Primary Care for Patients with Alcohol Use Disorder (Lund, 11/15/2023)

A recording of this presentation is available HERE. 

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Deep gratitude to our Assistant Program Director and local expert, Dr. Erin Lund, for an excellent presentation on Primary Care Management of Alcohol Use Disorder (AUD). Living in the wine country, this is a medical problem that sometimes hides in the shadows of social acceptability and cultural norms. 

Dr. Lund covered a broad range of topics related to AUD, including healthy drinking, screening for risky drinking, assessing severity of the use disorder and treatment (both acute withdrawal and chronic management). Alcohol, consumed around the world, is one of the oldest-used psychoactive substances, 2/2 only to caffeine.  There is documentation of humans indulging in alcohol dating back 9,000+ years.

(Note: much of the ETOH literature includes gender-based nomenclature. In an effort to be gender inclusive, I will use the following terms in this blogpost: AMAB: assigned male at birth, AFAB: assigned female at birth)

Healthy drinking

Standard drinks vary based on alcohol content and volume: 12 oz beer, 8-9 oz malt liquor, 5 oz wine, 1.5oz distilled spirits (see image below). Healthy drinking guidelines are based on age and gender assigned at birth: for adults under age 65, no more than 4 drinks for AMAB or 3 drinks for AFAB on any one day AND no more than 14 drinks/week for AMAB and 7 drinks/week for AFAB.

Risky Drinking

Rates of risky drinking and AUD are shockingly high in the US: 12-month prevalence of 13.9% of AUD (7% mild, 3% moderate and 3% severe) and a lifetime overall prevalence of 29%. Typically people AMAB have higher rates than people AFAB, but this is changing, as alcohol becomes more socially acceptable for AFAB patients. People ages 18-35 have the highest prevalence. 

A binge episode is defined as: 

•  >4 drinks for AFAB >5 drinks for AMAB,
• at least one day in the last 30 days

>5 days of binge drinking=HEAVY USE

Heavy use is NOT the same as AUD, but intervention should be considered, as heavy use is associated with increased all-cause mortality, earlier death, increased automobile accidents, increased accidental and intentional injuries, and social and legal problems.

Alcohol Use Disorder

DSMV outlines AUD* as "a maladaptive pattern of alcohol use" within the past 12 months, as defined by at least two of the following criteria:

• Drinking larger amounts/longer periods than intended
• Efforts/desire to cut down
• Great deal of time spent obtaining, using, recovering
• Craving
• Recurrent failure to fulfill role
• Continued use despite social/interpersonal problems related to drinking
• Activities given up (social, occupational, recreational)
• Recurrent physically hazardous behavior
• Continued use despite physical or psychological problems
• Tolerance
• Withdrawal

*Mild AUD: 2-3 criteria, moderate 4-5, severe ≥ 6

Screening for AUD

USPSTF gives a grade B recommendation to screen ALL adults for unhealthy alcohol use. Here's the good news: when we screen, it makes a difference! Patients actually cut back and change their use habits. People live longer. 

There are a variety of standardized screening tools; these include:

• 1Q screen: How many times in the past year have you had more than 4 drinks/day (AFAB) or 5 drinks/day (AMAB). Positive with answer of >1
• AUDIT-C (which is what is used at SRCH, see image below)
• 

A nice thing about using the AUDIT-C is that the results can be used to guide treatment. An AUDIT-C score of 0-3 indicates low risk drinking (no intervention needed), a score 4-5 is moderate risk (brief intervention indicated). A score 6-7 merits a brief intervention + psychotherapy and consideration of pharmacotherapy. A score of 8-9 is an indication for pharmaceutical intervention + psychosocial intervention+/-specialty care management. A score of 10+ merits urgent specialty referral.

Treatment of AUD

Treatment of AUD includes both psychosocial and pharmacological treatments. It also involves both an acute stage (active use, withdrawal) and a chronic stage (maintenance, harm reduction, reduction).

Psychosocial support involves both formal treatment programs (inpatient and outpatient programs), many of which are based in Peer Support. These include but are not limited to AA, smart recovery, etc.

Pharmacological management involves, at the minimum, 1 of 3 FDA-approved medications. These meds can be started in the inpatient or outpatient setting. We have great room to improve in this area. A study in 2012 found that only 8% of US patients with AUD were being treated with medications. 

Considerations in starting meds for patients should include goals (e.g. abstinence vs. reduced use), relevant health factors (e.g. comorbidities like chronic pain, cirrhosis, etc.), and external barriers. 

