Alcohol Use Disorder
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Welcome to the Treatment of Opioid Use Disorder in Primary Care series focusing today on alcohol use disorder in primary care I am Dr Gloria bechevitz and I am the co-primary investigator for the University of Rochester medicine Recovery Center of Excellence so we're here today to learn about the prevalence of alcohol use disorder to review and understand validated screening tools for alcohol use disorder review pharmacotherapy for alcohol use disorder and learn about barriers to treatment in rural communities and how to address them the figures on this slide are for past month alcohol use taken from the National Survey on Drug Use and Health in 2020.
the data reflects current binge and heavy alcohol use of people aged 12 and older 42 percent of survey respondents indicated that they used any alcohol at all in the past month of those nearly 45 percent indicated that they had binge used alcohol binge use is defined as consuming five or more drinks for males or four or more drinks for females in a several hour period on at least one day in the past 30 days heavy alcohol users made up 12.8 percent of all alcohol users and 28.8 percent of binge alcohol users heavy alcohol use is defined as binge drinking for five or more days within the past 30 days so what happened during the Covid-19 pandemic?
online liquor sales increased dramatically in the first three weeks of March 2020 those sales went up by 262 percent by April 2020 they were up an additional 234 percent a survey completed by the National Center for Drug Abuse Statistics indicated that of all alcohol drinkers surveyed only 12.8 percent decreased their drinking during the Covid-19 period studied and 27 percent made no change in their alcohol consumption an overwhelming 60 percent of alcohol consumers indicated that their drinking actually increased of those survey respondents who said that their drinking increased nearly 46 of them indicated that stress was the reason for their increased alcohol drinking if we look at the question of alcohol use in rural areas as compared to urban areas we see some interesting things in 2021 a smaller number of adult rural people said that they had used alcohol in the last 30 days compared to Urban people but equal numbers of rural and urban younger people ages 12 to 20 had used alcohol in the last 30 days when we look at numbers of alcohol-induced deaths found in CDC reports we find a dramatic increase since the year 2000.
the rate of alcohol-induced deaths increased in both urban and rural counties from 7.1 to 12.7 per 100 000 population in urban counties and from 7.0 to 15.8
per 100 000 population in rural counties in the year 2000 at the beginning of the graph we can see that the rates were very similar between rural and urban counties from 2000 to about 2004 but from 2005 to 2020 rates were higher in rural counties than in urban counties during 2005 to 2020 rural rates increased at a much greater pace than did Urban rates at the end of the time period from 2019 to 2020 at the end of the graph the rate increased by 26 percent for urban counties and 30 percent for Rural counties which was the largest increase for both urban and rural counties during that 2000 to 2020 time period overall in the entire 2000 to 2020 time period the rate of increase of deaths in rural counties from alcohol was 24 percent of course alcohol use has an impact on the overall health of an individual excessive alcohol use can increase the risk of stroke liver cirrhosis alcoholic hepatitis various forms of cancer and risk-taking behaviors such as driving while intoxicated in fact the CDC has reported that at least 29 people in the United States die in motor vehicle crashes that involved an alcohol impaired driver daily so why screen for alcohol use disorder and why screen especially for binge drinking screening is very important because treatment for alcohol use disorder works and you also want to determine which medical illnesses are influenced by the alcohol use as well binge drinking can cause injury disease and death more intervention is needed because four out of five binge alcohol users were not advised by their health care provider to reduce or stop their drinking so why might we often as providers overlook binge alcohol use many clinicians know that daily drinking is something that needs further investigation but clinicians may not always have binge drinking on their radar and the patient may also believe that binge use is less problematic and less worrisome than daily use as Primary Care Providers you can make the difference in addressing binge drinking among your patients you can do this by conducting universal screening of all adults we will review the validated screening tools on the next slide you can also provide feedback on the health risks of binge alcohol use a lot of people don't realize that there are health risks to binge alcohol use working collaboratively with your patient in a non-judgmental way is an important pathway to help them reduce or stop alcohol use if they wish to do that how can we screen for alcohol use disorder in Primary Care are there good validated screening tools?
