Alcohol (Part 1)Epidemiology and

Assessment

© 2009 University of Sydney

Learning outcomesBy completing this module, participants will

be able to:• Describe the epidemiology of alcohol problems in

Australia

• Obtain an alcohol history

• Describe the acute and chronic complications of alcohol use disorders

• Perform a relevant physical examination

• Describe the role of blood tests in assessing alcohol use disorders

Case: Mr H.• 60 y.o. man, interviewed via interpreter• Type 2 diabetes, oral hypoglycaemics• Hypertension• Admitted to hospital, drowsy after falling

and banging head• Smells of alcohol• Reports max 4 glasses spirits/day• 14cm Hepatomegaly• GGT 1042 U/L

Mr H: input from daughter

• Drinks up to a bottle of whisky per day

• Wife finding it difficult to cope with repeated falls and is considering a nursing home

Mr H: issues• How common are alcohol use disorders

and their complications?

• How to take a good alcohol history?

– When is a drinker dependent?

• Can we simply assume his liver problem is related to alcohol?

Epidemiology

Alcohol use in Australia• Nine out of every ten Australians aged

14 years or older (89.9%) had tried alcohol at some time in their lives.

• 82.9% had consumed alcohol in the 12 months preceding the 2007 survey

Australian Institute of Health and Welfare, 2008

Alcohol abuse in Australia• Prevalence of alcohol use disorders = 6%

of Australian population

• Alcohol-related conditions account for

– up to 40% of ED presentations

– up to 30% of hospital admissions

– about 50% of D&A CL activity

NSMHWB, 2007;Charalambous 2002, Alcohol, 37;

Conigrave et al 1991 Med J Aust, 154; Pols &Hawks, 1992

Impact of Drugs and Alcohol on hospitals: 2004/5

Deaths Hospital bed days Hospital costs ($M)

Tobacco 14,901 753,618 669.6

Alcohol 1,057 916,934 693.9

Opiates 228 22,463 13.1

Cannabis 1 7,287 3.1

ATS 17 5,288 3.4

Licit, combined, unspecified

483 40,811 23.0

Collins & Lapsley 2008, Commonwealth of Australia

Assessment

Alcohol Consumption• Every patient needs a quantified

drinking history

• Episodic drinking is common

• Make it easy for the patient to admit to heavy drinking

• e.g. suggest a high level of drinking

What is a standard drink?

NB: home or restaurant poured drinks are variable but are approximately 2 standard drinks

Drink-less Program, 2005

Non-standard drinks

Drink-less Program, 2005

Non-standard drinks • Home or restaurant-poured drinks

are often larger– Home poured wine and spirits are

typically 2-3 standard drinks

– Check rate of purchase of bottle/flagon

– Assess by packaged units (e.g. number of bottles of wine or spirit purchased per week)

Low risk drinking levelsNHMRC Australian guidelines to reduce health

risks from drinking alcohol (2009): 1. For reduced lifetime risk of harm from drinking:

2 standard drinks or less in any 1 day (for healthy men and women, aged 18 and over)

2. For reduced risk of injury in a drinking occasion:

No more than 4 standard drinks per occasion

3. For people <18 years of age: safest not to drink

Under 15: Especially important not to drink

Between 15-17: Delay drinking initiation for as long as possible

4. Pregnant (or planning a pregnancy) or Breastfeeding: Not drinking is safest option

Some definitions• Hazardous use: drinking patterns that

increase the risk of adverse consequences for the user or others.

• Harmful use: already experiencing consequences to physical or mental health from drinking. Could also include social consequences.

Babor et al, 2001, WHO

Some definitionsDependence – ICD10 • Three or more criteria present:

– Compulsion to drink– Loss of control– Tolerance– Salience/neglect of alternative interests or

obligations– Withdrawal symptoms – Persistent drinking despite harm

WHO, 2007

Why the definitions are important

• Dependent drinkers usually need to stop drinking and may experience a withdrawal syndrome

• Hazardous or harmful drinkers can usually cut down

5%

15%

65%

15%

High risk/dependent

At risk

Low risk

Non-drinker

Teesson, 2000 ANZ J Psych, 34 (NSMHWB)

Types of drinkers (adults)

Assessment of drinking• Alcohol consumption

• Presence of dependence

• Desire to change drinking, past attempts to cut down or stop

–Experienced withdrawals?

