23 Alcohol use disorder: beyond prohibition

Alyssa M. Peckham, PharmD, BCPP

Michael G. Chan, PharmD, BCCCP, CACP

Introduction

Alcohol use disorder (AUD) is a primary, chronic disease marked by cravings and continued drinking despite adverse outcomes.¹ It involves brain reward, motivation, and memory that can lead to progressive development if left untreated.¹ In 2019, approximately 5.6% of adults aged 18 years or older met criteria for AUD.² In that same year, 1.7% of adolescents, aged 12-17, also met criteria for AUD.² AUD diagnosis and severity are evaluated based on eleven criteria outlined in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).¹ Despite this high prevalence, it is estimated that AUD is vastly undertreated due to stigma and lack of screening.³ This undertreatment is highly problematic as alcohol is the third leading preventable cause of death in the United States, and the economic burden of alcohol misuse was approximately $249 billion in 2010.⁴ To improve care, it is important to identify AUD risk factors and screening tools to aid detection, in addition to understanding management of AUD and commonly associated complications, such as alcohol withdrawal syndrome (AWS).

Many risk factors are involved in the development of AUD that account for the heterogeneity of this population.⁵ Typically, female gender, positive family history, younger age, psychiatric comorbidities (particularly depression, anxiety, or personality disorders), and concurrence of other substance use disorders will increase the risk of developing AUD or increase risk for more severe disorder.⁵ However, even in the absence of risk factors, if an individual expresses concern about their alcohol consumption, further investigation is warranted. The US Preventative Service Task Force (USPSTF) recommends screening for unhealthy alcohol use in adults 18 years or older, including pregnant women, and offering interventions to those with risky or hazardous drinking.⁶ A comprehensive list of AUD screening tools is available through the National Institute of Drug Abuse (NIDA); a positive screen indicates further investigation per DSM-5 criteria.⁷

For those that screen positive and meet criteria for AUD based on DSM-5, treatment is indicated.^8,9 Individuals meeting criteria for mild AUD may respond well to non-medication treatment alone (e.g., psychosocial therapy) but may also receive medication treatment if interested.^8,9 Generally, individuals with moderate to severe AUD should receive medication as part of their treatment plan, with or without non-medication treatment.^8,9 Empirical data predicting which patients will respond to which AUD medication is lacking and therefore, an intimate understanding of medication advantages, disadvantages, restrictions, and caveats is important to drive medication choice. Medications may aid in achieving abstinence, maintaining abstinence, or decreasing binge drinking. All patients, particularly those who do not have a goal of abstinence but wish to engage in safer alcohol consumption, should receive counseling on harm reduction. Harm reduction strategies may include adequate hydration and nutrition, setting daily or weekly drinking limits, ensuring all drinks are measured to avoid “free pours” for accurate counting/tracking, and avoiding intoxication, drinking when alone, risky behaviors such as operating a motor vehicle after drinking, and mixing alcohol with other central nervous system depressants.

Two complications of AUD that can be prevented with medications are AWS and vitamin deficiencies.¹⁰ AWS can manifest as a complex group of symptoms upon abrupt alcohol cessation resulting from central nervous system and autonomic hyperexcitability and usually warrants medication intervention.¹⁰ The symptom onset is about 6-24 hours after alcohol cessation and peaks around 48-72 hours; symptoms lessen in severity overtime but may last for weeks.¹⁰ The severity of AWS can be measured by the Clinical Institute Withdrawal Assessment for Alcohol, revised version (CIWA-Ar) and patient should be monitored for a few days given variability in AWS onset.¹⁰ It is hypothesized that vitamin deficiencies, particularly thiamine, folic acid, and vitamin B6, develop due to poor diet and inability to absorb essential nutrients, both resulting from excessive alcohol consumption.^8-10 A deficiency in these vitamins can result in abnormal cell function and worsening AWS.^8-10 Therefore, it is recommended that patients improve diet to correct these deficiencies, but those requiring critical care for AWS management should receive vitamin repletion to prevent severe neurological manifestations of AWS.^8-10 Additionally, patients should increase hydration to avoid volume depletion and avoid caffeinated beverages.^8-10

Case

CC: “I really need to stop drinking”

Patient: NR (she/her) is a 32-year-old non-Hispanic white female (66 in, 70 kg).

HPI: NR started drinking in high school socially with a few beers at parties with friends. Her drinking became more regular in college because “everyone did it” and she started to feel more anxious in social settings where alcohol helped her relax. Her drinking became daily after college (around age 22) and she has been drinking almost daily for past 10 years, outside of one year of sobriety when she was 29 years old. She was brought to a psychiatric hospital after an alcohol-involved physical altercation one night with her ex-husband in mid-2017. She was hospitalized for a week for alcohol detoxification, was discharged on oral naltrexone 50mg daily, then participated in a partial hospitalization program for two weeks. She stopped taking naltrexone about one year later in mid-2018 though found it helpful for the year that she took it. Today, she endorses alcohol cravings, binge-drinking, “black outs”, drinking alone, and risky behaviors like operating a motor vehicle while impaired. Her last drink was 11pm yesterday, approximately 12 hours prior to clinic visit.

