Good morning everyone. I'm Dr. Howard Teitelbaum and it's my pleasure at this point to introduce our first speaker for today. It's Dr. David Best. Dr. Best graduated from Des Moines University College of Osteopathic Medicine in 2002. He completed his family medicine residency in 2005 at Garden City Hospital. In his final year of residency, he completed a course in office-based opioid treatment and began his work with treating patients in substance abuse disorder. He's been providing this standard of care for opiate use disorder in patients in northern Michigan since 2005. We thought it propitious to have a talk on this topic because of its prevalence in today's world and certainly in the future. He is well positioned to speak on this topic and we're glad that he had the time available. Dr. Best started his postgraduate career at the Bel Air Family Health Center in Bel Air, Michigan where he worked from 2005 to 2012. He's been in private practice since November 2012 and his office is in Traverse City, which is in about the fourth finger, if you can think of Michigan as a mitten or a glove, it's about that fourth finger and it's on a beautiful bay and it's gorgeous. It also is a home for the Detroit Red Wings summer camp, but it's a resort area and it's been well established in the state of Michigan for quite some time. He's been in private practice since November of 2012. He and his wife, Lindsey, who is also an osteopathic physician, own Best Medical Services, which was certified as an opioid health center in 2021. Best Medical Services specializes in family medicine and addiction medicine. Dr. Best is board certified in both family medicine and addiction medicine and has spoken on the topic of opioid use disorder in both local, statewide, and national level. I'm pleased to say as a resident of Michigan that Dr. Best was on the Michigan Osteopathic Association of Family Physicians on their board from 2007 to 2015, but he has been president of the Michigan Osteopathic Association and he was in 2021 to 2022. He served as president of the Northern Michigan Osteopathic Association from June 15 to June 17, 2017, and he has been a trustee of Des Moines University's alumni board since June of 22. He's been a trustee of the Novella Health Provider Organization since December of 22. He not only exhibits the best of osteopathic medicine, but he has been, as you can tell, not only an excellent administrator, but also a server of the underserved, namely those who are addicted to substances. His talk today is going to be on alcohol use disorder and other common addictions in the elderly. Dr. Best, welcome to our conference, and the floor, sir, is yours. All right. Thank you, Dr. Teitelbaum. Thank you for that very nice introduction there. So, I don't have any disclosures, and Dr. Teitelbaum went over my background in detail there. I'll just add a little detail about the Opioid Health Home Program in Michigan. If you get extra funding to treat patients who have Medicaid and who have opioid use disorder, and it's allowed me to hire more staff for the clinic. We hired two nurses, one full-time, one part-time, two more medical assistants, and that helps us serve our patients. The nurses serve as the case managers for those patients. And then another part of my experience, I think, is where I've dealt a lot in geriatrics was I was attending a nursing home in Bel Air where I worked for a long time. I had to give that part up because the addiction medicine practice started getting more busy, and then I was a hospice physician as well up until a couple years ago, and again, that's when the Opioid Health Home part of the practice got busier, and I had to drop off with that. But I have had a lot of experience with palliative care, hospice care, and treating older adults. So objectives, I'll review common addictions, which brings to mind tobacco and nicotine addiction is still the number one I think we got to worry about, and then alcohol use disorder, opioid use disorder, opioid use disorder is another very common problem. So those three are the ones I'll touch on today, and I'll go over a couple case studies. One for alcohol use disorder and the other chronic pain patient that did develop some opioid use disorder criteria, and you'll see what happened there. So food for thought, just the, when you look at the basic overall risks, I mean tobacco still is by far the highest risk, kills 8 million people a year in the world. In the United States, it's almost a half a million tobacco-related deaths every year. Alcohol, about 140,000 alcohol-related deaths annually, that's what the CDC reports. And drug overdoses, certainly that's well known to most people where, you know, the opioid overdose crisis is big, and opioids are about 70 to 80 percent of the overdoses in the United States. And now it used to be prescription drug overdoses, or prescription drugs were contributing to the overdoses. Now it's more fentanyl, which is in the illicit drug supply. But the reason to treat patients and get them off the street drugs is certainly to reduce that risk of overdose and death from fentanyl and other things. And then stimulant misuse is rising too, with methamphetamine being more common, and also, you know, prescription amphetamine abuse is a problem. So in regards to tobacco use, the World Health Organization's reported that there's a fundamental irreconcilable conflict between the tobacco industry's interests and public health policy interests. So we've known that since 1963, when the Surgeon General report came out. I was just reading a book on the last 100 days of John F. Kennedy's life, and that period was actually when the Surgeon General gave the report that tobacco was harmful. And all the negatives about tobacco, you can say similar things about alcohol. It can be considered a product that does cause more harm than benefits. I'll go over some of that in the next few slides. However, prohibition is not going to work, so then what do we do? I'd like to recommend this book to anyone who's interested in learning more about prohibition. This is a very well detailed and researched book, and actually Michigan plays a big part in the prohibition because of the