1. Copyright Alcohol Medical Scholars Program 2004 1 A Clinical Guide To Assessing Alcohol Use And Problems Andrea DiMartini M.D. University of Pittsburgh Medical Center Western Psychiatric Institute Alcohol Medical Scholars Program

2. Copyright Alcohol Medical Scholars Program 2004 2 This Lecture Will Cover: Why this is important What physicians need to know Perceived barriers to screening Effective screening techniques

3. Copyright Alcohol Medical Scholars Program 2004 3 Why This Is Important? Alcohol use is common Alcohol problems often missed or undetected

4. Copyright Alcohol Medical Scholars Program 2004 4 Alcohol Use Impacts Overall Health Direct toxic effects Systemic effects Biochemical / nutritional Cancer

5. Copyright Alcohol Medical Scholars Program 2004 5 Why Should Physicians Care? Alcohol use impacts overall health Treatment issues for general medicine Behaviors are changeable 3 rd leading cause of preventable death

6. Copyright Alcohol Medical Scholars Program 2004 6 Gender Genetics Body weight Metabolism Medical illness Pregnancy Prior alcohol use disorder How Much Is Too Much? Depends on risk factors

7. Copyright Alcohol Medical Scholars Program 2004 7 Alcohol Use And Disease Number of standard drinks per day Risk for health problems

8. Copyright Alcohol Medical Scholars Program 2004 8 Risk Of Alcoholic Cirrhosis Alcohol Cirrhosis Odds Ratio (drinks/day) (%) for Cirrhosis Teetotaler 0.04 0 < 3 0.15 0 3 - 6 1.0 10.9 > 6 - 9 2.3 25.0 > 9 4.9+ 52.9+ *Bellentani, Tiribelli. 2001

9. Copyright Alcohol Medical Scholars Program 2004 9 Assessment Domains Alcohol Use Patterns Alcohol Use Disorders Alcohol Related Health Problems

10. Copyright Alcohol Medical Scholars Program 2004 10 Alcohol Use Disorders: Alcohol Abuse If not dependent, 1+ in the same year of repetitive: Failure to fulfill major obligations Physically hazardous Legal problems Social / interpersonal problems

11. Copyright Alcohol Medical Scholars Program 2004 11 Alcohol Dependence 3+ in the same year: Tolerance Withdrawal Larger amounts / longer period than intended Attempts to cut down Excessive time spent with alcohol Activities given up due to alcohol Continued use despite problems

12. Copyright Alcohol Medical Scholars Program 2004 12 Which Patient Would You Ask?

13. Copyright Alcohol Medical Scholars Program 2004 13 Primary Barriers To Asking Issues on Interviewing Assumptions about patient Stigma of alcoholism Uncomfortable asking Afraid to uncover a problem Forgot Think you don’t have the time

14. Copyright Alcohol Medical Scholars Program 2004 14 Stages Of Evaluation Screening Assessment Treatment Adapted from Connors, 1995

15. Copyright Alcohol Medical Scholars Program 2004 15 Goals Of Screening Screening is not comprehensive Assess for problems Assess for patterns Inform / improve patient treatment plan

16. Copyright Alcohol Medical Scholars Program 2004 16 Methods Of Gathering Data Interview Questionnaires Alcohol Use Patterns Alcohol Use Disorders Alcohol Related Health Problems Physical exam Laboratory tests

17. Copyright Alcohol Medical Scholars Program 2004 17 Laboratory Tests Can supplement interview May identify health problems Not necessarily specific Sometimes identifies heavy use

18. Copyright Alcohol Medical Scholars Program 2004 18 Specific Tests: Gamma-glutamyltransferase (GGTP) Increased from enzyme induction or liver cell death Normal values (i.e. > 35 IU/L) may indicate heavy use Non-specific For non-medical populations –sensitivity 40-60% –specificity 90%

19. Copyright Alcohol Medical Scholars Program 2004 19 Specific Tests: Erythrocyte mean corpuscular volume (MCV) Alcohol is toxic to maturation of red blood cells MCV >98 fL reflects macrocytosis Non-specific For the general population –sensitivity 30-40% –specificity 90%

20. Copyright Alcohol Medical Scholars Program 2004 20 Specific Tests: Carbohydrate Deficient Transferrin (CDT) Deglycosylated form of transferrin (liver protein) 6 drinks / day for at least one week CDT can normalize in 2-3 weeks > 6 drinks/day –Sensitivity 60-80% –Specificity 80-90%

21. Copyright Alcohol Medical Scholars Program 2004 21 Specific Tests: Blood Alcohol Levels Acute intake (~12-18 hours) Amount and timing of intake and sampling Gas chromatography – very specific Limit of detection <0.01 g/dl

22. Copyright Alcohol Medical Scholars Program 2004 22 Physical Exam Physical features (heavy alcohol users) –Elevation in blood pressure –Irregular heart rhythms or tachycardia –Enlarged liver /spleen –Extremities -myopathy, neuropathy Other rarer features

23. Copyright Alcohol Medical Scholars Program 2004 23 Signs And Symptoms Of Withdrawal Many do not have withdrawal symptoms Most often symptoms mild to moderate: –Autonomic nervous system hyperactivity –Tremor –Increased reflexes –Gastrointestinal symptoms –Anxiety, irritability, restlessness

24. Copyright Alcohol Medical Scholars Program 2004 24 Questionnaires Efficient method of gathering data Self-administered /easy to score Supplements interview Assesses patterns / problems

25. Copyright Alcohol Medical Scholars Program 2004 25 Specific Questionnaires CAGE Cut down, Annoyed,Guilt, Eye-opener MAST - 25 items Covers alcohol problems AUDIT – 10 items Covers alcohol problems and patterns

26. Copyright Alcohol Medical Scholars Program 2004 26 Interviewing Techniques Initiate the discussion Follow-up on a positive leads Use sensitivity and non-judgmental attitude

27. Copyright Alcohol Medical Scholars Program 2004 27 Summary Alcohol frequently impacts health and heath care delivery Overcome barriers to screening Assess for problems / patterns of use Utilize effective screening techniques