Alcohol Use Disorders in General Hospital Patients:

The Psychiatry Consultation Service Experience

Jennifer Hanner, M.D., M.P.H.

Department of Psychiatry

University of North Carolina School of Medicine

Alcohol Medical Scholars Program

(slide 1)

©AMSP 2012

 

 

I.       Introduction

A.    Alcohol Use Disorders (AUD) in general hospital inpatients (slide 2)  

1.      High Prevalence

a.       ~25% + lifetime abuse or dependence (AUD) [1, 2]

b.      ~35% trauma surgical patients  [3]

1’ ~75% with BAC ≥100 mg/dL dependent [4]

2’ >50% alcohol-related auto accidents [5]

c.       ~20% burn pts possible AUD; important because [6]

1’ AUD + burn→ 3X ↑ death [7]

2’ Also ↑ stay by 9 days 

2.      AUD very costly [8]  

a.       $166 billion/yr: ↓ productivity, crime, health costs   

b.      Comorbid  AUD ↑ stay and cost of most disorders

3.      AUD ↑ medical complications (as discussed later) (slide 3)

a.       Alcohol interacts with meds

b.      ↓ general health and nutrition

B.     This lecture will review (slide 4)

1.      Definitions

2.      Screening/evaluation

3.      Medical/psychiatric complications, comorbidity, and Rx

4.      Interventions in the hospital

 

II.    Definitions [9] (slide 5)

A.    Standard Drink (~10 grams alcohol)

1.      12 oz. beer

2.      5 oz. wine

3.      1.5oz. hard liquor (80 proof)

B.     Hazardous Drinking [10]

1.      ↑ risk of alcohol related problems

2.      Men:  >14 drinks/wk or >4 drinks/sitting (40-50g)

3.      Women:  >7 drinks/wk or >3 drinks/sitting (20-25g)

4.      Frequent consumption of ≥6 drinks/sitting

C.     Abuse—repeated problems in same 12 month period with  1+ of: (slide 6)

1.      Failure fulfilling role obligations

2.      Recurrent use in physically hazardous situations

3.      Interpersonal or social problems

4.      Legal problems

5.      (Note: not dependent on alcohol)

D.    Dependence—repeated problems in same 12 months of  > 3 criteria: (slide 6)

1.      Tolerance: need more for effects or ↓ effect with same amount

2.      Withdrawal (discussed below)

3.      Take larger amounts or longer time than intended

4.      Efforts to cut down or stop

5.      Excessive time spent drinking or recovering from effects

6.      Important activities given up

7.      Continued use despite medical or psychological problems

 

III. Screening/Evaluation of AUD’s and alcohol misuse (slide 7)

A.    Commonly undetected by physicians [2,11,12] (slide 8)

1.      Inadequate training

2.      Misperceptions, negative attitudes, stereotyping

a.       False:  ↓ socioeconomic status only

b.      True:  middle-class pt

c.       False: present with ↑ BAC only

d.      True: present with non-specific problems-insomnia, sadness

3.      Uncertain about what to do

B.     Approach to general psychiatric consultation [13] (slide 9)

1.      Discuss case directly with referring clinician to clarify questions

2.      Review available medical records, labs, radiologic tests, etc.

3.      Review meds: home, hospital, doses of prn

4.      Interview/examine patient (discussed below)

5.      Get history from collateral informant (slide 10)

6.      Order further diagnostic tests as needed

7.      Formulate assessment, diagnosis, treatment plan

8.      Discuss findings and plan directly with referring clinician

C.     Taking AUD history [11] (slide 11)

1.      Current/past patterns of use

a.       Daily drinking

b.      Binge pattern (many days of drinking, only brief interruptions)

c.       Periods of abstinence

d.      History of treatment

e.       Blackouts (awake, but no recollection of events)

f.       Withdrawal (discussed below)

2.      Detail quantity and frequency

a.       Types of alcohol

b.      Amount per day

3.      Family history--genetic and environmental effects

D.    Screening tools can help in general medical setting (slide 12)

1.      Alcohol Use Disorders Identification Test (AUDIT) [14]

a.       10 questions, scored 0-4 point value

b.      ≥8 score = hazardous drinking (Sens=98%)

c.       ≥10 = alcohol dependence (Sens=99%)

