Google+Linking To And Excerpting From Addiction Medicine Podcast "#4 Wrapping Our Heads Around Alcohol Use Disorder Meds" With Links To Additional Resources - Tom Wade MD
“The AUDIT (Alcohol Use Disorders Identification Test) is a simple and effective method of screening for unhealthy alcohol use, defined as risky or hazardous consumption or any alcohol use disorder.
“Based on the data from a multinational World Health Organization collaborative study, the AUDIT has become the world’s most widely used alcohol screening instrument since its publication in 1989. It is currently available in approximately 40 languages.
“Importantly, the AUDIT provides a framework for intervention to help those with unhealthy alcohol use reduce or cease alcohol consumption and thereby avoid the harmful consequences of alcohol.
“The AUDIT can also help identify alcohol dependence and specific consequences of harmful drinking. It is particularly designed for health care practitioners and a range of health settings, but with suitable instructions it can be self-administered or used by non-health professionals.”
*Huxely-Reicher Z, Peterkin, A, Cohen S, Mullins K, Chan, CA. “#4Wrapping Our Heads Around Alcohol Use Disorders Meds w/Dr. Alyssa Peterkin”. The Curbsiders Addiction Medicine Podcast. http://thecurbsiders.com/addiction July 28th, 2022.
All that follows is from the above resource.
Get comfortable treating alcohol use disorder (AUD). In this episode, we discuss the diagnosis of AUD strategies to help patients develop therapeutic goals and options for pharmacotherapy. We are joined for this episode by Dr. Alyssa Peterkin (BU), an internal medicine and addiction medicine physician who encourages us to venture into offering pharmacotherapy for AUD as it is vastly undertreated. By the end of this episode, you will be naltrex-owning meds for AUD!
Claim CME for this episode at curbsiders.vcuhealth.org!
By listening to this episode and completing CME, this can be used to count towards the new DEA 8-hr requirement on substance use disorders education.
Production Partner: ACAAM
The Curbsiders Addiction Medicine are proud to partner with The American College of Addiction Medicine (ACAAM) to bring you this mini-series. ACAAM is the proud home for academic addiction medicine faculty and trainees and is dedicated to training and supporting the next generation of academic addiction medicine leaders. Visit their website atacaam.orgto learn more about their organization.
CME Partner: VCU Health CE
Show Segments
Intro, disclaimer, guest bio – 1:40
Guest one-liner – 3:29
Case from Kashlak – 7:15
Alcohol use history, defining Alcohol Use Disorder -8:15
Understanding patient goals around substance use – 14:10
Presenting treatment options – 18:50
Off-label treatment options: Topiramate and Gabapentin – 27:45
Effectiveness of medications – 35:10
Follow up – 37:30
Psychosocial interventions – 42:06
Harm reduction for AUD – 46:00
Outro – 50:00
AUD Pharmacotherapy Pearls
Only about 2% of patients with AUD are actively receiving treatment and medications for AUD work!
There is good evidence that reducing alcohol use (NOT just total abstinence) improves health outcomes, reduces mortality, and improves the quality of life.
FDA-approved medications for AUD include naltrexone, acamprosate, and disulfiram. Naltrexone is first-line for most patients unless they have active opioid use of any kind or acute hepatitis. For patients with decompensated liver disease, a discussion of the risks vs. benefits of the medication should occur. Acamprosate is contraindicated for patients with GFR <30.
If a patient does not have clinical signs of decompensated liver disease, the need to check LFTs should not delay the start of naltrexone treatment.
Topiramate and gabapentin can be considered for off-label treatment of AUD in some cases.
Many types of psychosocial support and/or treatment exist to support patients with AUD – if you do not feel comfortable helping your patients navigate these resources, find out who in your healthcare system you can refer to for assistance.
Take an alcohol use history – Dr. Peterkin recommends starting with general questions about how much a patient drinks in one sitting and how often in a week. Unhealthy alcohol use includes both binge drinking and heavy drinking. Binge drinking means exceeding daily limits – 4 or more drinks consumed on one occasion for women, or 5 or more drinks consumed on one occasion for men. Heavy drinking means exceeding weekly limits – 8 or more drinks or more per week for women, or 15 or more drinks per week for men (CDC 2019).
Assess whether a patient meets the criteria for unhealthy use or alcohol use disorder (AUD) using the following tools:
First, use a single-item, calendar-based screener that is validated in primary care settings (Smith, 2009). Ask “How many times in the past year have you had X or more drinks in a day?”, where X is 5 for men and 4 for women. A response of >1 means that the patient meets the criteria for unhealthy alcohol use.
Other screening tools include the AUDIT and AUDIT-C, but these are lengthier so they might be less user-friendly. The CAGE questionnaire has low sensitivity for detecting mild cases of unhealthy use (Dhalla, 2007).
Next, assess for AUD using criteria from the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) (NIAAA, 2021). These eleven criteria determine whether someone has experienced problems related to alcohol use. If a patient answers yes to two or more criteria, then they carry a diagnosis of AUD. Depending on the number of criteria that a patient meets, you can diagnose a mild, moderate, or severe use disorder. The criteria are included below.
