1. THE COSTS OF “AT-RISK” DRINKING & SCREENING FOR UNHEALTHY USE OF ALCOHOL IN A 15 MINUTE PATIENT VISIT Dangerous Alcohol Use

2. WARNING! The following presentation is heavy on definitions

3. Outline Learning Objectives Mini-lecture!  Learn some facts, grow together and individually. Cases!  Apply knowledge, save lives.

4. Learning Objectives By the end of this presentation, we should be able to:  Identify “at-risk” drinking, alcohol abuse, and alcohol dependence  Explain the USPSTF recommendations re: screening for unsafe alcohol use  Use a one question screening test to ID patients likely to be at- risk drinkers

6. THIS IS THE PERCENTAGE OF AMERICAN ADULTS WHO ARE AT-RISK DRINKERS

7. WHAT IS 28%

8. “At-risk” Drinking Per the CDC:  Averaged daily limits:  On average, more than 2 drinks/day for men, more than 1/day for women OR  Binge Drinking:  More than 5 drinks/occasion for men, more than 4 drinks/occasion for women

9. What is a “Drink”?

10. “At-Risk” for what? Many potential adverse outcomes Primarily, increased risk of having an “alcohol use disorder”  The point at which the patient’s drinking begins to cause distress or harm  DSM IV: Alcohol Abuse Alcohol Dependence

11. Alcohol Abuse The 5 “R’s

13. Alcohol Dependence

14. At-Risk drinking - Risks Immediate:  Accidental injury  Increased risk for violence  Risky sexual behaviors  Alcohol poisoning  Legal repercussions Long-term:  Neurologic  Dementia, stroke  CV  MI, HTN, a. fib, myopathy  Psychiatric  Depression, suicidality  GI  Cirrhosis, pancreatitis  Oncologic  Mouth, esophagus, liver, colon, and breast CA risk with  with  EtOH intake

15. At-Risk Drinking - Costs Attributable to excess alcohol consumption:  ~ 80,000 deaths annually  1.2 million ED visits  Total estimated cost of $223.5 BILLION to the economy  $24.6 billion spent on health care

16. So what now!? The U.S. Preventative Services Task Force recommends screening for alcohol misuse in adults in the primary care setting (Grade B).  Screening tools:  AUDIT-C  CAGE  Single-item screening

17. Single-Item Screening Validated by National Institute for Alcohol Abuse and Alcoholism One question:  “How many times in the past year have you had more than…”  “…5 drinks a day” – men  “…4 drinks a day” – women Positive if answer > 0  82% sensitive and 79% specific for at-risk drinking If positive, next step is to assess weekly average

19. LET’S DO SOME CASES!

20. Case #1 - AB AB is a 25 year-old medical student who presents to the Health Plan to establish primary care  CC: None  PMH, PSH, FH all unremarkable  SH:  Tobacco: non-smoker  EtOH: Drinks “I don’t know… maybe 10 drinks a week?” When asked Single-Item Screen, states that he drinks more than 5 “official drinks” at least one night every weekend.  Otherwise doing well – no EtOH-related incidents in past year

21. Case #1 - AB What do we make of AB’s alcohol use? How worried are we? What do you want to do next?

23. Case #2 - WW WW is an 55 year-old, recently divorced, electrician who presents to your office with a CC of insomnia  HPI: Has had trouble sleeping since the divorce two months ago. Falls asleep quickly after taking an Ambien, but wakes multiple times throughout the night. With each waking, he mixes a vodka and soda containing 4 oz. of liquor to help him fall back asleep. He has been doing this “pretty much every night” for at least the past month.

24. Case #2 - WW Assuming he wakes up twice on average, how many drinks a day is WW consuming? What questions do we want to ask to better assess WW’s alcohol use? What do we want to do next?

25. Case #3 - HS HS is a 45 year-old male new to your office. He is here to establish care.  CC: None  PMH: Obesity  PSH, FH unremarkable  SH: Works at nearby nuclear power plant, father of 3.  Tobacco: non-smoker  EtOH: “Has a few every night after work” – goes to a bar with friends for several hours most nights of the week When asked how many nights in the past year he’s consumed more than 5 drinks, he shrugs, saying “Most?”

28. Summary Unhealthy use of alcohol (including alcohol use disorders) is common, and is associated with significant personal, physical, and economic costs The USPSTF recommends that we screen our patients for unhealthy use – can be done with a single question

29. Thank You

30. References Centers for Disease Control and Prevention (CDC). Alcohol-Related Disease Impact (ARDI). Atlanta, GA: CDC.Alcohol-Related Disease Impact (ARDI). Atlanta, GA: CDC. Bouchery EE, Harwood HJ, Sacks JJ, Simon CJ, Brewer RD. Economic costs of excessive alcohol consumption in the United States, 2006. Am J Prev Med 2011;41:516–24.Economic costs of excessive alcohol consumption in the United States, 2006. Am J Prev Med 2011;41:516–24. Dawson DA, Grant BF, LI T-K. Quantifying the risks associated with exceeding recommended drinking limits. Alcohol Clin Exp Res 2005;29:902–908Quantifying the risks associated with exceeding recommended drinking limits. Alcohol Clin Exp Res 2005;29:902–908 NIAAA Clinicians Guide: Helping Patients Who Drink Too Much: http://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/guide.pdf http://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/guide.pdf Smith PC, Schmidt SM, Allensworth-Davies D, Saitz RS. Primary care validation of a single-question alcohol screening test. Gen Intern Med. 2009;24(7):783.\ Hasin DS, Stinson FS, Ogburn E, Grant BF. Prevalence, Correlates, Disability, and Comorbidity of DSM-IV Alcohol Abuse and Dependence in the United States: Results From the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry. 2007;64(7):830-842. doi:10.1001/archpsyc.64.7.830