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

Copyright Alcohol Medical Scholars Program 2004

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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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This Lecture Will Cover:

• Why this is important

• What physicians need to know

• Perceived barriers to screening

• Effective screening techniques


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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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• Gender

• Genetics

• Body weight

• Metabolism

• Medical illness

• Pregnancy

• Prior alcohol use disorder

How Much Is Too Much? Depends on risk factors


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Alcohol Use And Disease

0 1 to 2 3 to 5 6 or more

Number of standard drinks per day

Ris

k fo

r he

alth

pro

blem

s


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Risk Of Alcoholic Cirrhosis

Alcohol Cirrhosis Odds Ratio (drinks/day) (%) for Cirrhosis

Teetotaler 0.04 0< 3 0.15 03 - 6 1.0 10.9> 6 - 9 2.3 25.0> 9 4.9+ 52.9+

*Bellentani, Tiribelli. 2001


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Assessment Domains

Alcohol Use Patterns

Alcohol Use Disorders

Alcohol Related Health Problems


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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

Screening

Assessment

Treatment

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

• Interview

• Questionnaires

Alcohol Use Patterns

Alcohol Use Disorders

Alcohol Related Health Problems

• Physical exam

• Laboratory tests


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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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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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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 itemsCovers alcohol problems

• AUDIT – 10 itemsCovers 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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Copyright Alcohol Medical Scholars Program 2004 1 A Clinical Guide To Assessing Alcohol Use And Problems Andrea DiMartini M.D. University of Pittsburgh