Proven Screening Tool for Alcohol Abuse Underutilized

WASHINGTON ― Despite the fact that a growing number of older Americans have problems involving the use of alcohol, physicians still do not routinely offer universal screening, brief intervention, and referral to treatment (SBIRT) for drinking, despite established efficacy, new research shows.

Data presented here at the American Association of Geriatric Psychiatry (AAGP) 2016 Annual Meeting revealed that by 2020, 4.4 million adults will need treatment for alcohol use disorder, a 60% increase from 2000.

Study investigator Rushiraj Laiwala, MD, said that in contrast to the past, when individuals tended to drink less as they got older, today the reverse is true.

The total percentage of those aged 65 years and older who drink and who engage in heavy and binge drinking is on the rise, said Dr Laiwala, a geriatric psychiatry fellow at the University of South Carolina School of Medicine, in Columbia.

Because of the growing population of older Americans, the number of heavy drinkers will increase from 1 million currently to 2 million by 2060. The number of binge drinkers will increase from 4 million to 9 million by 2060, said Dr Laiwala.

And yet, he said, “we know that older drinkers are less likely to be identified compared to their younger counterparts.”

Rebecca Payne, MD, assistant professor of psychiatry at the University of South Carolina School of Medicine, who presented an overview of SBIRT, said that alcohol use is frequently missed in patients of all ages.

“We do know that physicians in general are less likely to ask their older patients about drinking specifically compared to younger patients,” Dr Payne told Medscape Medical News.

“It’s been proven that we can cut down on hazardous drinking by physician’s advice, but we still aren’t doing it,” says Lawrence Schonfeld, MD, professor emeritus of mental health law and policy at the Louis de la Parte Florida Mental Health Institute, College of Behavioral and Community Sciences, University of South Florida.
Dr Schonfeld, who was not involved in the AAGP presentation, developed the Florida BRief Intervention and Treatment of Elders (BRITE) project. The study was funded initially by the state and then through a grant from the Substance Abuse and Mental Health Services Administration (SAMHSA).

The study included SBIRT data on some 85,000 individuals aged 55 years or older at primary and geriatric practices, aging and mental health services centers, and urgent care clinics, among other sites. BRITE ran from 2006 to 2011.

Time is the major reason physicians are reluctant to screen or offer interventions, said Dr Payne. Clinicians may also feel that they have a knowledge or training deficit ― for example, they may feel unsure about sending patients for treatment. Personal and family history of alcohol use may also contribute to a hesitancy to screen.

Patients, on the other hand, seem to be willing to be screened, said Dr Payne. In a 2006 survey, 92% said they would give an honest answer if asked about their drinking, and 93% said they thought their physician should ask how much they drink, she said.

If physicians are not doing the most basic screening, “they’re not going to be asking critical questions, like, How much are you drinking?” said Dr Schonfeld. The BRITE project found that aging services sites did a better job than physicians at both screening patients and offering follow-up treatment and referrals (Am J Public Health. 2015;105: 205–211).

Both Dr Schonfeld and Dr Payne noted that physicians may also be reluctant to use SBIRT because they think they are not going to be paid for their time.

Medicare, private insurers, and some Medicaid programs pay for SBIRT, with pay differing by whether it is a 15-minute or 30-minute screening and intervention service. The primary codes for commercial insurance are 99408 and 99409, and Medicare has several G codes that apply, including 396, 397, 442, and 443.

New View of Drinking

The National Institute on Alcohol Abuse and Alcoholism recommends that people older than 65 years should have no more than seven drinks a week and no more than three drinks on any one day.

But the agency has also proposed a new way of looking at drinking, with new terms ― low-risk and at-risk or heavy drinking.

Dr Payne advocates universal screening for all patients and that it become incorporated into practice. First, patients should be asked a prescreening question, which could be, “Do you sometimes drink beer, wine, or other alcoholic beverages?” She encourages use of such language because some people may not consider beer or wine to be alcohol. A negative answer requires no further screening.

With a positive response, patients can be prodded to the next level, which may incorporate the Short Michigan Alcohol Screening Test–Geriatric Version, the Michigan Alcoholism Screening Test– Geriatric Version, the CAGE Questionnaire, or the Alcohol Use Disorders Identification Test.

Those “can be delivered by you or anyone in your office,” said Dr Payne. “Whatever makes the most sense to you and applies the best to your clinical practice, use it,” she said.

Physicians should review the patient’s responses with them. “It sends the message that you actually looked at it, and you can clarify any questions they might have about it.”

