Difference between revisions of "Alcohol use disorder"

(Clinical Features)
(Management)
 
(3 intermediate revisions by one other user not shown)
Line 25: Line 25:
  
 
==Evaluation==
 
==Evaluation==
* A history alone is sufficient to make the diagnosis of alcohol use disorder, however, if a patient presents to the ER, it is important to evaluate for the presence of acute alcohol intoxication, [https://wikem.org/wiki/Alcohol_withdrawal alcohol withdrawal], and co-ingestion with other drugs or [https://wikem.org/wiki/Toxic_alcohols toxic alcohols].
+
* A history alone is sufficient to make the diagnosis of alcohol use disorder, however, if a patient presents to the ER, it is important to evaluate for the presence of acute alcohol intoxication, [[alcohol withdrawal]], and co-ingestion with other drugs or [[toxic alcohols]].
  
 
==Management==
 
==Management==
* If the patient is not acutely intoxicated or at risk for alcohol withdrawal, they should be referred to a social worker or their PCP for resources to quit drinking and can usually be discharged safely.  
+
* If the patient is not acutely [[Ethanol toxicity|intoxicated]] or at risk for [[alcohol withdrawal]], they should be referred to a social worker or their PCP for resources to quit drinking and can usually be discharged safely.
* Disulfiram can be prescribed as alcohol avoidance therapy, but this should be done by a PCP or psychiatrist treating the patient's addiction.
+
 
 +
===Medication Assisted Treatment for Alcohol Use Disorder===
 +
=== [[Disulfiram effect|Dilsulfiram]] ===
 +
*Disulfiram can be prescribed as alcohol avoidance therapy. This can be prescribed in the emergency department or referred to PCP/psychiatrist treating the patient's addiction.
 +
 
 +
===[[Naltrexone]]===
 +
====Evidence:====
 +
**A Cochrane review assessed the efficacy of naltrexone in randomized control trials.<ref>Srisurapanont M, Jarusuraisin N. Opioid antagonists for alcohol dependence. Cochrane Database of Systematic Reviews. 2005;(1). </ref>
 +
**Naltrexone helps to reduce the number of participants who relapse or return to heavy drinking in a short time frame following treatment (12 weeks).
 +
**Naltrexone reduces the time in days to first drink when compared to placebo or disulfiram.
 +
**Naltrexone reduces reported cravings and the total amount of alcohol consumed.
 +
**Naltrexone should be offered to patients with alcohol use disorder who are interested in reducing alcohol intake.
 +
====Dosage:====
 +
**Naltrexone 380 mg IM or Naltrexone 50 mg PO qday #30 tabs, no refills
 +
Contraindications for use in AUD:
 +
**Any opioid use (including Buprenorphine):
 +
***Must be off short-acting opioids for 1 week and methadone for 2 weeks
 +
**Planned surgery/anesthesia in next 30 days (okay to use tablets, stop 1 day prior to surgery)
 +
**Acute liver injury with AST or ALT >/= 250 or decompensated cirrhosis (Childs Pugh Class 3)
 +
**Pregnancy
 +
**Allergy
 +
 
 +
===[[Gabapentin]]===
 +
====Evidence:====
 +
**A metanalysis of several randomized control trials demonstrates that use of gabapentin for alcohol use disorder reduces the number of total heavy drinking days. <ref>Kranzler HR, Feinn R, Morris P, Hartwell EE. A meta-analysis of the efficacy of gabapentin for treating alcohol use disorder. Addiction. 2019;114(9):1547-1555.</ref>
 +
**Furthermore, the addition of gabapentin to naltrexone further helped to reduce cravings in the first 6 weeks of AUD. <ref>Anton RF, Myrick H, Wright TM, Latham PK, Baros AM, Waid LR, Randall PK. Gabapentin combined with naltrexone for the treatment of alcohol dependence. Am J Psychiatry. 2011 Jul;168(7):709-17. doi: 10.1176/appi.ajp.2011.10101436. Epub 2011 Mar 31. PMID: 21454917; PMCID: PMC3204582.</ref>
 +
====Dosage====
 +
**Gabapentin 600 mg PO TID #90 tabs, no refills
 +
***counsel to decrease to 300 mg PO TID if dizzy, can increase after 1 week
 +
***renally dosed if CrCl<60
 +
***ACOG approves of use in pregnancy
 +
 
 +
 
 +
{{Vitamin prophylaxis for ETOH}}
  
 
==Disposition==
 
==Disposition==

Latest revision as of 00:49, 29 October 2020

Background

  • Chronic mental illness characterized by inability to limit alcohol ingestion, compulsive drinking, and a negative emotional state when not drinking.
  • Previously separated into alcohol abuse and alcohol dependence, but as of DSM-5, the diagnoses were combined into alcohol use disorder, and subdivided into mild, moderate, or severe.
  • It is estimated that about 6% of adults in the US suffer from alcohol use disorder.

