Primary Care of Alcohol Use Disorder (Lund 5/20/2020)

Thanks to Dr. Erin Lund, who gave an excellent Grand Rounds presentation this week on the Primary Care of Patients with Alcohol Use Disorder. Dr. Lund encouraged primary care providers to be forward thinking and proactive about diagnosing and treating alcohol use disorder.

Here's the quick and dirty: 1) AUD is super common 2) Screen for AUD 3) Start with brief interventions, and 4) Offer medications when indicated. Keep reading, you'll feel much more comfortable once you have a few of Dr. Lund's tools in your toolbox.

Alcohol use disorder (AUD) is SUPER common in the US with a 12-month overall prevalence of almost 14% of adults (7% mild, 3% moderate and 3.4% severe).

• Lifetime prevalence of AUD is is 29% (13% lifetime prevalence of severe AUD)
• Men>>women, Young>old
• Alcohol is the 3rd leading cause of death from modifiable risk factors (behind smoking and obesity/poor diet)
• Genetics definitely play a role: 5-10% of women and 25% of men have a relative with AUD

A little reminder about what is considered "one drink" when you ask a patient how much they drink:

Remember, however  that different beers and wines have different alcohol contents, so it's not uncommon that people are drinking 'more' than they realize.

How much is too much?

• Binge Drinking: at least 1 day in the past 30 days with >4 drinks for a woman, >5 for man on one occasion
• Heavy Alcohol Use: binge drinking more than 5 days (in the past 30 days)
• Drinking limits (cut offs for low risk vs. high risk drinking) are based on both gender AND age. 

**Note: for people over 65, limits are the same for men and women: no more than 3 drinks/day or 7 drinks/week.

**Note also that many people you know and love meet criteria for at least a mild AUD; this may be particularly true in this land of wine country and craft beers.

DSM-5 criteria for Alcohol Use Disorder : a maladaptive pattern of substance use with 2 or more of the following 11 criteria within past 12 months (Mild 2-3 criteria, moderate 4-5, severe ≥ 6)

1. Drinking larger amounts/longer periods than intended
2. Effort/desire to cut down
3. Great deal of time spent obtaining, using, and recovering
4. Craving
5. Recurrent failure to fulfill role
6. Continued use despite social/interpersonal problems related to drinking.
7. Activities given up (social, occupational, recreational)
8. Recurrent physically hazardous behavior.
9. Continued use despite physical or psychological problems
10. Tolerance
11. Withdrawal

Why screen for risky drinking?

• It's a USPSTF Grade B recommendation 
• AUD is really common; harmful drinking is estimated at 30% in primary care practices 
• Patients with AUD have a higher risk of death by ALL causes
• Plus, they die years earlier, increased automobile crashes, accidental and intentional injury, social and legal problems
• AUD affects every organ and system in the body: from brain (sleep, mentation) to gut (gastritis, cancers) to heart (cardiomyopathy, CAD)

How to screen? Two options;
1) Single question alcohol screening test (NIAAA): How many times in the past year have you had more than  X or more drinks/day? (X=4 for a woman and X=5 for a man) (>1 is a positive screen, 82% sens, 79% specificity)
2) AUDIT-C

Addiction medicine specialists use a format called SBIRT when talking about how to intervene. (SBIRT stands for Screening, Brief Intervention, Referral to Treatment)Brief Intervention:

You can use the AUDIT C to screen, but also to guide treatment ad your intervention:

0-3: health promotion (great job, keep it up! you are drinking responsible)

4-5: moderate risk drinking, brief intervention

6-7: high risk drinking, brief intervention +/- meds +/- specialty care mgt

8-9: severe risk drinking: start meds, psychosocial intervention, specialty mgt

10-12: specialty management

Here is an example of a brief intervention called FRAMES: 

Treatment for AUD includes 1) acute treatment of AUD (intoxication and withdrawal) AND 2) chronic treatment (abstinence initiation, use reduction, and relapse prevention)

• Psychosocial: formal therapy, self/help 12-step (There are LOTS, including AA, SMART Recovery, Rescue Recovery, and more). Each have varying levels evidence and should be tailored to patient's preferences
• Local resources available HERE, click to explore what is available in Sonoma County
• Medications???

Okay, what about the meds, do they actually work? 

• Pharmacologic management of AUD is underutilized in primary care
• AUD is one of only 3 substances with THREE FDA-approved medications
• Disulfiram (aka Antabuse)
• Acamprosate
• Naltrexone (oral vs. extended release injectable)
• Only 8% of adults with AUD in the US are treated with medications!
• There are also LOTS of medications with varying degrees of evidence used (off label) for AUD, including topiramate, baclofen, gabapentin, ondansetron and sertraline (more below)

Acute Alcohol Withdrawal (AWS):

• Look for signs of sympathetic nervous system hyperactivity: HR, BP, pupils, diaphoresis, tremor
• Use the CIWA vs. Short Alcohol Withdrawal Scale (SAWS) to characterize severity of the AWS: patient scores symptoms, <12 mild AWS, >12 moderate to severe AWS
• CIWA takes 2 minutes, assess 10 (mostly subjective) symptoms
• SAWS is completed by patient, validated in the outpatient setting



SAWS, AAFP 2013

Inpatient vs. outpatient management of AWS?

• 90% of patients with AWS can be managed outpatient
• Must be able to take oral meds, return for frequent follow-up visits, have a friend/relative/caregiver to watch for red flags
• Contraindications to outpatient management: serious lab abnormalities (e.g. profound anemia), hx of withdrawal seizures or DTs, serious medical or psychiatric comorbidity, current polysubstance use
• FYI: Supervised detox (with meds rx'd by YOU for symptom management) is available at Orenda Center. Call: 707-565-7460
• There is evolving evidence for the use of both anticonvulsants (e.g. valproic acid, carbamazepine, and more, see table) and gabapentin to treat AWS

Oral medications to treat AWS (AAFP 2013)

 A little more on the FDA approved meds to treat AUD. While none have great evidence at abstinence, they all have varying evidence for reducing quantity, frequency, etc. They are worth offering in shared decision-making conversations:

• Disulfiram (Antabuse): not really recommended by Dr. Lund because it doesn't really work
• oldest med around for AUD (approved in 1949)
• makes you sick when you drink, inhibition can last for days (up to 14)
• Two blinded studies in 2014 showed no better than placebo in reducing overall ETOH consumption
• Acamprosate,  2 tabs TID (1998 mg/day), covered by PHP
• short half life: has to be dosed so frequently
• NNT 12 to return to "any drinking", can use in people who are still drinking
• may be more effective in women, particularly women with anxiety
• Naltrexone (oral vs. injectable), covered by PHP
• oral tabs 50mg daily, injectable 380 mg IM/month
• oral NNT 20 to prevent return to 'any drinking', NNT 12 to prevent return to 'heavy drinking'
• injectable: reduces number of drinking days
• cannot be combined with opiates, cannot use in cirrhosis

Other meds (non FDA approved) with emerging data for AUD

• Topiramate: A 2014 meta-analysis found it more effective than naltrexone and acamprosate, particularly for increasing abstinence and reducing heavy drinking. Dosing: start with 25mg/day titrate up slowly by 25-50mg per week. Goal: 100-300 mg/day, divided BID
• Gabapentin: 2014 RCT found reduced craving and increased abstinence. Effective dose for relapse prevention: 600 mg TID, small abuse potential (esp in opiate use disorder), can be combined with naltrexone to increase efficacy. Can be sedating.

Okay, don't you feel braver!? Go out and heal, and remember: screen, intervene, and offer meds (when appropriate).