Mary is a 43-year-old woman with a history of hepatitis C and hypertension who presents with depressed mood and insomnia. She denies any suicidal thoughts but states, “Life just doesn’t seem to be heading in the right direction.” On this visit, she is most concerned about her persistently elevated blood pressure and insomnia. She reluctantly reports losing her job and apartment 3 months ago and now lives with her sister. She divorced 1 year ago and has one adult son who is estranged from her. She reports a history of intravenous heroin use more than 8 years ago, smokes two packs of cigarettes per day, and drinks three to four beers each evening. Her physical exam is unremarkable except for a blood pressure of 165/95 mmHg, heart rate of 108 beats per minute, moderate bilateral hand tremor, and inability to perform tandem gait.
CLINICAL HIGHLIGHTS
Problematic alcohol use is widespread, costly, and underrecognized by primary care providers.
Screening tools such as the CAGE and AUDIT-C questionnaires should be used in the primary care setting as they are highly effective in identifying patients at risk for alcohol use disorders (AUDs).
Management strategies of AUDs share similarities with those of other chronic illnesses, and treatment should be individually tailored in a stepwise fashion.
The mainstays of treatment of alcohol use disorders are behavioral interventions, but effective adjunctive pharmacologic options such as acamprosate and naltrexone are readily available in primary care settings.
Brief intervention for alcohol use disorders has been extensively studied. It is effective in primary care settings and can be delivered in as little as four 15-minute sessions.
Use of benzodiazepines and other hypnotics to treat long-standing alcohol dependence can undermine treatment goals and is not normally indicated. The short-term use of long-acting benzodiazepines does have an important role in the treatment of alcohol withdrawal.
Clinical Significance
The primary care community cannot afford to ignore the economic, social, medical, and personal impact of AUDs. Alcohol-related disorders are chronic, relapsing problems that have a prevalence of up to 20% in the primary care patient population, a rate similar to other primary care conditions like hypertension and diabetes mellitus (1). However, they are identified and treated by clinicians at one fourth the rate of similarly prevalent illnesses. On average, alcohol use is responsible for about 100,000 deaths and nearly $200 billion in direct and indirect costs each year (2).
Benzodiazepines (BZPs) are among the most widely prescribed drugs in the world. Like alcohol, BZPs act as central nervous system depressants by their agonist effects on the gamma-aminobutyric acid A (GABAA) receptor. The relatively new class of non-BZP hypnotics (e.g., zolpidem and zaleplon) has been increasingly used for the treatment of insomnia. They are chemically similar to BZPs and potential for misuse and dependence still exists. Like BZPs, non-BZP hypnotics are potentiated by alcohol and concomitant use can cause severe, potentially fatal respiratory depression. Although sedative-hypnotic use disorders are not addressed in this chapter, we caution providers on the judicious use of BZPs and non-BZP hypnotics and the potential for abuse, dependence, and cross-addiction with alcohol.
Diagnosis
Alcohol use can be characterized along a spectrum from nonproblematic use, misuse, abuse, to dependence. For simplicity, the rest of the chapter will describe AUDs to include alcohol abuse and alcohol dependence, unless otherwise specified. The unit of alcohol consumption is the standard drink (1.5 oz of liquor, 12 oz of beer, or 5 oz of table wine), which contains 12 to 14 grams of ethanol and raises the blood ethanol level to about 0.08 g/dL in a 150-pound man. Alcohol use or “moderate drinking,” by consensus, is no more than one to two drinks per day for men and no more than one drink per day for women. The National Institute on Alcohol Abuse and Alcoholism (NIAAA) considers “at-risk drinking” to be more than 14 standard drinks weekly (or more than four drinks per occasion) for men and more than seven drinks weekly (or three drinks per occasion) for women and anyone of either sex over age 65 (3).
ALCOHOL ABUSE
The core feature of the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision (DSM-IV-TR), diagnostic criteria for alcohol abuse (Table 7.1) is the recurring use of alcohol despite a person’s inability to fulfill social role obligations and despite hazardous, legal, and interpersonal problems (4). One or more of these problems must be present for more than 1 year in order to diagnose alcohol abuse. In order to meet the diagnostic criteria for alcohol abuse, alcohol dependence must be ruled out first. Therefore, when insufficient information is available, alcohol dependence should be considered first.
