1. Alcohol Use Disorder A Patient-Centered, Evidence-Based Diagnostic and Treatment Process 1,2,3 A Presentation for SOMC Medical Education A Presentation for SOMC Medical Education A Presentation for SOMC Medical Education Kendall L. Stewart, MD, MBA, DLFAPA October 18, 2012 1 This presentation is designed as a problem-based learning module. 2 You will be surprised by many of your patients throughout your career. 3 Some of you and your colleagues will abuse alcohol.

2. Why is this important? Alcohol misuse is a leading cause of morbidity and mortality. Alcohol problems are often comorbid with other physical and mental disorders. Alcohol-related healthcare costs are already north of $250 billion per year. Alcohol-related problems are under-diagnosed and under- treated. Treatment outcomes for alcohol use disorders are as good or better than those for other chronic illnesses. After listening to this presentation, you will be able to answer the following questions: –Why is this important? –What are the diagnostic criteria? –What are some of the demographics of alcohol use disorder? –What are some clues to alcohol abuse? –What is the CAGE screening tool? –What counseling techniques are helpful? –What medications are helpful? –What should you do? 1 1 Not surprisingly, these people are often untruthful; their families will call you with the real scoop.

3. What diagnoses will likely be included in this category in DSM-5? Alcohol-Related Disorders –Alcohol Use Disorder –Alcohol Intoxication –Alcohol Withdrawal –Alcohol Use Disorder Not Elsewhere Classified (NEC)

4. What are the diagnostic criteria? 1 Problematic pattern of alcohol use causing significant impairment or distress –Alcohol used in greater amounts and longer than intended –Unsuccessful efforts to cut down usage –A great deal of time consumed by alcohol-related activities and complications –An alcohol-related failure to fulfill obligations at school, work or home –Continued alcohol use in spite of the problems it causes –Alcohol use negatively impacts social, occupational or recreational activities –Recurrent use when physically hazardous –Continued use in spite of alcohol-related complications –Tolerance –Withdrawal –Craving 1 These are the proposed DSM-5 criteria.

5. How many people does drinking kill each year? 1 1 NBCNews.com.

6. What are some of the key demographics of alcohol use? 1 About 61% of Americans drink alcohol. About 15% of those abuse it. About 14% binge drink (5 or more drinks during one episode) Heavy use is more frequent in men (10%) than in women (3%). 2 Maximum moderate alcohol use is 2 drinks per day for men and 1 drink per day for women. Alcohol use disorders are as common as hypertension and much more common than diabetes. 1 Rakel and Rakel, Textbook of Family Medicine 2 Family physicians and anesthesiologists are over-represented among physician alcoholics.

7. What are some clues to alcohol abuse? 1 History –Arrest for operating a vehicle while intoxicated (OVI) 2OVI –Tremor –PancreatitisPancreatitis –GastritisGastritis –Hypertension –Stress –Trauma –Domestic disputes Lab –Mean cell volume (MCV) > 100MCV –Aspartate transaminase (AST) > alanine transaminase (ALT)ASTALT –LeukopeniaLeukopenia –ThrombocytopeniaThrombocytopenia –Positive response to the carbohydrate-deficient transferrin (CDT) levelCDT –Elevated Gamma- glutamyl transpeptidase (GGT)GGT 1 Rakel and Rakel, Textbook of Family Medicine 2 An OVI conviction means there is likely a problem; those so convicted rarely acknowledge this.

8. What is the CAGE 1 screen for alcohol abuse? Have you ever felt you should cut down on your drinking? Have people annoyed you by criticizing your drinking? Have you ever felt bad or guilty about your drinking? Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (eye opener)? (Any positive answer is a source of concern.) 1 Ewing JA, Detecting Alcoholism: The CASE Questionnaire. JAMA 1984; 252: 1905-1907.

9. What are some of the complications of alcohol use disorder? 1 Intoxication Coma Withdrawal Withdrawal seizures Withdrawal delirium (DTs)Withdrawal delirium Wernicke-Korsakoff Syndrome Wernicke’s encephalopathy Korsakoff’s psychosis Fetal alcohol spectrum disorder 1 Stern TA and others, MGH Comprehensive Clinical Psychiatry.

10. What counseling techniques may be helpful in alcohol use disorder? 1 Brief intervention Classic intervention Alcoholics Anonymous Inpatient treatment Outpatient treatment 1 Rakel and Rakel, Textbook of Family Medicine

11. What medications may be helpful in alcohol use disorder? 1 Disulfiram (Anabuse) 500 mg QAM after being off alcohol for 12 hoursDisulfiram Naltrexone (ReVia) 50 mg PO QAM after patient has been opioid free for 7 days; subcutaneous administration may be more effectiveNaltrexone Acamprosate (Campral) 666 mg PO TID after withdrawal; continue if relapse occursAcamprosate Topiramate (Topamax) Slowly increase to 200 mg BID.Topiramate Baclofen (Lioresal) Increase slowly to a max of 80 mg/day TID or QID.Baclofen 1 Rakel and Rakel, Textbook of Family Medicine

