2/24/2017
Disclosure
Diagnosis and
treatment of alcohol use
disorder in primary care
No financial conflicts
Trade names may be used for clarity
Scott Steiger, MD, FACP,
FASAM
HS Associate Clinical Professor
of Medicine and Psychiatry
UCSF-ZSFG
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
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?”
**If one of above not controlled on max therapy, or you see 3-4
on problem list, ask about alcohol!
• 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
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?
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
NIAAA, 2016. Accessible at
http://pubs.niaaa.nih.gov/publications/dsmfactsheet/dsmfact.htm
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
patient’s goal
Treatment options depend on
severity
• Mild (2-3 criteria)
– Trial of abstinence (TOA)
• Diagnostic and therapeutic
• Moderate (4-5 criteria)
– TOA
– Peer support
– Pharmacotherapy
•
•
•
•
Abstinence?
Reduction in # drinks?
Reduction in # drinking days?
Reduction in harm to pt from drinking?
• Severe (6+ criteria)
– TOA medically supervised withdrawal
– Peer support
– pharmacotherapy
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
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.
4 Spent a lot of time drinking? Or being sick or getting
over 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?
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?”
NIAAA, 2016. Accessible at
http://pubs.niaaa.nih.gov/publications/dsmfactsheet/dsmfact.htm
42 yo M moderate AUD
• Wants another TOA
• “I’ll do it this time, doc, 10 out of 10”
• Give the diagnosis
– “You meet criteria for Alcohol Use Disorder”
• TOA
Other next steps?
– 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.
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www.aasf.org
Something for everyone
PEER SUPPORT GROUPS
Do 12-step groups work?
www.smartrecovery.org
• 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
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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?
There’s a pill (or a shot) for that
PHARMACOTHERAPY FOR
AUD
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Meds to treat alcohol use disorder
Maintain abstinence
Decrease binges
•
•
•
•
•
•
•
•
•
•
•
Acamprosate
?naltrexone
Gabapentin*
?Baclofen*
Disulfiram**
Naltrexone
Gabapentin*
Topiramate*
Baclofen*
Ondansetron*
Varenicline*
*not FDA-approved
**in highly structured
environment only
Decrease binges: naltrexone
Pro
Con
• Mu-opioid antagonist
reduces endogenous
reward from EtOH
• ?improvement in abstinence
– 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**
– MA (n=2347): risk reduction
0.05 (0.1 – 0.002)
• SE: transaminitis
• Contraindications: opioids,
LFTs > 5x ULN
• Safe to take with EtOH
Ideal candidate: actively drinking patient not on opioids who wants help to “cut
down”
Rx: 50 mg po qday or 380 mg IM q4wks
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
Ideal candidates: post-medically supervised withdrawal, no ESRD, able
to manage pills
Rx: 666 mg po tid
*Rosner S, et al., Cochrane Database Syst Rev, 2010
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
*Rosner S, et al., Cochrane Database Syst Rev, 2010
**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 doserelated 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
Con
• 16 week RCT (n=151)
• No diff in time to relapse
placebo, low, or high
(150 mg) dose
Muller CA, et al. Eur
Neuropsychopharmacol, 2015
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 (“Dopeamax”)
• 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
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
Decrease use: ondansetron
Pro
• RCT: appears to work in
certain sub-pop (“earlyonset” AUD, genotype)*
Con
• Off-label for AUD
• Can’t ID genetics
• QT prolongation
– Reduced 1.5 drinks per day
– Reduced # drinking
episodes ~10%
Ideal candidate: young healthy pt normal QT already failed other
meds
*Johnson BA, Am J Psychiatry, 2011
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)
b)
c)
d)
Topiramate
Naltrexone
Acamprosate
All of the above
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Full citations for references cited (1/2)
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•
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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,
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Anton RF, Myrick H, Wright TM, et al. Gabapentin Combined with Naltrexone for the Treatment of
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doi:10.1176/appi.ajp.2011.10101436.
Batki SL, Pennington DL, Lasher B, et al. Topiramate Treatment of Alcohol Use Disorder in
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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,
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De Beaurepaire R. The use of very high-doses of baclofen for the treatment of alcoholdependence: 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
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Full citations for references cited (2/2)
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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
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doi:10.1001/jama.2014.3628
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