ALCOHOL DEPENDENCE
The diagnosis of alcohol dependence (Table 7.2) requires abuse of alcohol plus physical, psychological, and social consequences of the excessive use: physical tolerance and withdrawal, unsuccessful attempts to stop or reduce alcohol use, excessive time spent in alcohol-related activities, impairment in interpersonal and social functioning, and continued use despite physical or psychological consequences. Alcohol dependence is diagnosed when three of these criteria have been met for more than 1 year (4).
Table 7.1 DSM-IV-TR Diagnostic Criteria for Alcohol Abuse
A maladaptive pattern of alcohol use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period:
1.
Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school, or home (e.g., repeated absences or poor work performance related to alcohol use; alcohol-related absences, suspensions, or expulsions from school; neglect of children or household)
2.
Recurrent alcohol use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by alcohol use)
3.
Recurrent alcohol-related legal problems (e.g., arrests for alcohol-related disorderly conduct)
4.
Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of alcohol (e.g., arguments with spouse about consequences of intoxication, physical fights)
5.
The symptoms have never met the criteria for alcohol dependence.
From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed., text revision. Washington, DC: American Psychiatric Association; 2000.
Table 7.2 DSM-IV-TR Diagnostic Criteria for Alcohol Dependence
A maladaptive pattern of alcohol use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:
1.
Tolerance, as defined by either of the following:
•
A need for markedly increased amounts of the substance to achieve intoxication or desired effect
•
Markedly diminished effect with continued use of the same amount of alcohol
2.
Withdrawal, as manifested by either of the following:
•
The characteristic withdrawal syndrome
•
Alcohol (or a closely related substance like a benzodiazepine) is taken to relieve or avoid withdrawal symptoms
3.
Alcohol is often taken in larger amounts or over a longer period than was intended
4.
There is a persistent desire or unsuccessful efforts to cut down or control alcohol use
5.
A great deal of time is spent in activities to obtain alcohol, use the alcohol, or recover from its effects
6.
Important social, occupational, or recreational activities are given up or reduced because of alcohol use
7.
The alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g., continued drinking despite recognition that an ulcer was made worse by alcohol consumption)
From American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed., text revision. Washington, DC: American Psychiatric Association; 2000.
ALCOHOL WITHDRAWAL
Alcohol withdrawal is often part of the diagnosis of alcohol dependence. The symptoms of alcohol withdrawal stem from unregulated excitatory neuronal activity, and may include diaphoresis, tachycardia, increased blood pressure, peripheral tremor, anxiety, insomnia, nausea, vomiting, and restlessness. The symptoms begin anywhere from 4 hours to 3 days after the last use of alcohol. Potentially dangerous endpoints for the alcohol withdrawal syndrome include seizures and delirium tremens. These complications of severe alcohol withdrawal can have fatal consequences if left untreated.
ALCOHOL WITHDRAWAL SEIZURES
Alcohol withdrawal seizures are generally tonic-clonic seizures and, other than the temporal relationship to the discontinuation of alcohol, are clinically indistinguishable from other seizure disorders. They generally appear 2 to 48 hours after the last drink, and are also caused by central neuronal hyperactivity. Patients typically have a single seizure, but they can have multiple seizures in a row, and up to 3% of patients develop status epilepticus. Recurrent or prolonged seizures during withdrawal should prompt an investigation for other potential causes of the seizures. The risk of developing alcohol withdrawal seizures is proportionally increased by the number of times a patient has required detoxification.
ALCOHOLIC HALLUCINOSIS
In alcoholic hallucinosis, hallucinations develop within 12 to 24 hours of abstinence and resolve within 24 to 48 hours. These are typically visual hallucinations, but tactile and auditory hallucinations can occur. Formication, or tactile hallucinations, occurs classically in patients who describe a feeling of bugs crawling on their skin. The patient’s sensorium is otherwise clear, which differentiates hallucinosis from delirium tremens (DTs), where hallucinations also occur but concomitantly with global clouding of the sensorium. Delirium tremens does not usually begin until after 24 to 48 hours of abstinence.
DELIRIUM TREMENS
Delirium tremens occur in about 5% of all cases of alcohol withdrawal and can be life threatening with a mortality rate of up to 5% (5). DTs are characterized by acute altered consciousness that includes disorientation, confusion, agitation, hallucinations, and signs of severe autonomic instability (including tremor, hypertension, diaphoresis, tachycardia, and fever). Symptoms may appear within 2 weeks of abstinence, but usually 48 to 96 hours after the last drink. Risk factors for DTs include concurrent acute medical illness, daily heavy alcohol use, a previous history of delirium tremens or withdrawal seizures, age over 30, and at least 3 days since the last drink (6). Patients at high risk for alcohol withdrawal seizures or DTs require immediate evaluation at a medical emergency room. Those with DTs need close monitoring, fluid and electrolyte replacement, and high-dose intravenous benzodiazepines in an intensive care unit.