12. What should you do? 1 You must be the change you want to see in the world. Mahatma Gandhi Become a wellness champion and continue that lifestyle as long as you live. If you abuse alcohol, stop now; if you cannot, seek treatment and stick with it. Support prevention efforts for kids. Ask every new patient about alcohol use. If a patient drinks alcohol, screen them for misuse. Inquire whether patients who are abusing alcohol are ready to stop—at every visit. 1 Rakel and Rakel, Textbook of Family Medicine

13. What else should you do? 1 Seize every teachable moment to urge quitting. View this as a chronic disease. Remember that relapse is the rule rather than the exception. Focus on what you can do instead of fretting about what you can’t do. Bear in mind that the prognosis is not hopeless. Never, never, ever give up. 1 Rakel and Rakel, Textbook of Family Medicine

14. The Psychiatric Interview A Patient-Centered, Evidence-Based Diagnostic and Therapeutic Process Introduce yourself using AIDET 1.AIDET Sit down. Make me comfortable by asking some routine demographic questions. Ask me to list all of problems and concerns. Using my problem list as a guide, ask me clarifying questions about my current illness(es). Using evidence-based diagnostic criteria, make accurate preliminary diagnoses. Ask about my past psychiatric history. Ask about my family and social histories. Clarify my pertinent medical history. Perform an appropriate mental status examination. Review my laboratory data and other available records. Tell me what diagnoses you have made. Reassure me. Outline your recommended treatment plan while making sure that I understand. Repeatedly invite my clarifying questions. Be patient with me. Provide me with the appropriate educational resources. Invite me to call you with any additional questions I may have. Make a follow up appointment. Communicate with my other physicians. 1 A cknowledge the patient. I ntroduce yourself. Inform the patient about the D uration of tests or treatment. E xplain what is going to happen next. T hank your patients for the opportunity to serve them.

15. Where can you learn more? American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, 2000Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision Sadock, B. J. and Sadock V. A., Concise Textbook of Clinical Psychiatry, Third Edition, 2008Concise Textbook of Clinical Psychiatry, Third Edition Stern, et. al., Massachusetts General Hospital Comprehensive Clinical Psychiatry, 2008. You can read this text online here.here Flaherty, AH, and Rost, NS, The Massachusetts Handbook of Neurology, April 2007The Massachusetts Handbook of Neurology Stead, L, Stead, SM and Kaufman, M, First Aid© for the Psychiatry Clerkship, Second Edition, March 2005First Aid© for the Psychiatry Clerkship, Second Edition Klamen, D, and Pan, P, Psychiatry Pre Test Self-Assessment and Review, Twelfth Edition, March 2009 3Psychiatry Pre Test Self-Assessment and Review, Twelfth Edition Oransky, I, and Blitzstein, S, Lange Q&A: Psychiatry, March 2007Lange Q&A: Psychiatry Ratey, JJ, Spark: The Revolutionary New Science of Exercise and the Brain, January 2008Spark: The Revolutionary New Science of Exercise and the Brain Medina, John, Brain Rules: 12 Principles for Surviving and Thriving at Home, Work and School, February 2008Brain Rules: 12 Principles for Surviving and Thriving at Home, Work and School Stewart KL, “Dealing With Anxiety: A Practical Approach to Nervous Patients,” 2000Dealing With Anxiety: A Practical Approach to Nervous Patients,” Order the Kindle version of the Rakel and Rakel Textbook of Family Medicine here.here

16. Where can you find evidence-based information about mental disorders? Explore the site maintained by the organization where evidence-based medicine began at McMaster University here.here Sign up for the Medscape Best Evidence Newsletters in the specialties of your choice here.here Subscribe to Evidence-Based Mental Health and search a database at the National Registry of Evidence-Based Programs and Practices maintained by the Substance Abuse and Mental Health Services Administration here.here Explore a limited but useful database of mental health practices that have been "blessed" as evidence-based by various academic, administrative and advocacy groups collected by the Iowa Consortium for Mental Health here.here Download this presentation and related presentations and white papers at www.KendallLStewartMD.com. www.KendallLStewartMD.com Learn more about Southern Ohio Medical Center and the job opportunities there at www.SOMC.org.www.SOMC.org Review the exceptional medical education training opportunities at Southern Ohio Medical Center here.here

17. How can you contact me? 1 Kendall L. Stewart, M.D. VPMA and Chief Medical Officer Southern Ohio Medical Center Chairman & CEO The SOMC Medical Care Foundation, Inc. 1805 27th Street Waller Building Suite B01 Portsmouth, Ohio 45662 740.356.8153 StewartK@somc.org KendallLStewartMD@yahoo.com www.somc.org www.KendallLStewartMD.com 1 Speaking and consultation fees benefit the SOMC Endowment Fund.

18.  Safety  Quality  Service  Relationships  Performance   Safety  Quality  Service  Relationships  Performance  Are there other questions? Thomas Carter, DO Justin Greenlee, DO