Episode 175: Alcohol Use Disorder Basics

Future Dr. Sangha explains the clinical presentation, diagnosis, and fundamentals of the treatment of alcohol use disorder (AUD). Dr. Arreaza offers insights about the human aspect of the treatment of AUD.

Written by Darshpreet Sangha, MS4, Ross University School of Medicine. Editing and comments by Hector Arreaza, MD.

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What is Alcohol Use Disorder?

AUD is characterized as the inability to stop or control alcohol use despite adverse physical, social and occupational consequences.

According to DSM-5, it is a pattern of alcohol use that, over 12 months, results in at least two of the following symptoms, indicating clinically substantial impairment or distress:

Alcohol is frequently used in higher quantities or for longer periods than planned.
There is a persistent desire or unsuccessful attempt to reduce or manage alcohol use.
Activities that are required to get alcohol, consume alcohol, or recuperate from its effects take up a lot of time.
A strong need or desire to consume alcohol—a craving.
A pattern of drinking alcohol that prevents one from carrying out important responsibilities at work, school, or home.
Sustained alcohol consumption despite ongoing or recurring interpersonal or social issues brought on by or made worse by alcohol's effects.
Alcohol usage results in the reduction or cessation of important social, professional, or leisure activities.
Frequent consumption of alcohol under risky physical circumstances.
Continuing to drink even when one is aware of a chronic or recurrent health or psychological issue that may have been brought on by or made worse by alcohol
Tolerance: requiring significantly higher alcohol intake to produce the same intended effect.
Withdrawal: Characterized by the typical withdrawal symptoms or a noticing relief after taking alcohol or a closely related substance, such as benzodiazepine.

How can we determine the severity of AUD?

Mild: 2–3 symptoms
Moderate: 4–5 symptoms
Severe: >/= 6 symptoms

Who is at risk for AUD?

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The risk factors for AUD are:

Male gender
Ages 18-29
Native American and White ethnicities
Having Significant disability
Having other substance use disorder
Mood disorder (MDD, Bipolar)
Personality disorder (borderline, antisocial personality)

What is heavy drinking?

According to the National Institute of Alcohol Abuse and Alcoholism (NIAAA), heavy alcohol use is characterized as:

Males who drink > 4 drinks daily or > 14 drinks per week
Females who drink > 3 drinks on any given day or > 7 drinks per week

Pathophysiology of AUD.

The pathogenesis of AUD is not well understood, but factors that may play a role are genetics, environmental influences, personality traits, and cognitive functioning. Also, genetic factors may decrease the risk of AUD, i.e., the flushing reaction, seen in individuals who are homozygous for the gene that encodes for aldehyde dehydrogenase, which breaks down acetaldehyde.

Who should be screened?

A person with AUD may not be easy to diagnose in a simple office visit, but some clues may point you in that direction. First of all, patients with AUD may present to you during their sober state, that´s why ALL adults (including pregnant patients) must be screened for AUD in primary care )Grade B recommendation). The frequency has not been determined but as a general rule, at least in Clinica Sierra Vista, we screen once a year. The USPSTF has concluded that there is insufficient evidence to recommend screening adolescents between 12-17 years old.

What are the clinical manifestations of AUD?

Some symptoms may be subtle, including sleep disturbance, GERD, HTN, but some may be obvious, such as signs of advanced liver disease (ascites, jaundice, bleeding disorders, etc.)

If you draw routine labs, you may find abnormal LFTs (AST:ALT ratio >2:1), macrocytic anemia (MCV >100 fL), and elevated Gamma-glutamyl transferase (GGT). All these findings are highly suggestive of AUD.

Patients with AUD may present in either an intoxication or withdrawal state.

Signs and symptoms of acute intoxication may include “slurred speech, nystagmus, disinhibited behavior, incoordination, unsteady gait, hypotension, tachycardia, memory impairment, stupor, or coma.”

Signs and symptoms of withdrawal range from tremulousness to hallucinations, seizures, and death. They are seen between 4 and 72 hours after the last drink, peaking at 48 hours, and can last up to 5 days. Alcohol withdrawal is one of the few fatal withdrawal syndromes that we know in medicine, and the symptoms can be assessed using a CIWA assessment.

Treatment of AUD.

There are factors to consider before starting treatment:

Evaluating the severity of AUD
Establishing clear treatment goals is associated with better treatment outcomes
Assessing readiness to change: It can be done by motivational interviewing and using the stages of change model, which are, Pre-contemplation, contemplation, preparation, action, maintenance, and relapse.
Discussing treatment of withdrawal.

Treatment may be done as outpatient or it may require hospitalization. Dr. Beare sent an email with this information: “The approach to treating patients with AUD can be broken into two parts - the first is withdrawal management and the second is the long-term maintenance part. You MUST have a good plan for withdrawal treatment as it can be fatal if it's not addressed properly.”

“Patients with any history of seizures due to withdrawal or a history of delirium tremens need inpatient management. If their withdrawal symptoms are typically mild (agitation, tremors, sleeplessness, anxiety) then outpatient management may be appropriate, typically with a long-acting benzodiazepine such as Librium or Ativan.”

According to Dr. Beare, “the human aspect isa key element in treating alcohol use disorder. These patients arrive with tremendous amounts of suffering, shame, guilt, and fear. The relationship between the patient and provider needs to be built with compassion and understanding that this disease is horrible from the patient's perspective and using an algorithmic and calculated approach can cause significant harm to the rapport-building process, leading to lower success rates.”

Treatment requires a lot of motivation and willpower. Hopefully, we can use some tools to assist our patients to be successful.

-For mild disorder, Psychosocial interventions like motivational interviewing and mutual help groups like AA meetings may be enough to help our patient quit drinking.

-For moderate or severe disorder:

1st line treatment is Meditation and structured, evidence-based psychosocial interventions (CBT, 12-step facilitation); which leads to better outcomes

For patients who lack motivation, motivational interviewing can be a useful initial intervention
For motivated patients: medical management, combined behavioral intervention, or a combination of both can be utilized
For patients with limited cognitive abilities, 12-step facilitation, or contingency management can be helpful
For patients who have an involved partner: Behavioral couples therapy can be utilized

Medications for AUD.

The first-line pharmacological treatment is Naltrexone. It is given as a daily single dose and can be started while the patient is still actively drinking. There is a monthly dose of long-acting injectable naltrexone as well. Naltrexone is contraindicated in individuals taking opioids, and patients with acute hepatitis or hepatic failure. Alternative 1st line treatment is Acamprosate which can be used in people with contraindications to Naltrexone.

AUD is a chronic problem and requires a close follow-up to evaluate response to treatment and complications. Medications need to be used along with psychotherapy and support, and medications may need to be changed or adjusted depending on the patient. It is an individualized therapy that requires full engagement of the doctor, the patient, and their families or social support.

In conclusion, I would just like to add that, be compassionate because AUD is not a choice. AUD is a chronic problem like diabetes and HTN and may require a long road to recovery. Treatment includes psychotherapy, medications, and regular follow-up.

Thank you for listening!

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