yes and there is also the concept of screening brief intervention and referral to treatment also called S-B-I-R-T or SBIRT and we'll talk a little bit more about that there are three validated screening tools that can be used and our most common in primary care offices there is the AUDIT-C which stands for Alcohol Use Disorders Identification Test-Concise so this is a sort of a mini AUDIT which is a three question screening tool that can help identify patients with unhealthy alcohol use or patients who may have an active alcohol use disorder there is also the AUDIT which is a 10 question tool
this tool provides a framework for intervention to help the patient with unhealthy alcohol use if they are interested in reducing or stopping their alcohol consumption this tool can also help identify patients who may have an alcohol use disorder the CAGE-AID is a four question screening tool which many of you have learned over and over again and which stands for Cut down Annoyed Guilty and Eye-opener so the questions are have you ever wanted to cut down drinking or do others get annoyed at your drinking do you feel guilty about drinking and do you take an eye-opener drink in the morning
these CAGE-AID questions are yes or no questions and a yes answer to any of the questions May indicate a possible alcohol use disorder that would need further testing and possible intervention If you would like more information in implementing the SBIRT screening in your practice we encourage you to use our modules on Integrating SUD Treatment into a Primary Care Practice and the SBIRT module for more information about the best practices and additional screening tools it's important to be aware of where the various levels of care are located in your community or region this slide starts with
family intervention or referral to self-help groups and then can progress to a substance use evaluation substance use evaluation is what is often done by agencies that specialize in substance use disorder treatment then the patient can be referred to stabilization programs formerly referred to as detox programs and also outpatient treatment or inpatient treatment depending on what's available in your location there are many different forms of mandated treatment so sometimes people are mandated to go through treatment and substance use disorder treatment providers work with patients with
various forms of mandate one of the myths about treatment in general is that a person has to really want treatment to get into recovery mandated programs though can help by introducing people to treatment and monitoring their progress after they are released from the inpatient treatment or from incarceration this slide lists the medications approved for treatment of alcohol use disorder and the years of their approval by the FDA from the years 1950 to 1994 all we had to prescribe was Disulfiram then in 1994 Naltrexone was approved by FDA and in 2004 Acamprosate was approved later on in 2006
injectable Naltrexone was approved by the FDA if your patient is not on any of these medications and wants to try medication to reduce alcohol craving Naltrexone is the usual first choice for treatment Naltrexone prolongs abstinence from alcohol and reduces the total number of drinking days per month if the patient does drink Naltrexone use requires some monitoring of liver function tests and it is also important to remember that giving Naltrexone to someone who is taking opioid medication may precipitate opioid withdrawal since Naltrexone is an opioid blocker if the patient does happen to be
taking opioid analgesics or buprenorphine or methadone Naltrexone should not be used and a Acamprosate can then be used for treatment of craving another common situation in Primary Care occurs when one of your patients has been discharged from an inpatient rehabilitation facility the patient may have already been started on one of these medications for alcohol use disorder and may want you to continue to prescribe it or to administer it in the case of injectable Naltrexone the injectable Naltrexone administered monthly has some advantages over oral Naltrexone however it is more expensive and
does require more involvement of office billing staff to get the payment approved and nursing or medical staff to administer the injection but the good news is that most State Medicaid programs now cover the injectable Naltrexone though some states still require prior authorization for it several barriers to accessing treatment for alcohol use disorder in rural areas have been identified there can be a lack of Behavioral Health Providers a lack of privacy in rural communities lack of culturally appropriate treatment a lower use of evidence-based practices such as medications for substance use
disorder and there may also be a lower patient acceptance of these medications as well there may be transportation challenges and lack of broadband internet using a recovery focused approach we can develop creative models such as Hub and Spoke models that have been tried in some states we can embed treatment services in primary care offices and this can be with a Behavioral Health Care Manager we can increase cultural competency we can educate primary care offices on evidence-based practices and we can increase access and use of telehealth resources and utilize alternative spaces to deliver
services to solve some of the broadband problem building recovery oriented systems of care in rural communities there are many successful ways to provide treatment for alcohol use disorder and treatment often includes a mixture of the services you see on this slide we can also call this an Ecosystem of Recovery prevention includes early and universal screening of patients at the primary care practice which may help identify individuals who are at risk for alcohol use disorder by using the screening tools we have discussed earlier and which can also be integrated into the rooming of patients
collaboration with community systems such as child protective agencies and the VA can increase support for individuals at risk we can also work on prevention by focusing on reducing stigma among not only providers but also front desk staff and nursing staff in practices so patients feel more comfortable talking about their use of alcohol and other drugs with their provider or other staff okay intervention being aware of and building relationships with intervention and treatment services in your community can also help early intervention and pre-treatment options can be used either by
partnerships with these community services or by embedded Behavioral Health Specialists such as a Nehavioral Health Care Manager in the primary care practice recovery support and outreach services in the community can also include peer support specialists in the treatment category substance use treatment in communities should be able to offer a menu of treatment and recovery support services including medications for treatment of alcohol use disorder you can look also at alternative services and therapies such as mutual aid groups like Alcoholics Anonymous Alcoholics Anonymous also offers a
lot of online support and online chat rooms and even online meetings treatment agencies also focus on involving the family in the patient's care and they have services for prevention and ongoing coping with the alcohol use disorder for families the post-treatment one is a very important period of time for Primary Care Practices continuing care for patients can be provided in Primary Care Practices after patients have completed treatment and the patients may only require continuing medication or brief support and treatment in your practices simply asking patients whether they are continuing to
take advantage of peer support services or mutual help meetings can also make a big difference when Primary Care Providers do that they acknowledge that substance use disorder and recovery from substance use disorder are important topics to discuss for their ongoing health care you may also consider providing the patients with some kind of self-monitoring tools that they can use at home these can be paper checklists or monitoring questionnaires on websites or phone apps alcohol use disorder is a chronic illness and recovery from alcohol use disorder is a long-term process and is part of
ordinary Health Care in primary care offices thank you for attending this presentation our contact information is listed here we are known as the UR Medicine Recovery Center of Excellence and you can contact us by phone or by email we have many resources on our website and we also have a Twitter handle and a LinkedIn page thanks again
Gloria Baciewicz, MD
In this 20-minute module, Gloria Baciewicz, MD, provides a historical overview, discusses the prevalence of alcohol use disorder in rural and urban areas, and reviews best practices for screening and treatment. Participants learn about levels of concern, the impact of COVID-19 on alcohol use, and levels of care. The module addresses barriers that are common in rural communities and ways of overcoming them.