdrawal syndrome (AWS). Consider factors that may put them at increased risk.

• Treatment of AWS is provided typically with

benzodiazepines through symptom‐driven protocols.

• Be on the alert for complications in patients with AUD

and AWS.

Summary Continued

• People with alcohol use disorder are highly

stigmatized and rarely offered medical treatment for their condition.

• Be familiar with behavioral and medication
• ptions for alcohol cessation. Treatment should

not be proscriptive; build the person’s motivation for change (no fixin’).

• Multiple medication options are available for

AUD, which you should know that characteristics

• f for counseling of patients.

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Resources

• Ohio State Guidelines:

– https://evidencebasedpractice.osumc.edu/Documents/Guidelines/Alc

• holWithdrawal.pdf
• ZSFG alcohol withdrawal protocol: http://in‐

sfghweb01/documents/SFGH_EtOH_Withdrawal_Guidelines_rv021 716.pdf

• Cleveland Clinic Review Article:

https://www.mdedge.com/ccjm/article/105413/critical‐ care/alcohol‐withdrawal‐syndrome‐medical‐patients

• JAMA IM and NEJM Review Articles:

– AUD meds: doi:10.1001/jama.2018.11406 – Alcoholic Liver Disease: DOI: 10.1056/NEJMra1715733

• Substance Use Disorder Warm Line, UCSF

– 1‐855‐300‐3595, 10a‐6pm EST M‐F