Alcohol Misuse Assessment in the Primary Care Setting

Alcohol Misuse Assessment in the Primary Care Setting Lt Col Dawn Kessler-Walker Clinical Psychologist Chief, Substance Abuse and Drug Demand Reduction Programs AF Medical Operations Agency

Objectives At the conclusion of this presentation, the participant will: • Understand scope of problem in US and DoD • Understand what alcohol misuse is • Understand how to assess it • Describe the Screening, Intervention, & Referral process and your role in it • VA/DoD Substance Use Disorder Pocket Guide • Utilize evidenced based brief interventions that are appropriate to provide in the primary care setting

Scope of the Problem Driving Under the Influence of Alcohol in the Past Year among Persons Aged 16 or Older, by Age: 2011 Source: http://www.samhsa.gov/data/NSDUH/2k11Results/NSDUHresults2011

Scope of the Problem Level of Alcohol Use Source: http://www.samhsa.gov/data/NSDUH/2k11Results/NSDUHresults2011

Scope of the Problem How many American adults (ages 18 and over) drank in the past year and how much did they drink? Source: http://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/drinking-statistics

Epidemiology – US Binge Drinking • Common among US adults, especially males aged 18-34 years, whites, and with annual household incomes of $50K or more. (2009 Data) • Most binge and heavy alcohol users were employed in 2011. Among 56.5M adult binge drinkers, 42.1M (74.4%) were employed either full or part time. • Among young adults aged 18 to 22, the rate of binge drinking is declining. In 2002, the binge drinking rate within this age group was 41.0% compared with 36.9% in 2011. Among full-time college students, the rate decreased from 44.4 to 39.1%. Among part-time college students and others not in college, the rate decreased from 38.9 to 35.4%. Heavy Drinkers • In 2011, heavy drinking was reported by 6.2%of the population aged 12 or older, or 15.9 million people. This percentage was lower than the rate of heavy drinking in 2010 (6.7%). http://www.cdc.gov/ and http://www.samhsa.gov/data/NSDUH/2k11Results

Epidemiology – US Alcohol and Illicit drug use • Among the 15.9Mheavy drinkers aged 12 or older, 31.3%were current illicit drug users. • Persons who were not current alcohol users were less likely to have used illicit drugs in the past month (4.2%) than those who reported (a) current use of alcohol but no binge or heavy use (6.7%), (b) binge use but no heavy use (17.2%), or (c) heavy use of alcohol (31.3%). Alcohol and Tobacco Usage • Among heavy alcohol users aged 12 or older, 54.9% smoked cigarettes in the past month, while only 18.1%of non-binge current drinkers and 15.3% of persons who did not drink alcohol in the past month were current smokers. • Smokeless tobacco use and cigar use also were more prevalent among heavy drinkers (11.7 and 15.2%, respectively) than among non-binge drinkers (1.9 and 4.5%) and nondrinkers (1.9 and 2.2%). http://www.cdc.gov/features/healthdisparitiesreport and http://www.samhsa.gov/data/NSDUH/2k11Results

Special Populations College-age young adults • About 4 out of 5 college students drink alcohol • About half of college students who drink, also consume alcohol through binge drinking • Consequences (for students ages 18 to 24): • Death: 1,825 college students die each year from alcohol-related unintentional injuries • Assault: > 690K students are assaulted by another student who has been drinking • Sexual Abuse: > 97K students are victims of alcohol-related sexual assault or date rape Underage Drinkers • By the age of 15, half of teens have had at least one drink. By age 18, more than 70% of teens have had at least one drink (2009) • Risks Include: • Death: 5,000 people under age 21 die each year from alcohol-related car accidents, homicides, suicides, alcohol poisoning, and other injuries • Serious Injuries: More than 190,000 people under age 21 visited an ER for alcohol-related injuries in 2008 alone. http://www.niaaa.nih.gov/alcohol-health/special-populations-co-occurring-disorders/underage-drinking