Clinical Features

  • Drinking more or for a longer period of time than intended.
  • Feeling incapable of cutting back on the amount of alcohol consumed.
  • Becoming sick for an extended period of time as a result of drinking too much.
  • Inability to concentrate due to alcohol cravings.
  • Inability to care for a family, hold down a job, or perform in school.
  • Continuing to drink despite problems caused with friends or family.
  • Decreased participation in activities which were once important.
  • Finding oneself in dangerous or harmful situations as a direct result of drinking.
  • Continuing to drink despite adding to another health problem, feeling depressed or anxious or blacking out.
  • Drinking more as a result of a tolerance to alcohol.
  • Experiencing withdrawal symptoms.
Mild = 2-3 features
Moderate = 4-5 features
Severe = 6 or more features

Differential Diagnosis

Ethanol related disease processes

Evaluation

  • A history alone is sufficient to make the diagnosis of alcohol use disorder, however, if a patient presents to the ER, it is important to evaluate for the presence of acute alcohol intoxication, alcohol withdrawal, and co-ingestion with other drugs or toxic alcohols.

Management

  • If the patient is not acutely intoxicated or at risk for alcohol withdrawal, they should be referred to a social worker or their PCP for resources to quit drinking and can usually be discharged safely.

Medication Assisted Treatment for Alcohol Use Disorder

Dilsulfiram

  • Disulfiram can be prescribed as alcohol avoidance therapy. This can be prescribed in the emergency department or referred to PCP/psychiatrist treating the patient's addiction.

Naltrexone

Evidence:

    • A Cochrane review assessed the efficacy of naltrexone in randomized control trials.[1]
    • Naltrexone helps to reduce the number of participants who relapse or return to heavy drinking in a short time frame following treatment (12 weeks).
    • Naltrexone reduces the time in days to first drink when compared to placebo or disulfiram.
    • Naltrexone reduces reported cravings and the total amount of alcohol consumed.
    • Naltrexone should be offered to patients with alcohol use disorder who are interested in reducing alcohol intake.

Dosage:

    • Naltrexone 380 mg IM or Naltrexone 50 mg PO qday #30 tabs, no refills

Contraindications for use in AUD:

    • Any opioid use (including Buprenorphine):
      • Must be off short-acting opioids for 1 week and methadone for 2 weeks
    • Planned surgery/anesthesia in next 30 days (okay to use tablets, stop 1 day prior to surgery)
    • Acute liver injury with AST or ALT >/= 250 or decompensated cirrhosis (Childs Pugh Class 3)
    • Pregnancy
    • Allergy

Gabapentin

Evidence:

    • A metanalysis of several randomized control trials demonstrates that use of gabapentin for alcohol use disorder reduces the number of total heavy drinking days. [2]
    • Furthermore, the addition of gabapentin to naltrexone further helped to reduce cravings in the first 6 weeks of AUD. [3]

Dosage

    • Gabapentin 600 mg PO TID #90 tabs, no refills
      • counsel to decrease to 300 mg PO TID if dizzy, can increase after 1 week
      • renally dosed if CrCl<60
      • ACOG approves of use in pregnancy


Vitamin Prophylaxis for Chronic alcoholics

  • At risk for thiamine deficiency, but no symptoms: thiamine 100mg PO q day
  • Give multivitamin PO; patient at risk for other vitamin deficiencies

Banana bag

The majority of chronic alcoholics do NOT require a banana bag[4][5]

Disposition

  • Outpatient

See Also

External Links

References

  1. Srisurapanont M, Jarusuraisin N. Opioid antagonists for alcohol dependence. Cochrane Database of Systematic Reviews. 2005;(1).
  2. Kranzler HR, Feinn R, Morris P, Hartwell EE. A meta-analysis of the efficacy of gabapentin for treating alcohol use disorder. Addiction. 2019;114(9):1547-1555.
  3. Anton RF, Myrick H, Wright TM, Latham PK, Baros AM, Waid LR, Randall PK. Gabapentin combined with naltrexone for the treatment of alcohol dependence. Am J Psychiatry. 2011 Jul;168(7):709-17. doi: 10.1176/appi.ajp.2011.10101436. Epub 2011 Mar 31. PMID: 21454917; PMCID: PMC3204582.
  4. Krishel, S, et al. Intravenous Vitamins for Alcoholics in the Emergency Department: A Review. The Journal of Emergency Medicine. 1998; 16(3):419–424.
  5. Li, SF, et al. Vitamin deficiencies in acutely intoxicated patients in the ED. The American Journal of Emergency Medicine. 2008; 26(7):792–795.