SCREENING AND ASSESSMENT
Patients in the primary care setting who have alcohol dependence receive proper assessment and treatment for AUDs only about 10% of the time. The U.S. Preventive Services Task Force recommends that primary care practitioners screen all patients for AUDs, with an increased focus on those who are at high risk of alcohol abuse or dependence (i.e., family or personal history of substance misuse, recent stressors, or comorbid mood, anxiety, or psychotic disorders) (7). A number of userfriendly screening instruments have been validated to facilitate screening and diagnosis of AUDs. The most popular instrument is the 4-item CAGE questionnaire (Table 7.3), which has a sensitivity of up to 94% and specificity of 70% to 97% for detecting current abuse or dependence disorders in the primary care setting (8). One affirmative answer should lead to a more detailed evaluation (9).
The Alcohol Use Disorders Identification Test (AUDIT) is a 10-item questionnaire available from the World Health Organization (WHO). Despite the fact that the AUDIT can be given verbally or via written questionnaire in less than 3 minutes, its use in busy practices is reduced by its length. A quicker modification, called AUDIT-C, includes only the first three questions of AUDIT that quantify alcohol intake (Table 7.3). A score greater than 4 has a sensitivity of 86% and specificity of 72% for heavy drinking or abuse (10). Once a screening tool is positive, further assessment should assess the following: (1) quantity, frequency, and pattern of consumption; (2) alcohol-related problems; (3) use of other illicit or prescription drugs; (4) severity of dependence (e.g., history of withdrawal and symptoms with prior attempts to quit); (5) comorbid medical or psychiatric conditions; and (6) patient recognition of the problem and readiness to change. We recommend using either the CAGE or AUDIT-C screening tools as a means to determine the need for a more extensive substance abuse evaluation.
Table 7.3 Brief Screening Instruments for Alcohol Use Disorders
Have you ever felt that you should Cut down on your alcohol use?
2.
Have people Annoyed you by asking about or criticizing your alcohol use?
3.
Have you ever felt Guilty about your alcohol use?
4.
Have you ever used alcohol as an Eye-opener first thing in the morning to avoid unpleasant feelings?
Alcohol Use Disorder Identification Test-Consumption (AUDIT-C)c,d
1.
How often do you have a drink containing alcohol?
Never
0
Monthly or less
1
2-4 times a month
2
2-3 times a week
3
4 or more times a week
4
2.
How many drinks containing alcohol do you have on a typical day when you are drinking?
1 or 2
0
3 or 4
1
5 or 6
2
7 to 9
3
10 or more
4
3.
How often do you have six or more drinks on one occasion?
Never
0
Less than monthly
1
Monthly
2
Weekly
3
Daily or almost daily
4
a One affirmative answer should prompt further questioning about alcohol use and two or more affirmative answers increase the chance of alcohol use disorders.
b From U.S. Preventive Services Task Force. Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: recommendation statement. Ann Intern Med. 2004;140(7):554-556.
c A score of 4 or more most likely indicates alcohol abuse or dependence and warrants further investigation.
d From Fiellin DA, Reid MC, O’Connor PG. Screening for alcohol problems in primary care: a systematic review. Arch Intern Med. 2000;160:1977-1989.
Without using screening tools, AUDs are often overlooked in the clinical settings, and detection requires a high index of suspicion. Certain clinical conditions and findings should raise this suspicion (Table 7.4). Typical clues may include comorbid psychiatric symptoms such as anxiety, depression, irritability, panic attacks, impaired concentration, and persistent insomnia. Physical symptoms may include malaise, fatigue, headaches, loss of consciousness, amnesia, heartburn, hematemesis, jaundice, erectile dysfunction, hemorrhoids, and paresthesias or neuropathic pain from peripheral neuropathy. Several medical conditions are commonly associated with alcohol use: gastroesophageal reflux disease (GERD), peripheral neuropathy, hypertension, and pancreatitis. Alcohol use is also implicated as a factor in a large percentage of sexually transmitted infections and unintended pregnancies.
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