Special Populations Women • One in 8 women and 1 in 5 high school girls binge drink, increasing their risk of breast cancer, heart disease, STDs, and unintended pregnancy. • More than 14M US women binge drink about 3 times a month, and consume an average of 6 drinks per binge. • Drinking too much, including binge drinking results in about 23,000 deaths in women and girls each year and increases the chances of breast cancer, heart disease, sexually transmitted diseases, unintended pregnancy, and many other health problems. • Binge drinking is most common in high school girls and young women, whites and Hispanics, and among women with household incomes of $75K or more. Half of all high school girls who drink alcohol report binge drinking. http://www.niaaa.nih.gov/alcohol-health/special-populations-co-occurring-disorders/underage-drinking

Special Populations Olderadults/SeniorCitizens • 2008 survey: 40% of adults ages 65 and older drink alcohol • Other complications: take numerous meds, have multiple health problems • Increased sensitivity due to age can lower tolerance • Heavy drinking can make health problems worse; among these include: diabetes, high blood pressure, congestive heart failure, liver problems, memory problems, mood disorders, osteoporosis • Bad interactions with OTC meds such as aspirin, acetaminophen, cold and allergy meds, cough syrup, sleep pills, and prescription meds for pain, anxiety or depression http://www.niaaa.nih.gov/alcohol-health/special-populations-co-occurring-disorders/underage-drinking

Epidemiology – VA/DoD • In 2007 fiscal year, over 375,000 VA patients had a SUD diagnosis • FACT: 1 in 8 Troops: One in eight troops returning from Iraq and Afghanistan from 2006 to 2008 were referred for counseling for alcohol problems after their post-deployment health assessments, according to data from the Armed Forces Health Surveillance Center. • The NHSDA (National Household Survey on Drug Abuse), reported the following alcohol use among the nearly 30 million veterans aged 18 and older living in the US: • ALCOHOL USE: Males Veterans 56% vs. Female Veterans 41% • BINGE DRINKING: Male Veterans 23% vs. Female Veterans 14% • HEAVY DRINKING: Male Veterans 7% vs. Female Veterans 2% • Male veterans are more likely than female veterans to report alcohol use, binge drinking and heavy alcohol use. http://www.ncadd.org/index.php/learn-about-alcohol/seniors-vets-and-women/198-veterans-and-alcohol

DoD Surveys of Health Related Behaviors History Largest anonymous population-based health behavior surveys among military personnel 12 active duty surveys conducted,1980–2011; Two Reserve Component surveys 2006, 2010-2011 Coast Guard included in both the 2008 and 2011 surveys Sponsored by Asst Sec of Defense (Health Affairs) Purpose Assess lifestyle factors affecting health and readiness Identify/track health-related trends and high-risk groups Target groups and/or lifestyle factors for intervention Help identify future directions for additional studies, DoD programs and policies Data used by military leadership at all levels to make important policy and programmatic changes Source: Bray, R. (2011). Substance Use in the Active Duty Military: Findings from the DoD Surveys of Health Related Behaviors. RTI International; 2011 and : 2011 DoD Health Related Behaviors Survey of Active Duty Military Personnel.

Substance Use Trends for DoD Services, Past 30 Days, 1980-2008 2005 & 2008 surveys had question changes Heavy Alcohol Use = 5 or more drinks on the same occasion at least once a week in past 30 days. Any Illicit Drug Use Including Prescription Drug Misuse = use of marijuana, cocaine (including crack), hallucinogens (PCP/LSD/MDMA), heroin, methamphetamine, inhalants, GHB/GBL, or non-medical use of prescription-type amphetamines/stimulants, tranquilizers/muscle relaxers, barbiturates/sedatives, or pain relievers. Any Illicit Drug Use Excluding Prescription Drug Misuse = use of marijuana, cocaine (including crack), hallucinogens (PCP/LSD/MDMA), heroin, inhalants, or GHB/GBL. 13 Source: Bray, R. (2011). Substance Use in the Active Duty Military: Findings from the DoD Surveys of Health Related Behaviors.