The brief intervention is a discussion focused on raising awareness of use; it motivates the individual toward change. It can consist of one to five sessions, she said.

Physicians can give the patient information on how their drinking compares with recommendations of the NIAAA and what impact alcohol might have on medications or sleep patterns, for instance. Dr Payne said she asks patients to come up with a change plan. The plan is discussed with the patient and is revisited within an agreed-upon period.

Only about 5% of patients need referral to treatment, said Dr Payne.

Sofia’s Story

My name is Sofia and I am a recovering addict and alcoholic.

I started using when I was 12 years old. What started out as drinking alcohol and smoking weed quickly escalated into regular use of narcotics, and by the age of 13 I was abusing cocaine and prescription pills on a regular basis.

Unfortunately, my drug use was not the only cause for concern. I was also struggling with a severe eating disorder, anorexia nervosa, along with a handful of other psychological disorders including depression, anxiety, and obsessive compulsive disorder. I had an extremely negative self-image and hated the person I was becoming.

My life was out of control, and my drug use was exasperated by my desire to feel as if I had a sense of power over myself and my surroundings. I used in order to stop feeling and thinking about all the negative things in my life, and this desire to forget only increased with the shame of my drug use and the mistakes I made while using.

Not surprisingly, my drug abuse involved a number of run-ins with the law. At the mere age of 15, I was arrested for underage drinking and resisting arrest. My BAC (blood alcohol content) was more than double that of what is considered normal for someone of legal drinking age. However, this incident did nothing to deter me from my drug use and other harmful behaviors I was engaging in.

Over these years, my drug use progressed into using anything and everything I could get my hands on. In particular, ecstasy and LSD became my drugs of choice due to their quality of making one feel artificially “happy”. However, I was not happy at all. Not only did I have a horrible relationship with myself, but I had destroyed my relationship with my family in the process. I hated my parents for trying to stop me from using drugs, but I hated myself most of all.

After an incident in which I threatened to commit suicide, I was forced into a long-term drug treatment program where I resided for nearly three months. This experience not only changed my life forever – it saved my life. Looking back, I am so incredibly grateful for everything that my family did for me both during my years of drug abuse and my time spent in treatment. Without their unyielding support, I would not be alive and well today.

With the support of my family, the tools I learned while in treatment, and my newfound desire to change, I was able to successfully complete treatment and begin my journey of recovery. Today, I have been clean and sober for nearly seven years.

Over the past seven years, I have accomplished more than I ever thought possible while I was using. I graduated from college with high honors, have begun working within the field of substance abuse treatment, and will soon be continuing my studies in graduate school where I will earn a degree in Addiction Studies. I now have a wonderful relationship with my family, and most of all, I have a healthy and loving relationship with myself.

I hope that my story will give hope to those out there that are struggling with addiction, whether you’re concerned about your own drug or alcohol addiction or that of a loved one. I am a testament to the fact that there is always hope, and recovery is possible for anyone. There is strength in surrender, and I am so proud of myself for all that I have overcome.

U.S. House Passes Two Bills to Help Fight Opioid Abuse

The U.S. House of Representatives has unanimously passed two bills aimed at fighting opioid abuse and its harmful effects. One bill would reauthorize federal funding to states for prescription drug monitoring programs, while the other would create uniform standards for diagnosing and treating newborns exposed to opioids.

The prescription drug monitoring bill, called the National All Schedules Prescription Electronic Reporting Reauthorization Act (NASPER), would provide state funding to establish, implement and improve prescription drug monitoring programs, the Boston Herald reports. The programs are designed to help screen and treat people who are addicted to prescription opioids or at risk of becoming addicted, the article notes.

NASPER originally became law in 2005. It is administered by the Substance Abuse and Mental Health Services Administration (SAMHSA). The reauthorization of NASPER would allow SAMHSA to provide grants to states for prescription drug monitoring programs, offering timely access to accurate prescription information.

The bill on diagnosing and treating newborns exposed to opioids, if passed by the Senate, would become the first federal measure to address the issue, according to the newspaper. The bill, called the Protecting Our Infants Act of 2015, is designed to reduce the problem of neonatal abstinence syndrome (NAS). Babies born with NAS undergo withdrawal from the addictive drugs their mothers took during pregnancy, such as oxycodone, morphine or hydrocodone. Symptoms can include seizures, fever, excessive crying, tremors, vomiting and diarrhea, she said. Withdrawal can take several weeks to a month.

