1. Alcohol Use Disorders in General Hospital Patients: The Psychiatry Consultation Service Experience Jennifer Hanner, M.D., M.P.H. University of North Carolina School of Medicine 1 © AMSP 2012

2. AUD in General Hospitals High Prevalence High Prevalence 25% Lifetime abuse or dependence 25% Lifetime abuse or dependence 35% Trauma surgical patients 35% Trauma surgical patients 20% Burn patients 20% Burn patients Very costly Very costly $166 Billion/yr: ↓work, ↑crime, ↓health $166 Billion/yr: ↓work, ↑crime, ↓health Comorbid AUD ↑ stay and cost Comorbid AUD ↑ stay and cost 2 © AMSP 2012

3. ↑ Medical Complications Alcohol interacts with meds Alcohol interacts with meds ↓ General health ↓ General health Poor nutrition Poor nutrition 3 © AMSP 2012

4. This Lecture Reviews: Definitions Definitions Screening/evaluation Screening/evaluation Medical/psych complications, comorbidity and Rx Medical/psych complications, comorbidity and Rx Interventions in the hospital Interventions in the hospital 4 © AMSP 2012

5. Definitions Standard Drink (~10 grams alcohol) Standard Drink (~10 grams alcohol) 12 oz. Beer 12 oz. Beer 5 oz. Wine 5 oz. Wine 1.5oz. Hard liquor (80 proof) 1.5oz. Hard liquor (80 proof) Hazardous Drinking Hazardous Drinking Men: >14 drinks/wk or >4 drinks/sitting Men: >14 drinks/wk or >4 drinks/sitting Women: >7 drinks/wk or >3 drinks/sitting Women: >7 drinks/wk or >3 drinks/sitting 5 © AMSP 2012

6. Abuse & Dependence Abuse 1+ of: Abuse 1+ of: Failure in roles Failure in roles Hazardous use Hazardous use Social/interpersonal problems Social/interpersonal problems Legal problems Legal problems (Not alc dependent) Dependence 3+ of: Dependence 3+ of: Tolerance Tolerance Withdrawal Withdrawal Unable to ↓ or quit Unable to ↓ or quit Longer than intended Longer than intended ↑ Time find/use ↑ Time find/use ↓ Important activities ↓ Important activities Despite consequences Despite consequences 6 © AMSP 2012

7. This Lecture Reviews Definitions Definitions Screening/evaluation Screening/evaluation Medical/psych complications, comorbidity, and Rx Medical/psych complications, comorbidity, and Rx Interventions in the hospital Interventions in the hospital 7 © AMSP 2012

8. Screening/Evaluation Often undetected by MDs Often undetected by MDs Reasons include: Reasons include: Inadequate training Inadequate training Misperceptions/stereotyping Misperceptions/stereotyping Uncertain about what to do Uncertain about what to do 8 © AMSP 2012

9. Psychiatric Consultation Ask why refer Ask why refer Review records/labs/etc. Review records/labs/etc. Review all meds Review all meds Interview/examine patient Interview/examine patient 9 © AMSP 2012

10. Psychiatric Consultation Interview collateral Interview collateral Order diagnostic tests Order diagnostic tests Formulate assessment & plan Formulate assessment & plan Discuss w/ referring clinician Discuss w/ referring clinician 10 © AMSP 2012

11. Taking AUD History Current/past patterns of use Current/past patterns of use Usual drinks/day Usual drinks/day Binge pattern Binge pattern Periods of abstinence Periods of abstinence History of treatment History of treatment Withdrawal Withdrawal Family history Family history 11 © AMSP 2012

12. Screening/Evaluation Alc Use Disorders Identification Test Alc Use Disorders Identification Test 10 questions, scored 0-4 10 questions, scored 0-4 ≥8 = hazardous drinking (Sens=98%) ≥8 = hazardous drinking (Sens=98%) ≥10 = alc dependence (Sens=99%) ≥10 = alc dependence (Sens=99%) Short Michigan Alcohol Screening Test Short Michigan Alcohol Screening Test 13 questions, self-administered 13 questions, self-administered Accuracy=25 item MAST (Sens 90%) Accuracy=25 item MAST (Sens 90%) 12 AMSP 2012

13. Screening/Evaluation Lab markers Lab markers Gamma-glutamyltransferase Gamma-glutamyltransferase Aspartate & Alanine Aminotransferase Aspartate & Alanine Aminotransferase Carbohydrate deficient transferrin Carbohydrate deficient transferrin Mean Corpuscular Volume Mean Corpuscular Volume 13 © AMSP 2012