Alcohol Use Trends, DoD Services,Past 30 Days, 1980-2008 Statistically significant increase from 1980, but decrease from 2005. * Heavy Alcohol Use = 5 or more drinks/occasion at least once a week in past 30 days. *Significant at .05 level 14 14 Source: Bray, R. (2011). Substance Use in the Active Duty Military: Findings from the DoD Surveys of Health Related Behaviors.

Trends in Binge Drinking by Service,1998 - 2008 a Estimate is significantly different from the 1998 estimate at .05 level. b Estimate is significantly different from the 2002 estimate at .05 level. c Estimate is significantly different from the 2005 estimate at .05 level. d Estimate is significantly different from the 2008 estimate at .05 level. *2008 estimates for DoD Services (Army, Navy, Marine Corps, and Air Force) did not differ significantly from All Services (DoD Services plus Coast Guard). Binge Drinking = 5 or more drinks (4 or more for females) on a single occasion at least once in in the past 30 days Source: Bray, R. (2011). Substance Use in the Active Duty Military: Findings from the DoD Surveys of Health Related Behaviors. RTI International; 2011 (Table 3.2.3. Binge Drinking, Q31) 15 15

Scope of the Problem Source: 2011 DoD Health Related Behaviors Survey of Active Duty Military Personnel.

Scope of the Problem Drinking Levels (%), by Service Source: 2011 DoD Health Related Behaviors Survey of Active Duty Military Personnel.

VA/DoD Clinical Practice Guideline: Management of Substance Use VA & DoD provided the CPGs as recommendations Intent of CPG: • Reduce current practice variation & provide facilities with a structured framework to improve patient outcome • Provide evidence-based recommendations to assist providers and their patients in the decision-making process for patients with Substance Use Disorders (SUDs) • Identify outcome measures to support the development of practice-based evidence that can be used to improve clinical guidelines 2.

VA/DoD Clinical Practice Guideline: Management of Substance Use Goals of SUD CPG • Target Pop: CPG applies to adult patients with substance conditions, including those with substance use and other health conditions, and patients with severity ranging from hazardous and problematic use to SUDs. • Audience: CPG is relevant for all healthcare professionals providing or directing tx services to patients with substance use conditions • To identify patients with substance use conditions, including at-risk use, substance use problems and SUDs • To promote early engagement and retention of patients with substance use conditions who can benefit from treatment • To improve outcomes for patients with substance use conditions 2.

Extra Slides

Content of the CPG • Five Modules – each addresses inter-related aspects of care for patients with SUDs. • Module A: Screening and Initial Assessment for Substance Use includes screening, brief intervention, and specialty referral considerations • Module B: Mgmt of SUD in Specialty SUD Care focuses on patients in need of further assessment or motivational enhancement or who are seeking remission. • Module C: Mgmt of SUD in General Healthcare (including primary care) emphasizes earlier intervention for less severe SUD, or chronic disease mgmt for patients unwilling or unable to engage in tx in specialty SUD care or not yet ready to abstain. • Module P: Addiction-Focused Pharmacotherapy addresses use of medication approved by the FDA for the tx of alcohol and opioid dependence. • Module S: Stabilization and Withdrawal Mgmt addresses withdrawal mgmt including pharmacological mgmt of withdrawal symptoms

Alcohol Misuse Alcohol Misuse: Includes the full spectrum from drinking above recommended limits (i.e. risky/hazardous drinking) to alcohol dependence Costs of Alcohol Misuse • Associated with numerous health and social problems and more than 79,000+ deaths per year in the US • More than 700,000 Americans receive tx for alcohol dependence and alcohol abuse every day • Estimated annual cost of more than $220 billion • Third leading cause of preventable mortality in the US following tobacco use and being overweight • Over 15% of US workers report being impaired by alcohol at work at least 1x during the past year, and 9% of workers reported being hung-over at work 1 Source: www.cdc.gov/workplacehealthpromotion/implementation/topics/substance-abuse