“Right now there is no standard for treatment with NAS,” bill author Katherine Clark, U.S. Representative from Massachusetts, told the Herald. “This problem leads to long stays in the NICU and hundreds of millions in Medicaid dollars.”

In a news release, Clark noted, “Our nation‘s opioid crisis cuts across all boundaries, destroys lives, and has a devastating impact on hundreds of newborns every day.”

HHS Will Revise Regulations on Prescribing Buprenorphine for Opioid Addiction

The Department of Health and Human Services (HHS) will remove some obstacles that limit the ability of doctors to prescribe buprenorphine for patients who are addicted to heroin or prescription painkillers.

The Department of Health and Human Services (HHS) will remove some obstacles that limit the ability of doctors to prescribe buprenorphine for patients who are addicted to heroin or prescription painkillers, The Huffington Post reports.

Under current regulations, doctors who are certified to prescribe buprenorphine (sold as Suboxone) are allowed to write prescriptions for up to 30 patients initially. After one year, they can request authorization to prescribe up to a maximum of 100 patients. The HHS will develop revisions to the regulations “to provide a balance between expanding the supply of this important treatment, encouraging the use of evidence-based [medication-assisted treatment], and minimizing the risk of drug diversion,” the department said in a press release.

In areas hard hit by opioid addiction, doctors’ buprenorphine treatment slots can fill up quickly, the article notes. One recent study found buprenorphine treatment is unavailable in U.S. counties where more than 30 million people live.

Legislation proposed earlier this year by U.S. Senators Edward Markey of Massachusetts and Rand Paul of Kentucky would increase the first-year cap from 30 patients to 100, and would allow nurse practitioners and physician assistants to prescribe buprenorphine. After one year, physicians could seek to remove the cap entirely if they were certified as substance abuse treatment specialists, or if they went through an approved training.

Dr. Jeffrey Goldsmith, President of the American Society of Addiction Medicine, said in a statement that his organization “applauds the Administration for taking this step to expand access to evidence-based addiction treatment and close the gap between those who need treatment and those who receive it.”

Govt says Drugs to Treat Alcoholism don’t have to Lead to Sobriety

A regular bottle cap with a stop sign in red embossed on the top representing bandwidth cap or alcohol limits on an isolated background 

Drugmakers aiming to tackle alcoholism, a condition that affects 17 million Americans, may have a smoother path to market under a U.S. proposal to guide development of treatments.

Drugs to treat alcoholism can gain approval by proving patients using them no longer drink heavily, the Food and Drug Administration clarified Wednesday. The agency released draft guidelines for pharmaceutical companies wanting to develop alcoholism treatments that make clear that sobriety doesn’t have to be the main goal.

“The abstinence-based endpoints have often been considered an unattainable threshold in the clinical trial setting, and may be considered a hindrance to clinical development for drugs to treat alcoholism,” Eric Pahon, an FDA spokesman, said in an e-mail.

Clinical trials of the three drugs that are FDA-approved and sold for alcoholism focused on sobriety, and most required patients to be abstinent to start the studies, Pahon said. The National Institute on Alcohol Abuse and Alcoholism has said current medications are effective for some but that more treatments are needed for the broader population.

“While total abstinence from alcohol is desirable, reducing heavy drinking to within ‘low-risk’ daily limits presents an alternative goal in drug development so more treatments may be developed,” Pahon said.

Industry, researchers and addiction and recovery groups can comment on the proposal for 60 days.

Current Drugs

The drugs sold for alcoholism are: naltrexone, which limits the release of pleasure-inducing dopamine caused by alcohol; acamprosate, which can be used by those who have quit drinking to stay sober; and disulfiram, known as Antabuse, which creates unpleasant side effects in people who drink.

Alcoholism is identified as continued drinking despite physical and psychosocial consequences, according to the FDA proposal. Ultimately, an alcoholism drug should improve those consequences, which can be done through sobriety or a reduction in the use of alcohol, the agency said.

The NIAAA defines heavy drinking as a man consuming more than four standard drinks in a day or a woman taking more than three. A standard drink in the U.S. contains 14 grams of alcohol, which could be in the form of a shot of hard liquor, a 12-ounce bottle of beer or a 5-ounce glass of wine.

Selincro, made by H. Lundbeck A/S and Biotie Therapies Oyj, is the first and only drug approved in the European Union for reducing alcohol use, according to Bloomberg Intelligence analyst Grace Guo.

