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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 Medical Center
Western Psychiatric Institute
Alcohol Medical Scholars Program
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
Copyright Alcohol Medical Scholars Program 2004
3
Why This Is Important?
• Alcohol use is common
• Alcohol problems often missed or undetected
Copyright Alcohol Medical Scholars Program 2004
4
Alcohol Use Impacts Overall Health
• Direct toxic effects
• Systemic effects
• Biochemical / nutritional
• Cancer
Copyright Alcohol Medical Scholars Program 2004
5
Why Should Physicians Care?
• Alcohol use impacts overall health
• Treatment issues for general medicine
• Behaviors are changeable
• 3rd leading cause of preventable death
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
Copyright Alcohol Medical Scholars Program 2004
7
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
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 03 - 6 1.0 10.9> 6 - 9 2.3 25.0> 9 4.9+ 52.9+
*Bellentani, Tiribelli. 2001
Copyright Alcohol Medical Scholars Program 2004
9
Assessment Domains
Alcohol Use Patterns
Alcohol Use Disorders
Alcohol Related Health Problems
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
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
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
Copyright Alcohol Medical Scholars Program 2004
14
Stages Of Evaluation
Screening
Assessment
Treatment
Adapted from Connors, 1995
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
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
Copyright Alcohol Medical Scholars Program 2004
17
Laboratory Tests
• Can supplement interview
• May identify health problems
• Not necessarily specific
• Sometimes identifies heavy use
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%
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%
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%
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
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
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
Copyright Alcohol Medical Scholars Program 2004
24
Questionnaires
• Efficient method of gathering data
• Self-administered /easy to score
• Supplements interview
• Assesses patterns / problems
Copyright Alcohol Medical Scholars Program 2004
25
Specific Questionnaires
• CAGE Cut down, Annoyed,Guilt, Eye-opener
• MAST - 25 itemsCovers alcohol problems
• AUDIT – 10 itemsCovers alcohol problems and patterns
Copyright Alcohol Medical Scholars Program 2004
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Interviewing Techniques
• Initiate the discussion
• Follow-up on a positive leads
• Use sensitivity and non-judgmental attitude