Alcohol Misuse • Heart disease including coronary artery disease, atrial fibrillation (i.e. abnormal heart rhythm), hypertension and congestive heart failure • Various cancers (breast, colorectal, and liver) • Depression, insomnia, anxiety, and suicide • Violence (e.g. homicide, suicide) • Unintentional Injuries (e.g. motor vehicle accidents, falls) • Risky sexual behaviors and adverse pregnancy outcomes • Others: Cirrhosis, stroke, dementia, gastritis and gastric ulcers, neuropathy, cardiomyopathy, anemia, osteoporosis, cognitive impairment Is a risk factor (and a cost) of a number of adverse health outcomes including: 1 Source: www.cdc.gov/workplacehealthpromotion/implementation/topics/substance-abuse

Alcohol Misuse 1

Alcohol Use Disorders Proposedin DSM-5 • Major change proposed for DSM-5 is to replace the two separate DSM-IV (substance specific) categories of dependence and abuse with a single (substance specific) category, SUD. • Criteria for SUD merge the previous lists of seven dependence criteria and four abuse criteria into a single list of 11 criteria, but drop the criterion of recurrent legal problems and add a criterion for craving. • New Diagnostic Categories: • No Diagnosis: 0-1 symptoms • Mild Diagnosis: 2-3 symptoms • Moderate Diagnosis: 4-5 symptoms • Severe Diagnosis: 6 or more symptoms 1 Source: www.ncadd.org

Module A 1

Module A: Screening for Alcohol Use • All patients in primary care settings are the target population for alcohol screening. • Unhealthy Alcohol Use screening and counseling is ranked 3rd of the top five prevention priorities among preventive practices recommended by the US Preventive Services Task Force (USPSTF). • Population-based screening for drug use disorder is not recommended. • Why? Lower prevalence of drug use disorder • Use is recommended in selective high risk populations • USPSTF determined that an unhealthy alcohol use screening and counseling is similar to screening for hypertension, colorectal cancer, or vision in older adults, • The optimal interval for screening and intervention is unknown. Patients with past alcohol problems, young adults, and other high-risk groups (e.g. smokers) may benefit most from frequent screening. VA/DoD CPG, 2009 & http://www.uspreventiveservicestaskforce.org.

Screening for Alcohol Use Remember why we screen… • Majority of excessive drinkers are undiagnosed • They present to Primary Care (PC) with symptoms or problems that would not normally be linked to their drinking. • Allows PC professionals (PCMs and IBHCs) an opportunity to educate patients about low-risk consumption levels and the risks of excessive alcohol use. • Info on amount and frequency of alcohol consumption should inform clinician’s diagnosis of patient and it may alert provider to the need to advise the patients whose consumption might adversely affect their use of meds and other aspects of their tx. • Provides PC professionals an opportunity to take preventive measures that have proven effective in reducing alcohol-related risks. Source: AUDIT Manual, WHO (2009).

Screen Annually for Unhealthy Alcohol Use Using Validated Tool(s) VA/DoD CPG Recommendations: • Patients in general and mental healthcare settings should be screened for unhealthy alcohol use annually [A] • Use a validated screening questionnaire for last year of unhealthy alcohol use. [A] • Select one of two brief methods of screening:[A] • Alcohol Use Disorders Identification Test Consumption (AUDIT-C) or • Ask whether patient drank alcohol in the past year & administer the Single-item Alcohol Screening Questionnaire (SASQ) to assess the frequency of heavy drinking in patients who report any drinking. [see Annotation C] • The CAGE questionnaire alone is not a recommended screen for past-year unhealthy alcohol use (e.g. risky or hazardous drinking). [D] • The CAGE questionnaire, used as a self-assessment tool, may be used in addition to an appropriate screening method to increase patient’s awareness to unhealthy use or abuse of alcohol. Source: VA/DoD CPG, 2009.