2.      Short Michigan Alcohol Screening Test (S-MAST) [15]

a.       13 questions, self-administered

b.      Accuracy=25 question MAST (Sens=>90%)

E.     Lab markers of consistent recent drink 5+ drinks/day [16,17] (slide 13)

1.      Gamma-glutamyltransferase (GGT)—most commonly used (slide 14)

a.       ↑ with heavy drinking

b.      Also ↑ in: heart disease, kidney disease, pregnancy, etc.

c.       GGT >35 may = heavy drinking, ↑ before liver damage

d.      GGT >50 may indicate liver damage

e.       Sensitivity for heavy drinking ~75%

f.       Normalizes in 4-5 weeks of abstinence (nl range= 11-48 U/L)

2.      Liver enzymes: not as sensitive as GGT (slide 15)

a.       Aspartate and Alanine Aminotransferase (AST and ALT)

b.      ALT found mainly in liver, AST in many tissues

c.       ↑ in excessive alcohol use AND liver damage

d.      Absolute value and ratio important

1’AST (14-38 U/L normal range)

2’ALT (15-48 U/L normal range)

3’ AST:ALT ratio >2 suggestive of alcohol cause

e.       Less sensitive re heavy drinking than GGT

3.      Carbohydrate deficient transferrin (CDT): =sens to GGT (slide 16)

a.       Transferrin=blood protein, transports iron to bone marrow

b.      Abnormal form produced in ↑ drinking

c.        CDT >20 g/l indicates heavy drinking

d.      Few conditions ↑ except heavy drinking

e.       Sensitivity and specificity ~75%

f.       If ↑ during abstinence may indicate relapse

4.      Mean Corpuscular Volume (MCV): not very sensitive (slide 17)

a.       Average size measure of red blood cells (nl range=80-100 FL)

b.      Size affected by heavy drinking

1’ Directly ↑ size

2’ Folic acid deficiency→ ↑ size

3’ Liver disease→ ↑ size

c.       MCV >90 cubic microns suggests possible heavy drinking

d.      MCV elevated in other conditions

F.      Signs and symptoms [18] (slide 18)

1.      Cardiac-irregular heart rhythm

a.       High alc harms striated muscle

b.      Temporary arrhythmia in >50% AUD entering Rx

2.      Abdominal

a.       Enlarged tender liver (alc hepatitis)

b.      Hardened small liver (cirrhosis-only see in 20% of AUD)

1’Ascites (abdominal cavity fluid from liver failure)

2’ Jaundice (yellow skin/eyes from liver failure)

3.      Neurologic

a.       Tremor (hangover or early withdrawal)

b.      Hyperactive reflexes/↑ pulse/ etc.

IV. Medical/psychiatric complications, comorbidity, & Rx (slide 19)

A.    Alcohol Withdrawal [5] (slide 20)

1.      Cessation (or ↓) heavy/prolonged alcohol use

2.      2+ of following within hours after cessation or ↓

                                                                                     a.      Tremor (hands, arms, legs, tongue)

                                                                                    b.      ↑ pulse

                                                                                     c.      Insomnia

                                                                                    d.      Visual, tactile, or auditory hallucinations or illusions (rare)

1’ Hallucinations: perceptions of unreal stimuli

2’ Illusions: misinterpretations of real stimuli

                                                                                     e.      Psychomotor agitation (restlessness/agitation/aggression)

                                                                                     f.      Anxiety

                                                                                    g.      Grand mal seizures (generalized tonic-clonic) (also rare)

