Problem drinking and alcohol disorders

1. Family Physicians’
Encounter with Patients Having
Alcohol Use Disorder
Dr. Mohammad Mataro
R4, Family Medicine
Aga Khan Univeristy Karachi Sindh.

3. Objectives
• To know the primary care approach to a
patient with AUD
• To review different screening tools used at
primary care level for AUD
• To review the simple approaches and
interventions applicable for AUD patients
in primary care setting
• To learn how to manage frontline encounter
of Alcohol related emergencies

4. • A 45-year-old man presents to the CHC after falling off a some height
while repairing something
• He sprained both ankles
• The assessment nurse smells alcohol on his breath
• The patient admits to having had "a couple of beers" but denies being
intoxicated
• He states that he drinks 6-drinks of beer daily, after work, and more
on weekends.
• He denies that alcohol is a problem for him
• History of being arrested by Police while driving one month back
• History of frequent falls

5. Alcohol Use Disorder
• Common psychiatric disorder
– Multifactorial in etiology,
– Chronic in nature
– Associated with a wide variety of medical and psychiatric
sequelaee
• Approx.40 % develop their first symptoms between 15
and 19 years of age
• Screening for alcohol consumption in health care
settings remains lower than 50 %
• Approximately 70 % of alcoholics are heavy smokers

6. Risk factors

7. Extent of
Influence
Initiation of
Drinking
Progression Alcoholic
Drinking
Environmental (familial and non familial)
Personality/Temperament)
Pharmacological effects of ethanol
Initiation and Continuation of Drinking

8. Situation at Pakistan
The Pakistan penal code, under
the Prohibition (Enforcement of
Had) Order of 1979, awards 80
lashes to those convicted of
consuming alcohol.

9. • Back to our patient
• Approach?

10. Diagnostic Approach
• Diagnostic interview/examination
• Screening
• Behavioral assessment/Motivation

11. Cues From Clinical Encounter

12. Lab Investigations
• Breath Alcohol Concentration/BAC: > 200
= Diagnostic ,> 400=lethal
• Gamma-GT, ALT, AST
• CBC, high-density lipoprotein cholesterol
and triglyceride levels
• Urinary ethyl glucuronide

13. Definitions
• Safe Drinking: 01 /day for women and 02
standard drinks per day for men
• Problem drinking: >07/week Or >03 per
occasion for women; and >14 /week or> 04/
occasion for men
• Heavy drinking: >03 to 04 /day for women
and > 05 to 06 drinks /day for men

14. DSM5: Alcohol Use Disorder
• Alcohol use in larger quantities or over a longer period of time than intended
• Persistent desire or unsuccessful attempts to decrease or control alcohol use
• Significant time spent in activities needed to obtain or use alcohol or to
recover from its effects
• Cravings to use alcohol
• Recurrent use that results in failure to fulfill major role obligations at home,
work, or school
• Continued alcohol use despite social or interpersonal problems caused or
worsened by alcohol
• Decreasing or forgoing important social, occupational, or recreational
activities due to alcohol use
• Recurrent use of alcohol in hazardous situations
• Use of alcohol, despite knowing that alcohol is likely causing or worsening
chronic physical or psychological problems
• Physiological tolerance
• Withdrawal
2 to 3 criteria for mild,
4 to 5 for moderate,
and 6 or more for
severe

15. Screening Instruments
• The alcohol use disorders identification test
(AUDIT)
• Audit C
• Screen: CAGE

16. • Back to our patient
• What is your management plan?

17. Management
Factors to consider
– The severity of the alcohol problem
– Comorbid medical and psychosocial problems
– Patient’s motivation to change

18. Management
• Medical assessment and advice
• Realistic goals
• Detoxification & withdrawal symptom
management
• Rehabilitation and aftercare
• Relapse prevention/ abstinence
enhancement with pharmacotherapy

19. Key points :Mild to Moderate AUD
1. Review quantity and frequency of current drinking
2. Review personal drinking cues
3. Give feedback of personal risk for alcohol-related problems
4. Give explicit advice to reduce or stopdrinking
5. Discuss patient’s personal responsibility and choice for reducing
or stopping drinking
6. Find appropriate personal timing forchange
7. Establish a drinking goal and agree on a contract
8. Set up a drinking diary
9. Suggest ways for behavior modification, coping techniques, and self-
help materials.
10. Encourage self-motivation and optimism

20. • Consecutive three sessions with two weeks
intervals are mandatory for maintenance
and reinforcement
• No pharmacotherapy at this stage

21. Key points: Moderate to Severe AUD
• 02 stages:
– Withdrawal, detoxification, Complications
– Interventions to maintain abstinence

22. Alcohol Overdose
• ABC’s
• Oxygen
• Glucose, Thiamine
• IV, infuse fluid to support perfusion
• Lavage if within 2 hours
• Reffer to ER for Intubation

23. Acute Alcohol Withdrawal
• ABCs
• Glucose
• Fluids
• Benzodiazepines
• Diazepam: 5-10 mg PO/I/V/I/M every 6-8
hours
• B-Complex
• Refer for detoxification to inpatient settings

24. Long Term management
• Behavioral
• Pharmacological

25. Treatment
Intervention
Primary Target Population(s)
High-risk
Alcohol
Use
disorder
At risk drinking
Brief intervention   
Motivational
enhancement therapy
 
Cognitive behavioral
therapy

Couples (marital) and
family therapies

Community
reinforcement

Behavioral Therapies
Selected References: Moyer et al. (2002) Addiction, 97: 279-292; Miller et al. (2002) Addiction,
97: 265-277; O’Farrell et al. (2000) J. Sub.Abuse Treat., 18: 51-54

26. Medication Target Year Approved
Disulfiram Aldehyde Dehydrogenase 1949
Research from animal models over the past 25 years has provided
promising targets for pharmacotherapy
Naltrexone Mu Opioid Receptor 1994
Acamprosate Glutamate and GABA-
Related
2004
Naltrexone Depot Mu Opioid Receptor 2006
Abstinence Enhancement With
Pharmacotherapy

27. Medication Target
Topiramate GABA/Glutamate
Valproate GABA/Glutamate
Ondansetron 5-HT3 Receptor
Nalmefene Mu Opioid Receptor
Baclofen
Antidepressants
GABAB Receptor
Emerging Therapies To Prevent Relapse

28. Patients With Comorbid Conditions
Co-morbidities Medication(s)
AD/Depression naltrexone; sertraline
AD/Bipolar valproate; naltrexone
AUD/anxiety disorders venlafaxine (Effexor)
AD/schizophrenia clozapine (Clozaril)
AD/tobacco dependence bupropion (Zyban)
AD/cocaine dependence topiramate (Topamax)

29. Follow up
• Weekly or every 2 weeks for patients
attempting to cut down alcohol use
• Sobriety tests:
– Liver function tests, including gamma-gt, ALT,
AST.

30. Prevention
• Public / Institutional
• Education/Awareness/Mass-Media campaign
• Reducing availability
• Increasing Prices/Taxes
• Legislation & Implementation
• Ban on Alcohol use on public places
• Proper screening during doctor Visits
• Avoid Triggers

32. References
• BMJ 2014
• AFP 2003,2014
• Uptodate
• Book: Clincal Guidelines in Familly
Medicine 2014