How does the patient get referred to you? IBH Consultant Source: VA/DoD, SUD Pocket Guide Overview.

Screening, Intervention & Referral These steps correspond with Module A: Screening and Initial Assessment and Module C: Management of SUD in General Health Care. They include guidance for screening, educating and providing brief interventions, referrals or care management, if necessary, to patients who may present with unhealthy alcohol use. (Boxes 1 to 3 in Module A) All patients seen in general medical and general psychological health settings are the target population for alcohol screening. Use the Alcohol Use Disorders Identification Test (AUDIT-C) (preferred) or Single-Item Alcohol Screening Questionnaire (SASQ) to identify where patients fall on the continuum of unhealthy alcohol use, including those who drink above recommended limits (i.e. risky or hazardous drinking) to those with severe alcohol dependence. Step A: Screen Annually for Unhealthy Alcohol Use Using Validated Tool Source: VA/DoD, SUD Pocket Guide Overview.

Screening, Intervention & Referral When the Audit-C is administered by self-report add a “0 drinks” response option to question#2 (0 points based on validations studies). In addition, it is valid to input responses of 0 points to questions #2-3 for patients who indicate “never” in response to question #1 (past yearnon-drinkers). The minimum score (for non-drinkers) is 0 and the maximum possible score is 12. Consider a screen positive for unhealthy alcohol use if AUDIT-C score is ≥ 4 points for men OR ≥ 3 points for women. Source: http://www.healthquality.va.gov/sud/SUDPocketGuideOverview.pdf

Screening, Intervention & Referral Step A: Screen Annually for Unhealthy Alcohol Use Using Validated Tool Single-Item Alcohol Screening Questionnaire (SASQ) • Positive screen is any report of drinking 5 or more (men) or 4 or more (women) drinks on an occasion in the past year. • One standard drink = 12 ounces of beer, or 5 ounces of wine, or 1.5 ounces of 80-proof spirits

Screening Step A: Screen Annually for Unhealthy Alcohol Use Using Validated Tool • Cut-down, Annoyed, Guilty, Eye-opener (CAGE) Questionnaire : The 4-item CAGE is the most popular screening test for detecting alcohol abuse or dependence in primary care. • CAGE has very low sensitivity for detecting risky/hazardous drinking and is therefore not a good screening test for identifying risky/hazardous drinking.

Brief Intervention Step C: Provide Brief Intervention Brief Intervention Sample Dialogue: “E-PASS” Express Concern Provideeducation Advisepatient to abstain Supportpatient Suggest treatment referral Step D: Follow-Up

Brief Intervention Sample Dialogue:Remember “E-PASS” Step C: Provide Brief Intervention Add screen shot of E-Pass

Brief Intervention:Follow-Up Step D: Follow-Up Add screen shot of Follow-up (pg.24)

Referral Step E: Relapse Prevention, Care Management, and Referral (Boxes 10 to 12 in Module A, and Boxes 7 to 10 in Module C) Relapse Prevention NOTE: Successful relapse prevention requires extended efforts from multiple providers. For Patients Who Drink Above Recommended Limits or Despite Contraindications • Educate patient about: • Substance use and associated problems • Relapse prevention • Re-evaluate treatment plan: • Discuss current use of alcohol and other drugs • Convey openness to discuss any future concerns that may arise • Address any potential problem areas: • Recent initiation or increased use • Use to cope with stress • Periodically inquire about alcohol and drug use at future visits • Encourage drinking below recommended limits

Referral Step E: Relapse Prevention, Care Management, and Referral For Patients Who Are Not Improving • Adapt to any new objectives or goals that patient may express by: • Increasing intensity of care • Changing to another medication or intervention • Increasing the dose of or add medication • Consider consultation with psychological health or SUD specialty care • (See following Tab 3, page 25)

Alcohol Misuse Assessment in the Primary Care Setting