            1’ In 1% of withdrawal

            2’ ↑ if past w/d sz, sz disorder, or brain injury

            3’ 6-48 hours after last drink

            4’ Highest risk in first 24 hours

           5’ Can have 2 sz, but prolonged sz happens in < 10%

3.      Begin w/in 6-8 hours after last drink; BAC not need be zero (slide 21)

4.      Symptoms → clinically significant distress/impair functioning

5.      Symptoms not from general medical or other mental disorder

6.      Could have Delirium Tremens (DT’s) (slide 22)

                                                                                     a.      Only 5% AUD ever have this

                                                                                    b.      Disorientation to time, place, or person

                                                                                     c.      Waxing and waning consciousness, attentiveness

                                                                                    d.      Fluctuating level consciousness/alertness

                                                                                     e.       Hyperactivity/excitation

                                                                                     f.      ↑ heart rate

                                                                                    g.      ↑ blood pressure

                                                                                    h.      Fever

                                                                                      i.      Frightening hallucinations (slide 23)

                                                                                      j.      Can be fatal if severe medical problems persist

                                                                                    k.      Onset 48-96 hours after last drink

                                                                                      l.      Highest risk if prior episodes or current medical problems

                                                                                  m.      Need rule out

1’ Low blood glucose

2’ Metabolic disorders (low Na+)

3’ Side effect (SE) of meds (e.g. anticholinergics)

4’ Head injury

B.     Treatment of withdrawal (medical detoxification) [19] (slide 24)

1.      Rule out medication SE, medical illness, etc.

2.      Benzodiazepines (e.g. diazepam [Valium]) are Rx mainstay

                                                                                     a.      Benzodiazepines: best studied, cheapest, lowest risk

                                                                                    b.      Correct major transmitter alc withdrawal problems by

1’ ↑ gamma aminobutyric acid (GABA)

2’ Sedate, ↓ seizure risk, help sleep

                                                                                     c.      Day 1 give enough to ↓ symptoms

                                                                                    d.      ↓ dose ~20% day 1 dose each day

                                                                                     e.      ↑ dose for a day if symptoms ↑, then ↓ dose next day

3.      Anticonvulsants rarely needed

C.     Clinical Case Vignette (slide 25)

1.      80 year old female: hypertension, 3 days s/p hip replacement

2.      Keeps trying to get out of bed

3.      Confused

4.      Agitated

5.      ↑ blood pressure and bilateral hand tremor

6.      Diagnosis:  alcohol withdrawal delirium (Delirium Tremens DT’s)

D.    Review of case vignette criteria for DT’s (slide 26)

1.      Symptom onset at 72 hours

2.      Confusion

3.      Psychomotor agitation

4.      ↑ blood pressure/pulse/temperature/etc.

E.     Rx recommendations for this patient (slide 27)

1.      Needs 1:1 observation for safety as long as in DT’s

2.      Multivitamin, folate 1mg daily, thiamine 100mg daily

3.      Rule out other causes of delirium

                                                                                     a.      Metabolic→recheck electrolytes (e.g. sodium)

                                                                                    b.      Review meds: anticholinergics (e.g. diphenhydramine [Benadryl])

                                                                                     c.      Check for infection (e.g. urinalysis, chest x-ray)

                                                                                    d.      Adequate pain control

                                                                                     e.      Head CT scan  if indicated to rule out head injury (e.g. fall)

4.      Rx DT’s with benzodiazepine (slide 28)

                                                                                     a.      E.g. chlordiazepoxide (Librium) or diazepam (Valium)

1’ Longer half-life=smoother withdrawal course

2’ Better seizure protection

3’ But ↑ risk over-sedation in elderly and liver impaired

                                                                                    b.      Lorazepam (Ativan)=better choice in this pt to avoid oversedation

1’ Shorter half-life = ↓ risk of over-sedation in elderly

2’ ↓ Risk if pt has liver probs because not metab in liver 

                                                                                     c.      Use pulse/bp to guide dose needed on day 1

                                                                                    d.      ↓ Dose ~10-20% of first day dose each day

                                                                                     e.      If symptoms ↑ , go back to prior day dose, then start ↓ again

5.      Additional supports used for any delirium

                                                                                     a.      Room well lit during day

                                                                                    b.       Frequent reorientation to person, place, time, situation

F.      Wernicke-Korsakoff Syndrome [20] : very rare (slide 29)

1.      Wernicke’s encephalopathy-first described in 1881

                                                                                     a.      Acute onset

                                                                                    b.      Cause: ↓ thiamine (Vit B1)