Arbaclofen from Reckitt Benckiser Group Plc and XenoPort Inc., TKM-ALDH2 from Tekmira Pharmaceuticals Corp. and Alnylam Pharmaceuticals Inc. and ADX71441 from Addex Therapeutics Ltd. are in early development to treat alcohol-use disorder, Guo said.

The NIAAA said in September it would start a clinical trial in the first half of this year on Santa Clara, California-based XenoPort’s restless-leg syndrome medicine Horizant as a treatment for alcohol use disorder.

Binge Drinking isn’t just for College Kids Anymore

Black line art illustration of a drunk man with a beverage.

The typical picture of a binge drinker may look as much like a middle-age man working long hours as it does a college fraternity boy partying late at night.
Doctors are increasingly focusing on that older population after years of placing a higher priority on experimenting adolescents and young alcoholics. Evidence is emerging that high-pressure jobs push millions of people toward binge drinking, and deaths from alcohol abuse escalate as people get older.
A new study from 14 countries published in the British Medical Journal found that people who work more than 48 hours a week are more likely to drink to excess — defined as 14 drinks a week for women and more than 21 for men. And the U.S. Centers for Disease Control and Prevention estimated in a report last week that six people die daily from alcohol poisoning, mainly those ages 35 to 65.
“Drinking is a fast and easy way to shake off work. That’s where the problem comes,” said Cassandra Okechukwu, an assistant professor at Harvard School of Public Health in Boston. “We have defined it and call it risky alcohol use. We aren’t paying as much attention to that as we pay to the definition of alcoholism. We need to pay more attention.”
Numerous studies show regular drinking, as long as it doesn’t turn into a binge, is healthy, especially for the heart. While red wine is generally touted for its health benefits, beer and liquor have also been shown to ward off various medical conditions. Doctors warn against starting to drink or consuming more for the potential health benefits, and point out that excessive consumption can lead to a raft of ailments ranging from cancer to sudden death.
Poisoning Deaths
The numbers on excessive drinking don’t make sense right away, and they puzzle researchers. Young people are still more likely to binge drink — defined as five or more drinks in a few hours for men and four or more for women. People 65 and older who binge drink do it more frequently than other age groups.
The people dying of alcohol poisoning, however, are middle-aged. Three in four are men, the CDC found.
In a 2012 survey by the agency, 71 percent of Americans said they’d had a drink in the past year, while about 56 percent had done so in the past month. There are a small and growing number of people who drink excessively at one sitting, and it’s not clear why, said George Koob, director of the National Institute on Alcohol Abuse and Alcoholism.
“We’re seeing a higher number of drinks per individual,” he said. “What’s growing is the intensity of drinking in a single bout. We are concerned about that. We haven’t figured out how to address it.”
Longer Hours
Working long hours may exacerbate the problem. The study in the BMJ found that people who worked 49 to 54 hours a week and 55 hours a week had an increased propensity of 13 percent and 12 percent, respectively, for risky drinking.
A glass of wine or a beer or two after the work is a common way to take the edge off after a tough day at the office. The problem is when it morphs into something more. For people who already drink, stress at work or home can lead to an even greater reliance on alcohol, said Sandra Brown, a psychology and psychiatry professor who’s vice chancellor for research at the University of California at San Diego.
“People develop tolerance when they drink regularly,” Brown said. “They don’t realize they are drinking more and put themselves in a more dangerous situation.”
Nationwide, alcohol is responsible for 88,000 deaths a year, making it the third-leading cause of preventable death in the U.S.
Liver, Pancreas
For people in their 30s, 40s and 50s, the effects of alcohol can linger much longer than just a nasty hangover. It taxes the liver and the pancreas, and can lead directly to depression.
The damage from drinking can accumulate over a lifetime, with new risk factors appearing in middle age, said Joseph Lee, a medical director at the Hazelden Betty Ford Foundation. And while most people who have trouble drinking show signs when they’re young, that’s not always the case, he said.
“Just because you went through your college frat days unscathed, it doesn’t mean you have a free pass for the rest of your life,” Lee said. “We see a lot of people who always had a risk for addiction that didn’t manifest until something happened, like a promotion to a high-pressure job, a divorce or a death in the family.”
For middle-aged drinkers, the beer pong and drinking games they played when they were younger can simply carry over as they age and try to hold onto their “adolescent joys,” Koob said. They need to realize their brains and bodies have changed, however, and can’t handle it the same.
“When you are young, the pleasurable effects of alcohol are more rewarding and the hangovers are less,” Koob said. “As you get older, there is a switch over where the hangovers become more excruciating and the pleasurable effects become less. That’s when the demons come rushing out of the bottle.”