Assessment of drinking (cont’d)

• Consumption level• Presence of dependence• Desire to change drinking, past attempts• Complications/comorbidity

– Physical and psychiatric problems• e.g. hep C, obesity

– Other substance use• Benzodiazepines, opiates (licit/illicit),

cannabis, stimulants

Assessment of drinking (cont’d)

• Other factors which could make change difficult:

– Housing

– Employment

– Social/family environment

Risk factors for alcohol use disorders

• Genetic– Polygenic– 4x risk of dependence if dependent father,

even if reared apart– Males > females

• Environmental/social– Availability (including cost and ease of

access), occupation, peer/family behaviour– Psychological trauma (e.g. childhood

abuse), unemployment

• Psychiatric illness

Natural history of dependence

• Most common in young adult men, aged 18-34 years

• Overall consumption falls with age except for severely dependent drinkers

• A chronic relapsing condition

• Only 5% return to stable controlled drinking without treatment

Acute complications

• Account for around 50% of the harm associated with drinking

• Trauma, physical/sexual assault, unprotected sex, harm to others, suicide, drowning, burns, arrhythmias

Chronic complications

• Can affect every body system• Seen in more advanced, long

standing drinkers• Many dependent drinkers have

none

Chronic complications cont’d

• GI: liver, dyspepsia, diarrhoea, delayed healing of peptic ulcer, pancreatitis

• Psychiatric: depression, suicide

• Neurological: cognitive impairment, wernicke/korsakoff’s, neuropathy, stroke

• CVS: hypertension, cardiomyopathy, arrhythmias

Chronic complications cont’d

• Nutritional: thiamine, folate, B12, malnutrition

• Musculoskeletal: osteoporosis, myopathy

• Immune: ↓T-cell function

• Respiratory from associated smoking, TB

• Renal: electrolyte disorders

• Endocrine: cortisol, ↓testosterone, type 2 diabetes

• Cancer: aerodigestive, breast, rectum

• Fetal development: fetal alcohol syndrome

Early symptoms and signs of chronic alcohol problems

• Hypertension

• Insomnia

• Indigestion/diarrhoea

• Anxiety

• Depression

• Sick days

Alcohol induced liver disease

Overlapping processes:• Fatty liver

– reversible

• Alcoholic hepatitis

– Severe cases rare

• Cirrhosis– Largely irreversible– 15% persons drinking 150g/d for 10+

yrs

Why does alcohol cause organ damage?

• Multiple factors, varies between organs• Harmful consequences of metabolism

– Oxidative (acetaldehyde toxicity, oxidant stress, acidosis)

– Non-oxidative (fatty acid ethyl esters damage membranes)

• Nutritional impairment• Endotoxinaemia

– Abnormal gut absorption of bacterial products

Does alcohol really have health benefits?

Moderate drinking and coronary heart disease

Alcohol

Lipids

(HDL-C and Triglycerides)

Hemostatic Function (Fibrinogen)

Insulin Sensitivity

Other

Coronary

Heart

Disease

Mortality by alcohol consumption

0.60

1.00

1.40

1.80

abstain 1-1.9 3-3.9 5-5.9standard drinks per day

Rel

ativ

e ri

sk

Men

Women

Holman et al, Meta-analysis, 1996, MJA, 164

Moderate consumption apparently reduces total

mortality

15 year mortality in Swedish army

0.5

1

1.5

2

2.5

0 <15 g/d 15-29 g/d 30+ g/d

mean daily alcohol at recruitment

Od

ds

rati

o

Andreasson et al, 1991, British Journal of Addiction, 86, 379-382

No reduction of mortality in young people

Health benefits of alcohol are still uncertain

• Restricted demographic:

– Overall, most harms and fewest benefits occur in young people who drink the most

• Health of moderate drinkers is compared to abstainers. However, many only abstain when already sick.

• Very few Australians are lifelong non-drinkers and these may not be representative of the general population.

Fillmore et al, Ann Epidemiol 2007: 17: S16-S23

Clinical Assessment

Brief questionnaires• Sensitive and specific

• Validated

• Cheap, instant, quantifiable

• Suitable for screening e.g. in waiting room

• e.g.:– CAGE and its modifications (4-6 items)1

– AUDIT (10 items) or AUDIT-C (first 3 items)2

1 Ewing, 1984, JAMA, 2522 Babor et al, 2001, WHO

Physical examination• Intoxication or withdrawal

• Tolerance: mild observable impairment despite high consumption or BAC

• Complications: – Complete physical examination

– Remember blood pressure

• Intoxicated people can also be sick– Remember head injury!

Assessment: Putting it all together

• Is your patient drinking above reduced risk levels?

• If so is he or she: – Willing to attempt change ?

– Dependent ?• If so, is a withdrawal syndrome likely?

• Is there organ damage or other harm(s)?

