Transcript Alcohol Use Assessment - Alcohol Medical Scholars Program

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
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2004
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This Lecture Will Cover:
• Why this is important
• What physicians need to know
• Perceived barriers to screening
• Effective screening techniques
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2004
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Why This Is Important?
• Alcohol use is common
• Alcohol problems often missed or
undetected
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Alcohol Use Impacts Overall Health
• Direct toxic effects
• Systemic effects
• Biochemical / nutritional
• Cancer
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Why Should Physicians Care?
• Alcohol use impacts overall health
• Treatment issues for general medicine
• Behaviors are changeable
• 3rd leading cause of preventable death
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How Much Is Too Much?
Depends on risk factors
• Gender
• Medical illness
• Genetics
• Pregnancy
• Body weight
• Prior alcohol use
disorder
• Metabolism
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Alcohol Use And Disease
0
1 to 2
3 to 5
6 or more
Number of standard drinks per day
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Risk Of Alcoholic Cirrhosis
Alcohol
(drinks/day)
Cirrhosis
(%)
Odds Ratio
for Cirrhosis
0.04
0.15
1.0
2.3
4.9+
0
0
10.9
25.0
52.9+
Teetotaler
<3
3-6
>6-9
>9
*Bellentani, Tiribelli. 2001
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Assessment Domains
Alcohol Use Patterns
Alcohol
Related
Health
Problems
Alcohol Use
Disorders
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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
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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
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Which Patient Would You Ask?
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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
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Stages Of Evaluation
Treatment
Assessment
Screening
Adapted from Connors, 1995
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Goals Of Screening
• Screening is not comprehensive
• Assess for problems
• Assess for patterns
• Inform / improve patient treatment plan
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Methods Of Gathering Data
Alcohol Use Patterns
• Physical exam
• Laboratory
tests
Alcohol
Use
Disorders
• Interview
• Questionnaires
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Alcohol
Related
Health
Problems
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Laboratory Tests
• Can supplement interview
• May identify health problems
• Not necessarily specific
• Sometimes identifies heavy use
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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%
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2004
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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%
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2004
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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%
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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
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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
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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
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Questionnaires
• Efficient method of gathering data
• Self-administered /easy to score
• Supplements interview
• Assesses patterns / problems
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Specific Questionnaires
• CAGE
Cut down, Annoyed,Guilt, Eye-opener
• MAST - 25 items
Covers alcohol problems
• AUDIT – 10 items
Covers alcohol problems and patterns
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Interviewing Techniques
• Initiate the discussion
• Follow-up on a positive leads
• Use sensitivity and non-judgmental
attitude
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Summary
• Alcohol frequently impacts health and
heath care delivery
• Overcome barriers to screening
• Assess for problems / patterns of use
• Utilize effective screening techniques
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2004
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