14. Lab Markers 1 (GGT) Gamma-glutamyltransferase Gamma-glutamyltransferase ↑ With heavy drinking ↑ With heavy drinking ↑ In: heart disease, kidney disease, preg ↑ In: heart disease, kidney disease, preg GGT >35 GGT >35 -Heavy drinking -↑ Before liver damage -Sensitivity for heavy drinking ~75% GGT >50 may indicate liver damage GGT >50 may indicate liver damage Normalizes ~5 weeks of abstinence Normalizes ~5 weeks of abstinence 14 © AMSP 2012

15. Lab Markers 2 (LFT) Liver enzymes: AST and ALT Liver enzymes: AST and ALT ALT in liver, AST in many tissues ALT in liver, AST in many tissues ↑ In high use AND liver damage ↑ In high use AND liver damage Absolute value &ratio important Absolute value &ratio important -AST (14-38 U/L normal range) -ALT (15-48 U/L normal range) -AST:ALT ratio >2 suggestive of alcohol Less sensitive than GGT Less sensitive than GGT 15 © AMSP 2012

16. Lab Markers 3 (CDT) Carbohydrate deficient transferrin Carbohydrate deficient transferrin Transferrin=protein; transports iron Transferrin=protein; transports iron Abnormal form produced in ↑ drinking Abnormal form produced in ↑ drinking CDT >20 g/l indicates heavy drinking CDT >20 g/l indicates heavy drinking Few other conditions ↑ Few other conditions ↑ Sensitivity & specificity ~75% (=GGT) Sensitivity & specificity ~75% (=GGT) Normalizes ~1 month of abstinence Normalizes ~1 month of abstinence 16 © AMSP 2012

17. Lab Markers 4 (MCV) Mean Corpuscular Volume Mean Corpuscular Volume Size of red cells (nl =80-100u) Size of red cells (nl =80-100u) ↑ By heavy drinking ↑ By heavy drinking >90u suggests heavy drinking >90u suggests heavy drinking MCV ↑ in other conditions MCV ↑ in other conditions 17 © AMSP 2012

18. Screening/Evaluation Signs and symptoms Signs and symptoms Irregular heart rhythm Irregular heart rhythm Enlarged tender liver (alc hepatitis) Enlarged tender liver (alc hepatitis) Hard small liver (cirrhosis- in 20% of AUD) Hard small liver (cirrhosis- in 20% of AUD) Ascites (abdom. cavity fluid in liver failure) Ascites (abdom. cavity fluid in liver failure) Jaundice (yellow skin/eyes in liver failure) Jaundice (yellow skin/eyes in liver failure) Tremor (hangover or withdrawal) Tremor (hangover or withdrawal) Hyperactive reflexes/↑ pulse/ etc. Hyperactive reflexes/↑ pulse/ etc. 18 © AMSP 2012

19. This Lecture Reviews Definitions Definitions Screening/evaluation Screening/evaluation Medical/psych complications, comorbidity, and Rx Medical/psych complications, comorbidity, and Rx Interventions in the hospital Interventions in the hospital 19 © AMSP 2012

20. Alcohol Withdrawal Cessation or ↓ heavy use Cessation or ↓ heavy use 2+ w/in hrs: 2+ w/in hrs: Tremor (hands, arms, legs, tongue) Tremor (hands, arms, legs, tongue) ↑ Pulse ↑ Pulse Insomnia Insomnia Agitation (restlessness/agitation/aggression) Agitation (restlessness/agitation/aggression) Anxiety Anxiety Visual/tactile/auditory hallucinations (rare) Visual/tactile/auditory hallucinations (rare) Grand mal seizure (rare) Grand mal seizure (rare) 20 © AMSP 2012

21. Alcohol Withdrawal 6-8 hours after last drink 6-8 hours after last drink Declining BAC (not at zero) Declining BAC (not at zero) Symptoms → distress/↓ functioning Symptoms → distress/↓ functioning R/O general medical or mental dx R/O general medical or mental dx Delirium Tremens (DT’s) (rare) Delirium Tremens (DT’s) (rare) 21 © AMSP 2012

22. Delirium Tremens (DT’s) Seen in ~5% AUD Seen in ~5% AUD Disorientation (confusion) Disorientation (confusion) Fluctuating consciousness Fluctuating consciousness Hyperactivity/excitation Hyperactivity/excitation ↑ Pulse, bp, temp, etc. ↑ Pulse, bp, temp, etc. 22 © AMSP 2012

23. Delirium Tremens (DT’s) Hallucinations Hallucinations Can be fatal if med problems Can be fatal if med problems Onset 48-96 hours after last drink Onset 48-96 hours after last drink ↑ Risk prior episodes/med probs ↑ Risk prior episodes/med probs R/O other causes R/O other causes 23 © AMSP 2012

