Part 1 Recognition and Intervention. An estimated 17% to 27% of the US population will misuse...

Part 1

Recognition and Intervention

Alcohol and Drug Abusefor Primary Care Providers

• An estimated 17% to 27% of the US population will misuse alcohol, tobacco, or other drugs in their lifetime.

• Studies also report that 10% to 50% of hospitalized patients suffer from a disorder related to substance misuse.

• More than 20% of adults seen by primary care physicians have a current or past alcohol, tobacco, or other drug misuse disorder.

• About 539,000 deaths in the United States each year are attributable to alcohol, tobacco, and other drug misuse, with an aggregate societal cost that exceeds $238 billion.

• Clearly, these ailments are too common to be dealt with only by specialists; yet, they are poorly diagnosed and treated by most physicians.

The Problem

• The USPSTF recommends that clinicians screen adults age 18 years or older for alcohol misuse and provide persons engaged in risky or hazardous drinking with brief behavioral counseling interventions to reduce alcohol misuse.

• The USPSTF recommends that clinicians ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco products.

• The USPSTF recommends that clinicians provide interventions, including education or brief counseling, to prevent initiation of tobacco use in school-aged children and adolescents.

• The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening adolescents, adults, and pregnant women for illicit drug use.

Screening Recommendations

Public Beach, Vieques, Puerto Rico

• Several obstacles keep physicians from assisting substance abusing patients.

• These include physician pessimism about the effectiveness of intervention and treatment, a moralistic approach to substance misuse, and a perceived lack of time and training necessary to participate in successful interventions.

• Several predictive patterns are also evident in the management of patients who misuse alcohol, tobacco, and other drugs.

• Many physicians simply refer patients with addictive diseases to psychiatric or social services, thereby jeopardizing continuity of care.

• Others scold patients, and some even administer benzodiazepines to hospitalized alcoholic patients to prevent withdrawals, but fail to address the disease formally.

Barriers to Recognition and Intervention

• Many health care professionals simply ignore the diagnosis, failing to recognize these conditions as chronic psychiatric diseases characterized by relapses and remissions.

• Like a patient with untreated hypertension, those who are substance misusers will continue to use health care services heavily until their underlying disease is addressed.

Barriers to Recognition and Intervention

Harbor at Esperanza, Vieques, Puerto Rico

• High levels of alcohol intake are associated with impairment of multiple organs, including brain, liver, pancreas and the immune system.

• The first stage of liver damage following chronic alcohol consumption is the development of fatty liver, which may be followed by inflammation, apoptosis, fibrosis and cirrhosis.

• Alcohol and its metabolite acetaldehyde are carcinogens, and excessive alcohol consumption is associated with increased risk for mouth and oropharyngeal cancer, breast cancer and liver cancer.

• Depression, epilepsy, hypertension and hemorrhagic stroke occur secondary to alcohol consumption.

• Finally, alcohol consumption during pregnancy can result in birth defects that comprise fetal alcohol syndrome

Complications of Alcoholism

Alcoholism is a common substance-abuse disorder that leads to significant medical complications. Alcohol affects virtually every organ system, and alcoholics are at increased risk for cirrhosis, gastrointestinal (GI) bleeding, pancreatitis, cardiomyopathy, trauma, mental health disorders, and a wide variety of cancers. Patients should be made aware of the numerous devastating short- and long-term complications of alcohol abuse. The computed tomography (CT) scan shown in the slide demonstrates an unresectable pancreatic adenocarcinoma surrounding the superior mesenteric artery (sma), a malignancy that is more common in alcoholics.


Alcohol abuse is the second most common cause of cirrhosis in the United States, after hepatitis C. Damage to the liver parenchyma from alcohol leads to progressive fibrosis, producing a nodular contour to the liver (white arrows). The subsequent increased resistance to portal blood flow induces portal hypertension, which may cause splenomegaly (yellow arrow), transudative ascites (red arrow), and varices. The CT image shown in the slide demonstrates very prominent esophageal varices (green arrow).


• Hepatocellular carcinoma (HCC) is one of the most common causes of cancer-related death worldwide.

• Life expectancy after diagnosis is generally in the range of 6-20 months. Roughly 30% of HCCs are due to excessive alcohol use.

• In patients with 10 years of chronic alcohol use, risk is increased fivefold.

• Among patients who drink more than 30 g of ethanol daily, the risk ratio for squamous cell carcinoma of the esophagus is 4.61 in comparison with abstainers.

• Dysphagia with solids and eventually with liquids is the most common presenting symptom.


• Stroke is the third leading cause of death in the United States and is a major cause of disability.

• Although low-to-moderate alcohol use is associated with a reduced risk of stroke, heavy alcohol use significantly increases the risk of both ischemic and hemorrhagic stroke.

• In addition to the increased risk of head trauma in alcohol abusers, alcohol has an anticoagulant effect. Although this effect may be protective at lower levels of alcohol consumption, it is thought to be partly responsible for the increased risk of hemorrhagic stroke at higher levels of consumption.