PMH: Bulimia nervosa, in remission (active ages 22 to 30); obsessive-compulsive personality disorder; AUD (severe); social anxiety disorder

FH:

• Father: alive; no known medical conditions
• Mother: alive; HTN, hyperlipidemia
• Sister: alive; generalized anxiety disorder, alopecia areata
• Brother: alive; major depressive disorder, gambling disorder, marijuana use

SH:

• Lifetime non-smoker
• Drinks 4-5 beers on weeknights, and about double this amount on weekends
• Denies use of other substances

SDH: NR endorses a normal childhood. She grew up with two parents in the home (though they divorced when she was 24 years old). She always had a roof over her head, food on the table, a bed to sleep in and always felt safe. She denies physical/sexual abuse, she felt supported and loved by her family growing up, says that she was “popular” in high school, a “star soccer player,” and did well in school. She earned her bachelor’s degree in middle school education and presently works as a fourth-grade teacher. She was married at age 24 and divorced at age 30. She is currently in a relationship with her boyfriend of one year. She lives in her boyfriend’s home with her two daughters (ages 7 and 6) from her prior marriage; she shares custody with her ex-husband. She owns a vehicle, has steady income through work, and has regular access to food. She is sexually active and monogamous with her boyfriend, and she is on long-acting reversible contraception (LARC). She denies any arrests or warrants but notes she has a past episode of domestic violence that resulted in law enforcement involvement. She has never served in the military.

Medications:

• Mirena intrauterine device
• Fluoxetine 40 mg daily

Allergies: NKDA

Vitals

• BP 128/88 mmHg
• HR 65 bpm
• RR 13/min
• Temp 98.6^oF

Labs

• CMP normal
• CBC normal

Case Questions

1. What tool would you use to determine the severity of AUD in NR? If this patient did not already have a diagnosis of AUD, what factors place her at an increased risk of developing AUD or a more severe disorder, and where would you find AUD screening tools to screen her?

2. What scale would you recommend using to monitor for AWS and for how many days? Why?

3. For AWS, when would you recommend no treatment (i.e., supportive care only) versus outpatient treatment versus treatment in a medical setting?

4. Which medication for AUD is best to start in this patient that is treatment-seeking? Why?

5. If this patient did not wish to abstain from alcohol completely, would your treatment plan change? If so, to what and why? What harm reduction measures would you discuss with her?

6. Would your treatment plan change if this patient were pregnant?

7. In what circumstances might it be appropriate to trial off-label medications such as gabapentin or topiramate?

Author Commentary

In addition to alcohol use being the leading cause of premature death and disability among those 15 to 29 years old, it has been associated with approximately 2.3 million years of potential life lost and has a direct causal relationship with many mental health conditions including suicide (7 to 37-fold risk), violent crime (costing approximately $36.7 billion in the United States), unintentional injuries (responsible for 21% of alcohol-involved death), liver disease, infectious diseases, and at least seven types of cancer.¹¹ Additionally, alcohol consumption has been associated with numerous and serious health concerns that outweigh any benefits that may exist; new data demonstrates that the only amount of alcohol that can minimize health complications is zero.¹² Alcohol minimization or elimination should always be encouraged, and prompt recognition and treatment for those with AUD is imperative.

The American Society of Health-System Pharmacists (ASHP) specifically recognizes pharmacist contributions in three areas of AUD: prevention, education, and assistance.¹³ For prevention, pharmacists can contribute to the development of programs and policies that advocate for safer alcohol consumption.¹³ For education, pharmacists can collaborate with clinicians and support groups, in addition to didactic and experiential training of pharmacy trainees, to educate individuals about detrimental effects of excessive alcohol consumptions and appropriate treatment strategies.¹³ Lastly, for assistance, pharmacists can identify those with unhealthy alcohol consumption, assist in pharmacotherapy or other treatment selection, and develop protocols to streamline pharmacotherapy selection and access.¹³

Patient Approaches and Opportunities

All individuals should be screened for unhealthy alcohol consumption and, if positive, should be evaluated for AUD. Upon meeting criteria for AUD, individuals should be promptly offered treatment which may include evaluation and acute management of AWS in addition to chronic management of AUD with non-medication and medication treatment. Treatment plans should be individualized based on patient preference, health status, comorbidities, and concurrent medications.

There are three FDA-approved agents for AUD (naltrexone, acamprosate, and disulfiram) and two agents (topiramate, gabapentin) that are used off-label for this indication; these medications may be utilized in special populations as well.^8,9 For elderly and adolescents, naltrexone remains the treatment of choice, but any of these medications are appropriate choices after considering comorbidities and concurrent medications.^8,9 For pregnancy, abstinence is preferred over pharmacotherapy whenever possible as none of the medications have been proven absolutely safe as all are pregnancy category C medications.^8,9 The risks and benefits of medications should be weighed against the risks of ongoing alcohol consumption during pregnancy which can lead to miscarriage, stillbirth, premature delivery, fetal alcohol syndrome, or fetal alcohol spectrum disorder.^8,9 In general, disulfiram is not preferred due to risk of disulfiram-ethanol reaction which is unsafe during pregnancy.^8,9

When interacting with patients with AUD, keep in mind that this is chronic illness that is subject to relapse and progression if left untreated. AUD, like many other substance use disorders, is not “cured” by a three- to five- day detoxification alone and requires ongoing medical management to minimize harm to the individual and community and decrease avoidable healthcare costs. Utilizing inviting, non-stigmatizing language to engage and retain patients in care is essential. It is also important to respect the individual’s goals and timeline. Patients should still be supported via harm reduction if abstinence is not their immediate goal.