24. Withdrawal Tx Benzodiazepines (e.g. diazepam [Valium]) Benzodiazepines (e.g. diazepam [Valium]) Correct transmitter problems Correct transmitter problems Day 1: give enough to ↓ symptoms Day 1: give enough to ↓ symptoms ↓ Dose ~20% day 1 dose each day ↓ Dose ~20% day 1 dose each day ↑ Dose if symp ↑; ↓ dose next day ↑ Dose if symp ↑; ↓ dose next day Anticonvulsants not needed Anticonvulsants not needed 24 © AMSP 2012

25. Clinical Case 80 y/o female 80 y/o female ↑BP, 3 days s/p hip surgery ↑BP, 3 days s/p hip surgery Keeps trying to get out of bed Keeps trying to get out of bed Confused Confused Agitated Agitated ↑ BP and bilateral hand tremor ↑ BP and bilateral hand tremor Dx: EtOH withdrawal delirium (DT) Dx: EtOH withdrawal delirium (DT) 25 © AMSP 2012

26. Clinical Case Review criteria for DT’s Review criteria for DT’s Symptom onset at 72 hours Symptom onset at 72 hours Confusion Confusion Psychomotor agitation Psychomotor agitation ↑ Blood pressure/pulse/etc. ↑ Blood pressure/pulse/etc. 26 © AMSP 2012

27. Clinical Case Rx recommendations: Rx recommendations: 1:1 observation 1:1 observation Folate 1mg/d, thiamine 100mg/d Folate 1mg/d, thiamine 100mg/d R/O other causes R/O other causes Benzodiazepine Benzodiazepine 27 © AMSP 2012

28. Benzodiazepine Rx Chlordiazepoxide (Librium);diazepam (Valium) Chlordiazepoxide (Librium);diazepam (Valium) Longer half-life=smoother withdrawal Longer half-life=smoother withdrawal Better seizure protection Better seizure protection But can over-sedate elderly and liver impaired But can over-sedate elderly and liver impaired Lorazepam (Ativan)=better choice in this pt Lorazepam (Ativan)=better choice in this pt Shorter half-life = ↓ risk of oversedation Shorter half-life = ↓ risk of oversedation ↓ Risk if liver prob; not metabolized in liver ↓ Risk if liver prob; not metabolized in liver 28 © AMSP 2012

29. Wernicke Encephalopathy Wernicke Encephalopathy Cause: ↓ thiamine (Vit B1) Cause: ↓ thiamine (Vit B1) Emergency: untreated →20% death Emergency: untreated →20% death Triad: Confusion, ataxia (incoordination), ophthalmoplegia (eye muscle paralysis) Triad: Confusion, ataxia (incoordination), ophthalmoplegia (eye muscle paralysis) Rx: IV thiamine (to optimize absorption) Rx: IV thiamine (to optimize absorption) 29 © AMSP 2012

30. Korsakoff’s Syndrome Korsakoff’s Syndrome Impaired memory in alert, responsive pt Impaired memory in alert, responsive pt Limited insight to memory loss Limited insight to memory loss Confabulation -- makes up stories Confabulation -- makes up stories Retrograde & anterograde memory loss Retrograde & anterograde memory loss 30 © AMSP 2012

31. Psychiatric Disorders: MDE Co-morbid major depression Co-morbid major depression Gen pop major depressive episode (MDE) ~15% Gen pop major depressive episode (MDE) ~15% AUD slightly ↑ even when not drinking AUD slightly ↑ even when not drinking MDE unrelated to drinking MDE unrelated to drinking -Alcohol ↑ depressive symptoms -Alcohol intoxication/withdrawal ↑ suicidal ideation 31 © AMSP 2012

32. Psychiatric Disorders: AID Alcohol induced: severe intoxication → temporary MDE in ~30% Alcohol induced: severe intoxication → temporary MDE in ~30% Causal relationship--psychiatric disorder not predating AUD Causal relationship--psychiatric disorder not predating AUD Treatment = abstinence (≠ meds) Treatment = abstinence (≠ meds) Depression ↓↓ in 2 d to 4 wks abstinence Depression ↓↓ in 2 d to 4 wks abstinence 32 © AMSP 2012

33. Psychiatric Disorders: Psychosis Psychosis – Hallucinations Psychosis – Hallucinations Delirium (e.g. post surgery, DT’s) --usually disappear as delirium resolves Delirium (e.g. post surgery, DT’s) --usually disappear as delirium resolves ~3% AUD during severe intoxication ~3% AUD during severe intoxication -No delirium -Alcohol-induced psychosis -Disappears 2 d to 4 wks without meds -Antipsychotics (e.g. risperidone) control symp 33 © AMSP 2012