                                                                                     c.      Emergency: untreated→20% death, → 85% Korsakoff’s (see next)

                                                                                    d.      Symptom triad:

1’Confusion

2’ Ataxia (incoordination)

3’Ophthalmoplegia (eye muscle paralysis)

                                                                                     e.      Rx:  IV thiamine (to optimize absorption)

                                                                                     f.      Course:

1’ Confusion improves 1-2 days

2’ Eyes improve days to weeks

3’ Ataxia improves weeks to months

2.      Korsakoff’s Syndrome  (slide 30)

                                                                                     a.      Impaired memory in otherwise alert, responsive patient

                                                                                    b.      Patient limited insight to memory loss

                                                                                     c.      Confabulation—make up story for what has forgotten

                                                                                    d.      Memory loss

1’ Retrograde (recent past >distant past) and

2’ Anterograde (forget very recent new information)

                                                                                     e.      MRI=↓ volume thalamic nuclei, mammillary bodies, frontal lobe

                                                                                     f.      Damage can be permanent

                                                                                    g.      Early high dose IV thiamine (100mg daily)

G.    Psychiatric Disorders (slide 31)

1.      Co-morbid depression lasting longer than intoxication

a.       Gen pop severe major depressive episode (MDE) ~15%

b.      AUD  have slightly higher even when not drinking

c.       If  have MDE unrelated to drinking

1’Alcohol ↑ depressive symptoms

2’ EtOH intox/withdrawal ↑ suicidal ideation

d.      Alcohol induced depression: severe intoxication → temporary MDE in ~30% (slide 32)

1’ Psychiatric disorder did not predate AUD

 2’ Primary treatment = abstinence (≠ medication)

 3’ Depression ↓↓ in 2 d to 4 wks abstinence (no meds)

2.      Psychosis (slide 33)

a.       During DT’s can have hallucinations

1’ True of any delirium (e.g. post surgery)

2’ Usually disappear as recover from DT’s

b.      ~3%  AUD have halluc/delusions during severe intox

1’ No delirium present

2’ Is alcohol induced psychosis

3’ Disappears in 2 d to 4 wks even without meds

4’Antipsychotics (e.g. risperidone) help control symptoms

V.    Interventions for AUD in the Hospital (slide 34)

A.    Brief intervention for heavy drinkers [21-28] (slide 35)

1.      Target non-dependent, harmful or hazardous drinkers

2.      E.g. regular drink  >3 drinks/day

3.      Goal=early intervention & prevent future med problems

4.      ~10 mins education or for Motivational Interviewing (see below)

5.      Can be delivered by non-specialist staff (or by any doc)

6.      → ↓ Alcohol intake at 6 and 9 mo follow up

7.      Fewer deaths at 6 mo and 1 yr follow up

8.       Brief intervention based on FRAMES

a.       Give feedback about person’s own risk with heavy drinking

b.      Responsibility—emphasize patient responsible for change

c.       Advice to cut down or abstain

d.      Menu of options to change drinking pattern

e.       Empathic interviewing style

f.       Self-efficacy—pt’s belief that change will be effective

B.     Motivational Interviewing (MI) [29,30] (slide 36)

1.      Described in 1980’s

a.       Useful for any behavior change (e.g. take meds in diabetes)

b.      Views changes as a process with multiple steps

2.      Stages of change model describes the process (slide 37)

a.       Precontemplative- does not believe there is a problem

b.      Contemplative- recognizes problem, considers change

c.       Preparation- wants to change, makes plans

d.      Action- changes behavior

e.       Maintenance- sustains change in behavior

f.       Goal: help patient move toward action & maintenance

3.      Emphasis on:

a.       Collaboration with patient (not. confrontation)

b.      Work to ↑  pt’s own motivation

c.       Respecting pt’s need to make own decision

4.      General Principles: (slide 38)

a.       Say you understand the problems in changing (empathy)

b.      Discuss the pt’s ambivalence to change

c.       Really listen to their concerns (skillful listening)

d.      Point out when behavior contrast with goals

e.       Roll with resistance—avoid telling what to do

f.       Support pt’s belief in capacity to change (self efficacy)