proximity to Canada. At one point during prohibition, 1,500 crossings of the Detroit River were happening every day, transporting alcohol from Ontario to Michigan. So it was kind of a farce to think that it could be controlled. Alcohol was reduced overall in use, but it still never went away, and then prohibition was ended in 1933. And part of my talk is just to help encourage clinicians to continue messaging to patients about the risks of alcohol, tobacco, other drugs. And in terms of the alcohol, note that we are inundated with advertising and messaging that promotes alcohol consumption. Same thing with fast food and unhealthy diets. So you'll see commercials and ads for all these things about a product and behavior that's damaging to our health, but that's not the about a product and behavior that's damaging to our health, but that advertising is made designed to make things look fun, attractive, and encourage people to do those behaviors. And if you don't think there's power in advertising, I would reference the Mad Men show where Don Draper was such an effective messenger in his job as an ad executive. And one scene in particular was when he was promoting the carousel, which was the Kodak slide projector, and just the sales pitch he gave was amazing. It almost brings you to tears about how much emotion he brings from that type of product. And that just tells you that there's professional agencies that are made to promote alcohol, other things that certainly we see all the time. And just our job is to start, continue to message to patients and help them develop, know the risks involved, and hopefully change behaviors. So this is where the World Health Organization has very effectively led to reduction in tobacco, at least in the United States. Some countries, it's still not, it's actually rates are going up. In the United States, it's gone way down. So they have this Empower initiative that I think you could use similar tactics in alcohol as well. So monitor the use, protect people from the use, offer to help quit, warn about the dangers, enforce bans on advertising, promotion, sponsorship, and taxes. Certainly anytime you increase taxes on tobacco, it lowers the number of packs that tobacco sold. So I think with alcohol, it's the same thing. This just shows the efforts that are made in terms of promoting smoking cessation and messaging against smoking certainly have helped. Also laws that are made to say you can't smoke in public places or businesses, that's really helped, especially in Michigan. It was about 2010 when the law was made that you no longer smoke in restaurants, any public building or private building or business. And just the messaging, advise or ask, advise, assess willingness, assist in cessation and arrange quit date. And this just shows how people are going to be interested in quitting. So when you bring it up, you have the opportunity to then help. And without help, it's going to be 7.9% quit rate. With just giving some guidance, 10%, nicotine replacement products increase the quit rate up to 26%. And then if you combine behavioral therapy plus medications such as bupropion and the nicotine replacement, and I would add Chantix or Varencycline, you'd get up to 35% quit rate. And so why does this matter? I mean, this is a slide I've seen for many years, and it's really useful to just show to patients, yeah, if you quit, you're not going to regain your lung function that you would have had if you never smoked, but you can change the curve to where your rate of decline is less and you will not have as much disability or risk of death. So for example, if someone quit before the age of 50, that's the green dotted line there, you would definitely hold off on having complete disability from the nicotine or the tobacco use. And the number to look at is the FEV1 or forced expiratory volume one in one second. If you get below 25 to 30%, that's when typically people would start needing oxygen replacement or oxygen supplemental therapy. So this is a good slide to show that, yeah, if you quit at any time, you're going to lower your risk of the rapid decline and hopefully prevent the disability and ultimately prolong life. And then I would encourage people to recommend lung cancer screening. The last statistic I heard is only 6% of eligible people are actually getting this test, but the low dose lung CT is a good test for patients ages 50 to 80. And the requirements are you have to have a 20 year minimum of PAC years, and you have to have quit within 15 years or less. So if someone quit 30 years ago, they wouldn't be technically eligible. But this is a test I've been ordering a lot for patients, and it's supposed to be an annual test if you meet criteria. So now that was tobacco, now we'll talk about alcohol use and the risk. And in the United States, as I said before, 140,000 deaths a year, and it shortens lives by an average of 26 years in those deaths. And for the younger adults, it's responsible for one in five deaths. So as people age, it's more other diseases like heart disease, cancer that caused the death, but at the younger age, accidental death and the alcohol risk is very high. And it's estimated that $249 billion is the economic cost. And that would average out to about $2 a drink. And so that was the overall death rate. Now, this graph shows how in the age group of 55 to 64, that's actually the highest rate of alcohol induced death rates in the United States. So at that age group, that's when the rate is higher. And that's where you're starting to see the heart disease, cancers that are developing and liver disease, and so on. So that's the highest rate as a consequence of long-term alcohol use. So when does alcohol become a problem? So that's the question. So it's a socially accepted addictive drug. So it's used worldwide for thousands of years. Excessive alcohol. So the definition of binge drinking is four or more drinks on an occasion for a woman or five or more for a man. And then heavy drinking would be eight or more drinks per week for a woman or 15 or more for a man. But I think the guidelines of what's considered safe, I think we need to reevaluate that because some people think, well, one or two