• Alcohol abuse is the second most common cause of acute pancreatitis, after gallstones. Pancreatitis may develop either from an isolated episode of binge drinking or from habitual abuse. Injury to the pancreatic acinar cells creates an inflammatory cascade, leading to significant damage to the pancreas.


• Alcohol induces a number of pathologic changes to the heart.

• The classic manifestation is heart failure from dilated cardiomyopathy.

• Patients have subsequent systolic dysfunction and are at risk for arrhythmias, thromboembolism, and sudden death.

• Holiday heart syndrome refers to the development of rhythm disturbances after alcohol use in patients without structural heart disease. Atrial fibrillation is the most common disturbance, and most cases are self-limiting.

• Chronic alcohol abuse suppresses the immune system. The chemotactic ability of neutrophils is impaired, and this impaired chemotaxis leads to poor response to injury and infection.


35-year-old woman presents to the clinic with her husband after discovering she is pregnant. She does not know when her last menstrual period was, but US confirms a gestational sac (blue arrow) with yolk sac (red arrow). Your triage nurse determines that the patient has been drinking alcohol, sometimes to excess. The patient and her husband are concerned about complications to the pregnancy. You advise them that maternal alcohol consumption can be associated with fetal alcohol syndrome (FAS).

During which period of pregnancy does maternal alcohol consumption pose an especially high risk of FAS?

A.First trimester

B.Second trimester

C.Third trimester

D.Post dates (post term)

E.None of the above; the effect is equivalent throughout pregnancy


• Alcohol-related psychosis is a secondary psychosis that manifests as prominent hallucinations and delusions occurring in a variety of alcohol-related conditions.

• For patients with alcohol use disorder, psychosis can occur during phases of acute intoxication or withdrawal, with or without delirium tremens. In addition, alcohol hallucinosis and alcoholic paranoia are 2 uncommon alcohol-induced psychotic disorders, which are seen only in chronic alcoholics who have years of severe and heavy drinking.

• In chronic alcoholic patients, lack of thiamine is a common condition. Thiamine deficiency is known to lead to Wernicke-Korsakoff syndrome, which is characterized by neurological findings on examination and a confusional-apathetic state.


Bioluminescent dinoflagellates, Mosquito Bay, Vieques, Puerto Rico

• For the past two decades, evidence has accumulated that supports the effectiveness of brief interventions for patients suffering from substance misuse.

• The literature contains nearly 40 controlled studies on brief interventions targeting drinking behavior.

• These studies included more than 6,000 problem drinkers in various clinical settings and across 14 nations.

• Brief interventions were consistently found to be effective in reducing alcohol consumption and facilitating treatment referral.

Brief Intervention for Alcohol Use

• A Canadian randomized study evaluating three brief interventional methods in 159 adults showed a reduction in the frequency and quantity of drinking of 66% for men and 74% for women.

• There was no difference in the length of the intervention or whether the advice was given by the patient's own physician, an assigned physician, or a nurse.

• A meta-analysis of 12 randomized controlled trials showed that those receiving brief interventions were twice as likely to have moderated their drinking at 6 to 12 months' follow-up as those who received no intervention. This was consistent across sex, intensity of intervention, or type of clinical setting.


• In Spain, a multicenter randomized controlled trial with a follow-up of 12 months evaluated brief interventions in 229 patients.

• It showed that a 15-minute physician intervention led to 67% of patients reaching their target to reduce alcohol consumption compared with 44% of patients who were given only 5 minutes of physician advice.

• A randomized controlled clinical trial in the U.S., with a follow-up of a year looked at the efficacy of brief physician interventions in 723 problem drinkers.

• The intervention consisted of two 10 to 15 minute counseling visits delivered by physicians using a script including advice and education.

• On follow-up, a significant reduction was found in the mean number of weekly drinks, episodes of binge drinking, frequency of excessive drinking, and length of hospital stays.


300 year-old Ceiba tree, Vieques, Puerto Rico

• Substance use disorder in DSM-5 combines the DSM-IV categories of substance abuse and substance dependence into a single disorder measured on a continuum from mild to severe.

• Each specific substance (other than caffeine, which cannot be diagnosed as a substance use disorder) is addressed as a separate use disorder (e.g., alcohol use disorder, stimulant use disorder, etc.), but nearly all substances are diagnosed based on the same overarching criteria.

• Whereas a diagnosis of substance abuse previously required only one symptom, mild substance use disorder in DSM-5 requires two to three symptoms from a list of 11.

Substance Use Disorder DSM-V

• The DSM-V explains that activation of the brain’s reward system is central to problems arising from drug use –- the rewarding feeling that people experience as a result of taking drugs may be so profound that they neglect other normal activities in favor of taking the drug.

• This occurs because in persons with addiction, the substance used stimulates dopamine release, and/or interacts with dopamine in a unique way.