C.     Clinical Case Vignette (slide 39)

1.      45 year old male high school principal

2.      3rd admission for alcoholic pancreatitis

3.      Was given AUD treatment options in previous admissions

4.      No follow up treatment pursued

5.      Reports marital discord, expected job lay-off, parenting stressors

6.      Acknowledges alcohol problem and need for action

D.    Review of case vignette (slide 40)

1.      Stage of change: contemplative

2.      Express empathy for pt’s situation, multiple stressors

3.      Discuss what stopped him from changing before (ambivalence)

4.      Discuss contrasts between goals (e.g. job, parenting) and behavior (continued drinking=continued problems, repeat hospitalization)

5.      Support pt’s ability to change if he wants to

6.      Result: pt takes initiative

                                                                                                 a.      Makes own appt for follow-up

                                                                                                b.      Calls friend about Alcoholics Anonymous (AA) meeting

7.      Stage of change: contemplation→preparation

E.     Treatment referral options [31, 32] (slide 41)

1.      All options work to

                                                                                                 a.      Change how pt thinks about AUD

1’Medical model/disease concept

2’ Chronic disorder that can be managed successfully

                                                                                                b.      Address behavior re AUD and avoid relapse

1’Recognize pt’s specific triggers for cravings

2’Avoid high risk situations

3’Learn tools to cope with cravings

                                                                                                 c.      I.e., all are cognitive-behavioral based

2.      Rehabilitation (most costly and intensive approach) (slide 42)

                                                                                                 a.      Lessons and support given in 24 hr mileu

                                                                                                b.      Best if failed in outpatient and/or severe med/psych illness

                                                                                                 c.      Residential, 24-hr live-in setting

                                                                                                d.      Typically 14-28 days, sometimes longer

                                                                                                 e.      Learn through group discussions

                                                                                                 f.      Safe and stable living environment to develop recovery skills

                                                                                                g.      Usually introduce to self-help groups (e.g. AA) as well

                                                                                                h.      Continued outpatient groups and self-help groups important

3.      Intensive Outpatient Treatment (less costly, but less intensive)

                                                                                                 a.       Best initial option if available

                                                                                                b.      Groups daily or multiple days of week outside of work/school

                                                                                                 c.      Treatment provided in “real world” setting

                                                                                                d.      Access to medical and psychiatric consultation

                                                                                                 e.      Usually advised to go to self-help groups as well

4.      Outpatient Treatment (slide 43)

                                                                                                 a.      Sessions with substance or mental health treatment provider 

                                                                                                b.      Provided in a variety of settings

5.      Alcoholics Anonymous (AA) Meetings

                                                                                                 a.      Self-help group/fellowship of alcoholics

                                                                                                b.      Membership requirement: desire to consider stop drinking

                                                                                                 c.      Change through working “12 steps” (cognitions)

                                                                                                d.      Work with sponsor (sober AA member, completed 12 steps)

                                                                                                 e.      Emphasis on spirituality (not necessarily religion)

                                                                                                 f.      Begin with 90 meetings in 90 days

                                                                                                g.      Widely available, free

F.      Medication options (slide 44)

1.      Medications initiated by PMD in hospital or in referral treatment setting

2.      Can consider 2 meds (naltrexone, acamprosate)

                                                                                                 a.      Naltrexone (ReVia or Vivitrol)

1’Oral (50mg/d) or injectable (380mg/mo)

2’Opioid receptor antagonist

3’↓ Cravings assoc w/ rewarding effects of alcohol

                                                                                                            b.      Acamprosate (Campral)

1’Oral (~2g/d)

2’NMDA receptor antagonist

3’ ↓ Cravings assoc w/ post-withdrawal neg effects

                                                                                                 c.      Take either or both for 3-6 months

                                                                                                d.      ~15% improvement in abstinence rates c/w cog Rx alone

 

VI. Conclusions (slide 45)

A.    AUD’s – common and negative impact on the hospital course and cost

B.     Have effective interview techniques and screening instruments

C.     AUD’s have medical and psychiatric problems and complications

D.    Have effective interventions for Rx and referral in medical settings

 

 

 

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