34. This Lecture Reviews Definitions Definitions Screening/evaluation Screening/evaluation Medical/psych complications, comorbidity, and Rx Medical/psych complications, comorbidity, and Rx Interventions in the hospital Interventions in the hospital 34 © AMSP 2012

35. Interventions Brief intervention for heavy drinkers Brief intervention for heavy drinkers Non-dependent (e.g.regular >3 drks/d) Non-dependent (e.g.regular >3 drks/d) Goal: early intervention & prevention Goal: early intervention & prevention ~10 min educ. or MotivationaI Interviewing ~10 min educ. or MotivationaI Interviewing Delivered by MD/staff Delivered by MD/staff 35 © AMSP 2012

36. Motivational Interviewing (MI) Behavior change (e.g. taking meds) Behavior change (e.g. taking meds) Change: process with multiple steps Change: process with multiple steps Stage of change model Stage of change model Collaboration (not confrontation) Collaboration (not confrontation) ↑ Pt’s motivation ↑ Pt’s motivation Respect pt’s own decision Respect pt’s own decision 36 © AMSP 2012

37. Stages of Change Model Precontemplative- not a problem Precontemplative- not a problem Contemplative – considers change Contemplative – considers change Preparation - makes plans Preparation - makes plans Action - changes behavior Action - changes behavior Maintenance - sustains change Maintenance - sustains change 37 © AMSP 2012

38. Motivational Interviewing General principles: General principles: Empathy Empathy Discuss ambivalence to change Discuss ambivalence to change Skillful listening Skillful listening Point out behavior contrast to goals Point out behavior contrast to goals Roll with resistance Roll with resistance Support self-efficacy Support self-efficacy 38 © AMSP 2012

39. Clinical Case 45 year old male high school principal 45 year old male high school principal 3 rd admission for alcoholic pancreatitis 3 rd admission for alcoholic pancreatitis Given AUD treatment options in past Given AUD treatment options in past No follow up No follow up Now: marital discord, job lay-off, etc. Now: marital discord, job lay-off, etc. Admits alcohol a problem Admits alcohol a problem 39 © AMSP 2012

40. Clinical Case Stage of change: contemplative Stage of change: contemplative Express empathy for situation/stressors Express empathy for situation/stressors Discuss barriers to change Discuss barriers to change Discuss goals vs behavior Discuss goals vs behavior Support ability to change if desired Support ability to change if desired Result: pt takes initiative Result: pt takes initiative Stage : contemplation→preparation Stage : contemplation→preparation 40 © AMSP 2012

41. Treatment All options work to: All options work to: Change thinking about AUD Change thinking about AUD -Chronic disorder -Can be managed Help prevent relapse Help prevent relapse -Recognize triggers -Avoid high risk situations -Cope with cravings 41 © AMSP 2012

42. Referral Option 1 Inpatient/residential rehabilitation Inpatient/residential rehabilitation Lessons/support in 24 hr milieu Lessons/support in 24 hr milieu Typically 14-28 days Typically 14-28 days Learn through group discussions Learn through group discussions Intensive Outpatient Treatment (IOP) Intensive Outpatient Treatment (IOP) Groups multiple days of week Groups multiple days of week Provided in “real world” setting Provided in “real world” setting 42 © AMSP 2012

43. Referral Option 2 Outpatient treatment Outpatient treatment Substance or mental health Rx provider Substance or mental health Rx provider Provided in variety of settings Provided in variety of settings Self-help groups (AA) Self-help groups (AA) Introduced in rehab or IOP Introduced in rehab or IOP Requires only desire to stop drinking Requires only desire to stop drinking Change through working “12 steps” Change through working “12 steps” 43 © AMSP 2012

44. Medications Naltrexone (ReVia or Vivitrol) Naltrexone (ReVia or Vivitrol) Oral (50mg/d) or injectable (380mg/mo) Oral (50mg/d) or injectable (380mg/mo) Opioid receptor antagonist Opioid receptor antagonist ↓ Cravings ↓ Cravings Acamprosate (Campral) Acamprosate (Campral) Oral (~2g/d) Oral (~2g/d) NMDA receptor antagonist NMDA receptor antagonist ↓ Post-withdrawal symptoms ↓ Post-withdrawal symptoms Rx 3-6 months Rx 3-6 months ~15% improvement ~15% improvement 44 © AMSP 2012

45. Conclusions AUD important issue in general hospital AUD important issue in general hospital Effective screening and evaluation Effective screening and evaluation Multiple medical/psychiatric complications Multiple medical/psychiatric complications Effective interventions for Rx and referral Effective interventions for Rx and referral 45 © AMSP 2012