11 – DSM-V Criteria
Substance is taken in larger amounts or over a longer period of time than intended
There is a persistent desire or unsuccessful efforts to cut down or control substance use
A great deal of time is spent in activities necessary to obtain, use or recover from its effects
Craving, or a strong desire to use the substance
Recurrent substance use resulting in failure to fulfill major role obligations at work, school, or home
Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of substances
Important social, occupational, or recreational activities are given up or reduced because of substance use
Recurrent substance use in situations in which it is physically hazardous
Continued use despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by substance
Tolerance (defined as a need for markedly increased amounts of substance to achieve intoxication or desire effects, OR markedly diminished effect with continued use of the same amount of a substance)
Withdraw
Defining a standard drink:
Patients (and providers) may not have a great sense of what a standard drink is, so we need to clarify units to quantify use. Use familiar metrics such as a bottle of wine or 12-ounce beer. Walk through this visual tool with patients or with this interactive tool where a patient “pours” their drink can help.
Identifying patient goals:
First and foremost, it is essential to help your patient articulate their specific goals concerning their drinking in a patient-centered way. Aim to meet patients where they are at. Ask your patient – what do you want to do here? What are your goals? Do you want to cut down? How much, in what time frame? Often patients may be pre-contemplative about making changes to their alcohol use – this is an opportunity to use motivational interviewing techniques. Ask patients what they enjoy about drinking, what they dislike, and how they think it has impacted their health. These questions are helpful to explore in both the hospital and outpatient settings because you can offer treatment from either location.
Remember that abstinence is not the only successful outcome – evidence supports that reducing use is associated with improved health outcomes and quality of life and can be sustainable for some people. (Witkiewitz, 2018) (Witkiewitz, 2017) (Witkiewitz 2021) (Falk, 2019).
Explaining AUD to patients-
Dr. Peterkin makes sure to frame addiction to patients as a chronic disease, NOT as a choice or a moral failing. People choose to use substances for many reasons, and genetic and psychosocial factors influence their responses. Substance use disorders involve uncontrolled use despite negative consequences. Patients may express that they plan to stop right now; Dr. Peterkin advises digging deeper to help patients develop concrete plans.
Pharmacotherapy for AUD:
AUD is severely undertreated. Roughly 2% of patients with AUD are prescribed pharmacotherapy (Joudrey 2019) (Harris 2012). Offer pharmacotherapy in inpatient and outpatient settings (Wei, 2015) (Joudrey 2019). Three medications (naltrexone, acamprosate and disulfiram) have FDA approval to treat AUD. Off-label options include topiramate and gabapentin.
Naltrexone
Naltrexone is the first-line medication for AUD for most patients. Naltrexone is an opioid receptor antagonist and is contraindicated for patients who use opioids (including prescription pain medication, heroin, methadone, or buprenorphine) and do not plan to stop their use. Naltrexone comes in an oral formulation with a dosage of 50 mg or an IM form of 380 mg that is injected monthly.
Dr. Peterkin recommends starting at 25 mg (½ dose) for 3 days and then increasing to 50 mg daily. It has a number needed to treat of 12 for return to heavy drinking and 20 for return to any drinking, which is comparable to (or better) than medications we use every day to treat other chronic conditions (e.g., statins, SSRIs) (Jonas 2014). Common side effects include dysphoria, fatigue, headache, and GI side effects. If patients experience fatigue or dizziness, they can take the naltrexone at night or take it with food if they experience GI side effects (which typically resolve after the first few days). Of note, IM naltrexone does not undergo first-pass metabolism in the liver, which theoretically gives it a lower risk of hepatotoxicity, yet this lacks a real-world comparison (SAMHSA, 2009).
In addition to opioid use, acute hepatitis or acute hepatic failure is a contraindication. For patients with decompensated cirrhosis, the risks vs benefits of using the medication should be discussed with the patient and hepatologist. Naltrexone is generally safe to use and can be considered in decompensated cirrhosis with close monitoring, particularly since reducing alcohol use is so essential to maintaining liver function. Often, initiating naltrexone will improve LFTs in patients with alcohol-related liver disease (Augustin, 2022). Clinically monitor a patient taking naltrexone for signs of liver disease. Still, a patient does not necessarily need baseline LFTs or routine monitoring to start or continue the medication – in fact, the absence of these labs should not prevent you from starting the medication (Springer, 2014). The choice between daily oral pills or intramuscular injections should be made with your patient.
Acamprosate
Acamprosate is an appropriate treatment option if your patient cannot take or is not interested in naltrexone. Discuss up front that this medication consists of two pills three times per day, which is challenging for medication adherence. Reduce the dose by ½ in patients with moderate CKD and do not prescribe if GFR is less than 30. The dosing for this medication is 666 mg TID, or 333 mg TID for patients with moderate CKD. The number needed to treat for acamprosate is 20 to reduce the likelihood of a return to any drinking (Jonas 2014).
Disulfiram
The third FDA-approved medication for AUD is disulfiram. This medication inhibits the metabolism of alcohol, causing a systemic build-up of acetaldehyde. Any exposure to alcohol while taking this medication makes a patient uncomfortably ill, with common symptoms including flushing, sweating, headache, nausea, and vomiting; this is extremely important to counsel patients about upfront. Accordingly, this medication is only appropriate if a patient’s goal is complete abstinence and works best if another person can make sure that a patient is taking this medication daily or even administer it directly to the patient. Contraindications include active alcohol use, cardiac disease, pregnancy, and psychosis, and caution should be used in patients with cirrhosis, diabetes, epilepsy, or hypothyroidism. Be aware that disulfiram interacts with many prescription drugs.