• While the pharmacological mechanisms for each class of drug is different, the activation of the reward system is similar across substances in producing feelings of pleasure or euphoria, which is often referred to as a “high.”


Substance-Use Disorder

A. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by 2 (or more) of the following, occurring within a 12-month period:

1. Recurrent substance 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 substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household)

2. Recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)

3. Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights)


4. Tolerance, as defined by either of the following:a. a need for markedly increased amounts of the substance to achieve intoxication or desired effect

b. markedly diminished effect with continued use of the same amount of the substance (Note: Tolerance is not counted for those taking medications under medical supervision such as analgesics, antidepressants, ant-anxiety medications or beta-blockers.)

5. Withdrawal, as manifested by either of the following:a. the characteristic withdrawal syndrome for the substance (refer to Criteria A and B of the criteria sets for Withdrawal from the specific substances)

b. the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms (Note: Withdrawal is not counted for those taking medications under medical supervision such as analgesics, antidepressants, anti-anxiety medications or beta-blockers.)

6. The substance is often taken in larger amounts or over a longer period than was intended


7. There is a persistent desire or unsuccessful efforts to cut down or control substance use

8. A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects

9. important social, occupational, or recreational activities are given up or reduced because

of substance use

10. the substance 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

11. Craving or a strong desire or urge to use a specific substance.


Severity specifiers:• Mild: 2-3 criteria positive

• Moderate: 4-5 criteria positive

• Severe: 6 or more criteria positive

Specify if: • With Physiological Dependence: evidence of tolerance or withdrawal

• Without Physiological Dependence: no evidence of tolerance or withdrawal

Course specifiers:• Early Full Remission

• Early Partial Remission

• Sustained Full Remission

• Sustained Partial Remission

• On Agonist Therapy

• In a Controlled Environment


Playa Chiva (Blue Beach), Vieques, Puerto Rico

• Twin studies have demonstrated that the amount of alcohol one consumes has a genetic influence.

• Age at first drink appears to be associated with alcohol-related problem behavior, but progression to alcoholism is under stronger genetic control than initiation, and the effect of early exposure to predict outcome is genetically mediated.

• Alcohol-related phenotypes are typical quantitative traits, with population variation attributable to multiple segregating loci with effects that are sensitive to environmental exposures.

Genetics of Addiction

• The main pathway of ethanol metabolism involves its conversion to acetaldehyde by alcohol dehydrogenase.

• Acetaldehyde is oxidized to acetate by aldehyde dehydrogenase. The activated form of acetate, acetyl-CoA, can be metabolized into ketone bodies, fatty acids, amino acids and steroids, in addition to oxidation in the Krebs cycle. Cytochrome P450s and catalase also metabolize a small fraction of ingested ethanol.

• Multiple ADH and ALDH enzymes are encoded by different genes, and different ADH and ALDH alleles can differ in expression levels and in the rate at which their corresponding enzymes metabolize ethanol or acetaldehyde.

• ADH1B, ALDH2 and ADH4 influence alcohol consumption and have been implicated as risk factors for developing alcohol abuse or dependence.

Genetics of Addiction

Ethanol is converted to acetaldehyde by alcohol dehydrogenase (ADH) and subsequently to acetate by aldehyde dehydrogenase (ALDH). Acetate is conjugated to coenzyme A and the resulting acetyl-CoA can be metabolized in the Krebs cycle, or utilized for the synthesis of fatty acids. In addition, a small fraction of ethanol is metabolized by cytochrome P450 2E1 (CYP2E1) and in the brain by catalase. Accumulation of acetaldehyde is responsible for the physiological malaise commonly known as 'hangover'.

Alcohol metabolism

Genetics of Addiction• The positive reinforcing effects of alcohol are

mediated through the corticomesolimbic dopaminergic reward pathway, which extends from the ventral tegmental area to the nucleus accumbens and is modulated by a wide range of neurotransmitters.

• This pathway is indirectly activated by alcohol through the release of other neurotransmitters, including acetylcholine, dopamine, glutamate, gamma-aminobutyric acid (GABA), opioids and serotonin.

• Several candidate genes in neurotransmitter pathways associated with the ventral tegmental area and nucleus accumbens have been associated with alcohol dependence.

The Genetic Basis of Alcoholism: Multiple Phenotypes, Many Genes, Complex Networks. Tatiana V Morozova, David Goldman, Trudy FC Mackay and Robert RH Anholt. Genome Biology 2012; 13(2): 239

Alcohol-Related Problems: Recognition and Intervention. SANDRA K. BURGE, PH.D., and F. DAVID SCHNEIDER, M.D., M.S.P.H., University of Texas Health Science Center, San Antonio, Texas. Am Fam Physician. 1999 Jan 15;59(2):361-370.

Resources

Red Beach, Vieques, Puerto Rico

Part 1 Recognition and Intervention. An estimated 17% to 27% of the US population will misuse...

Documents

Transcript of Part 1 Recognition and Intervention. An estimated 17% to 27% of the US population will misuse...