Alcohol withdrawal scale

• Moderately useful tools (e.g. AWS, CIWA-AR)

– Objective– Guide to treatment once diagnosis has been

made

• Limitations– Not specific– Inaccurate scoring is problematic– Not validated for complex patients with

comorbidity and should not be used in that setting

Investigations

Blood tests for alcohol use• For recent consumption

– Blood or breath alcohol

• For “chronic” consumption– GGT, AST, ALT– MCV– (CDT)

Blood alcohol (BAC)• Detects recent drinking only

– ethanol metabolised at 10g/hour

• Breath levels correlate closely with blood

• In a person smelling of alcohol, BAC can– confirm recent drinking– suggest tolerance if high BAC, low

impairment

• Urine alcohol: longer window of detection

GGT(Gamma glutamyltransferase)

• The most sensitive blood test that is widely available– BUT only positive in 30% heavy drinkers in

community

• Alcohol is commonest cause of elevation– But up to 50% GGT elevation is for other

reasons inc. obesity, medications

• Half Life: 2 weeks

• Prognostic value, tool in monitoring

GGT• More likely to be elevated if:

– Male– Obese– Long drinking history– Regular (cf episodic) drinker– >30 years

Conigrave et al, 2002, Alcoholism: Clinical and experimental research, 26(3) © Wiley 2002

Other conventional markers

• Aminotransferases

AST:ALT >1.5 suggests alcohol

• MCV: slow return to normal

– t1/2 60 days

– Non-specific

(e.g. nutritional, drugs, liver disease)

– Increased even when folate/B12 normal

CDT (carbohydrate deficient transferrin)

• Increase in isoforms of transferrin with lower carbohydrate content

• t1/2 2 weeks

• Similar sensitivity to GGT, but higher specificity

– higher levels with pregnancy, anaemia, PBC, advanced cirrhosis

• % of total transferrin a little more accurate

• Not reimbursed by Medicare, expensive, limited access

• Used in medico-legal settings to monitor pts

Other investigations

If indicated:• Psychological testing: bedside or

by psychologist• Hepatic ultrasound • Liver biopsy – rarely

Follow-up on Mr. H• Advised that whatever amount he is drinking, he

needs to stop• Further history eventually elicited that for Mr H:

– 3 glasses = up to 3 x 250mls spirits daily– Agitated if stops drinking, no tremor

• Feedback/treatment provided, including pharmacotherapy

• Outcome at two month follow-up:– reduced drinking to three times per week– No further falls– GGT fallen from 1042 to 726 U/L– Wife: “I have a life again”

Summary• Alcohol use disorders are common

• Quantified alcohol history essential

• Collateral report may be revealing

• Assess dependence where clues to diagnosis

• Complications affect every system, but occur late and not in all heavy drinkers

• Laboratory tests are not sensitive enough for screening, but may provide additional information

Self Evaluation Question 1

Please choose the correct statement:a) More than 80% of Australian adults used

alcohol within the last 12 months

b) Only 10% of Australians associate alcohol with a drug problem.

c) 6.1% of the Australian population has an alcohol use disorder.

d) All of the above

e) None of the above

Self Evaluation Question 2Please choose the correct statement:

According to the NHMRC Guidelines, reduced risk drinking is defined as:

a) On average, Men: no more than 4 SD/day, Women: no more than 2SD/day with 2 alcohol free days a week

b) Men and women: 3 SD/day with 2 alcohol free days

c) Men and women: 2 SD/day or less in any one day

d) Not drinkinge) No more than 1 SD per hour

Self Evaluation Question 3

Which one of the following is the most sensitive indicator of chronic alcohol consumption?

a) BAC

b) MCV

c) ALT

d) AST

e) GGT

Self Evaluation Answers• 1: Correct answer is D.

– Yes it is a major public health problem.

• 2: Correct answer is C. – NHMRC advises 2SD/day or less for

healthy men and women.• 3: Correct answer is E.

– But please revisit the slides on GGT and remember the limitations of GGT.

Self-test case• Laura is a 27 year old woman who describes

herself as a social drinker.• When you assess her further, she tells you she

goes out with her friends and tends to drink 9 mixed drinks, 3 times per week.

• She has had episodes of being unable to remember how she got home after an evening drinking.

• Questions:– What risks does Laura face from her drinking?

– What factors might encourage heavy drinking in a young woman?

– Would you expect to see evidence of liver disease on examination or blood tests?

Self-test case answers• Laura runs the risks associated with acute

intoxication: e.g. sexual or physical assault, drink driving, falls, other trauma.

• There can be peer pressure to engage in heavy drinking from the group. Some occupations, such as sales, where entertaining is often done over alcohol, pose an additional risk.

• It would be surprising to see any evidence of hepatic impairment given the episodic nature of her drinking and her young age.

ContributorsAssociate Professor Kate Conigrave Royal Prince Alfred Hospital & University of Sydney

Dr Ken CurryCanterbury Hospital & University of Sydney

Dr Apo DemirkolSSWAHS Drug Health Services & University of Sydney

Professor Paul HaberRoyal Prince Alfred Hospital & University of Sydney

Associate Professor Martin Weltman Nepean Hospital & University of Sydney

All images used with permission, where applicable