Alcohol Withdrawal Syndrome (AWS)

The slide pasted below demonstrates the timeline for Alcohol withdrawal and some recommendations in terms of who can withdraw in an outpatient setting vs. those who need inpatient support.

Alcohol withdrawal is most likely to occur in patients who have been drinking for more than 2 weeks and who have abruptly stopped drinking. Once a person is 5 days past their last drink, they are outside the window of acute withdrawal. And one can move onto the maintenance stage of management of AUD. 

Providers should use standardized scores to keep an objective assessment of a patient's alcohol withdrawal. There are several, including the CIWA (10q, objective + subjective report), the SAWS (10q, patient-completed), and the SEWS (7q, clinical assessment)

CIWA: <10: very mild AWS, 10-15 mild AWS, 16-20 modest AWS, >20 severe (DTs)

SAWS: patient scores their own symptoms in past 24 hours, <12 is mild AWS, >12 is moderate to severe AWS

SEWS

The severity of AWS dictates the level of care the patient needs. Patients with mild-moderate withdrawal can be managed in the outpatient setting, assuming they can also 1) have consistent follow-up 2) take PO meds 3) have friend/relative/support person 4) have no prior hx of DTs 5) have no high risk comorbidities (physical or psychiatric) that would make home withdrawal unsafe (e.g. extreme anemia, decompensate cirrhosis) 6) do NOT have polysubstance use.

All other patients should be managed in an inpatient setting.

Pharmacotherapy for AWS

Goal of treatment of AWS is to help patients withdraw safely (prevent DTs, seizures, death) and reduce likelihood of relapse. This can be accomplished using either benzodiazepines (e.g. chlordiazepoxide or lorazepam), which was the previous gold standard, and/or with benzo-sparing protocols, most of which use anticonvulsants and anti-adrenergic medications. 

Anticonvulsants: phenobarbital, gabapentin, valproic acid, carbamazepine

Anti-adrenergic: clonidine, propranolol, guanfacine, precedex

Everyone with AWS should get folic acid (1gm/day) and vitamin B1 (thiamine, 100mg/day)

The idea behind the benzo-sparing protocols is that these medications are AS effective in safe withdrawal with less abuse potential than benzos. There are still evolving studies in this area, and some agents have more evidence than others. These protocols vary based on location and experience. 

See below the draft algorithm (not yet live) at SRCH, which screens for patients who may safely withdraw outpatient and uses fixed dose gabapentin (300mg TID vs. 600mg TID).

Older algorithms use fixed vs. on demand dosing of lorazepam and/or chlordiazepoxide. You can find a link to those older guidelines HERE. 

Chronic Management of AUD

Okay, finally, moving onto medications that prevent relapse and/or help people cut back and/or help people remain abstinent. Most studies look at a period of time of 12-16 weeks of reduced use and/or abstinence, but in clinical practice a minimum of a year of maintenance therapy is recommended, particularly if there is a high risk of relapse.

FDA approved: naltrexone, Acamprosate, disulfiram

• Naltrexone: 50mg PO daily OR 380mg IM monthly, reduces risk to any drinking (NNT 10) and heavy drinking (NNT 12), injectable has evidence for reducing number of heavy drinking days. Reduces craving and pleasurable effect of drinking. Contraindicated in liver failure, concomitant opiate use (within 7 days). Pregnancy is relative contraindication.
• Acamprosate 333mg, 2 tabs TID daily. Reduces return to any drinking (NNT 12), reduces withdrawal associated dysphoria. Has mixed evidence on efficacy compared to placebo. Contraindicated in renal failure (GFR<30) and pregnancy. 
• Disulfiram: oldest med on the market for AUD (1949), anticipation of feeling sick discourages use. Blinded studies don't show great effect, but open label studies do show reasonable effect. 

Non-FDA approved but have some evidence: topiramate, baclofen, gabapentin, ondansetron, sertraline, semaglutide

• Topiramate: non-FDA approved, may reduce cravings, impulsivity and post-withdrawal dysphoria, 100-300mg/day (titrated up over 6 weeks from 25mg day starting dose, increase by 50 mg per week), BID dosing recommended. Contraindicated in pregnancy and renal failure.
• Gabapentin: non-FDA approved, may be continued after using for treatment of AWS, 300mg-600mg TID for maintenance dosing to reduce cravings and return to drinking