a day is considered safe. I'll show you a study that gives the opposite information. Because the current guidelines may be saying an acceptable level is actually one that would shorten life expectancy. So this study is from the Lancet. It was in a 2018 article. And it said that regardless of gender, higher alcohol consumption was associated with higher risk of stroke, fatal aneurysms, heart failure, and death. And even seven to 14, so one or two per week, you could expect a six-month shorter life expectancy. If you have 14 to 25 per week, so two to three and a half, the life expectancy reduction was one to two years. And anyone drinking more than three and a half a day, so just short of a binge for women, could expect a shorter life expectancy by four to five years. So it was a really interesting article that came out almost six years ago now. So as people age, the changes can be more harmful, or the risk is higher because the person's body fat content has increased. You have less total body water. And this contributes to higher blood alcohol concentrations. So if someone had the same intake at age 30, at age 60, you're going to have a higher blood alcohol concentration because of those changes, the increased body fat and lower water content. And prolonged alcohol effects in older adults are present compared to younger individuals. And this is a website I like to use for all medical conditions, fpnotebook.com. It just showed the prevalence of alcohol dependence, eight to 14% lifetime. So almost one in seven of your patients may have a disorder. And in the lifetime prevalence is 29%. And it's early age of onset is usual case. So if someone started at that age and you're seeing them at age 60 or 70, there could be a multi-decade problem that's now becoming more prevalent and more risky. And it does run in families, so there's a genetic predisposition. So make sure to get a good family history for your patients. And the chronic health effects, heart problems, high blood pressure, heart disease, stroke, cardiomyopathy, irregular heartbeat, so atrial fibrillation can be a cause or can be a result of alcohol use, liver disease, of course, the hepatitis that can develop, and eventual cirrhosis. And specific risks in the elderly, falling, you know, that could be a real problem. If someone fractures a hip, there's really high morbidity mortality from that. Incoordination from alcohol can be more of a problem in the elderly. Alcoholic dementia, so I saw cases of that when I was working in a nursing home. Some of the younger residents in their 50s, 60s, there's 50s and 60s, a couple of them had dementia, but the main cause was the alcohol over the years. And then I saw one case, so it's not extremely common that you're gonna see this, but Wernicke-Korsakoff syndrome. I saw a gentleman who had had knee replacement surgery in his early 70s and was at a nursing home recovering, and he developed this delirium, and it seemed like the patient had developed some kind of dementia, but looking closely and getting his history, it was determined it was from alcohol. And the Wernicke-Korsakoff syndrome diagnosis was made. So I'll just go a little bit about that syndrome. It's a brain condition that's usually, but not exclusively associated with chronic alcohol misuse and severe alcohol use disorder. Prevalence is not well-established, but it's estimated to be undiagnosed in 80% or more cases. And the age is usually 30 to 70, but it's something to keep in mind if you see a patient that has mental status change, who's older and there's no history of dementia, but now they seem to have some memory impairments and change of behavior that seems consistent with some dementia. But the results of this disorder, it's from brain damage associated with alcohol use and a vitamin D1 deficiency, so thiamine deficiency. So thiamine replacement is key, and just educating and helping the person recover. Some of the symptoms of the Wernicke's disease is confusion, lack of energy, hypothermia, low blood pressure, coma, decreased coordination, and some vision problems can certainly be noted. Then the Korsakoff psychosis, this is the thing you don't want to miss. And it's where you start having memory impairments, problems with forming new memories, recall memories. Then the confabulation, that's what I noticed with this patient I saw. He was just speaking nonsense stories, and that kind of got me to think about the Wernicke's Korsakoff diagnosis. And he did have a very high level alcohol intake prior to going in for his knee surgery. And so there was some risk of withdrawals as well, so you got to realize that could be a problem too. So anyway, just a little bit about Wernicke's Korsakoff, so that's an interesting disease. Cancer risk, this is something I read more about as I was preparing for this talk, is where alcohol use can contribute to cancers of the mouth and throat, larynx, esophagus, colon, rectum, liver, and breast. And even one drink a day can increase the risk, even less than one drink a day. And so the less you drink, the less of your risk of cancer. The immediate effects of alcohol use, certainly the injury risk, the falls, but it can increase the risk of violence, homicide, suicide, and sexual assault. Also contributes to poisoning or overdoses, certainly when you're combining with other substances as well, and in the elderly, it'll be more of a problem with the combination of effects of, let's say, alcohol and any medicine that causes sedation. So be aware of, and because of the higher fat content, the higher blood alcohol level can contribute more as people age. And a recent study found that more than 40% of people who died violently had alcohol in their bloodstream. So I think that's more attributing to the high risk in the young population, but it can certainly contribute all the way through the lifespan. So the pathophysiology of this, the alcohol increases activity at GABA receptors with some CNS depression. So it is a sedative. So alcohol would be considered, what you'd think of as a downer, just like opioids cause a sedation effect. So chronic alcohol use down-regulates the GABA receptors. And so that leads to the increased tolerance and it up-regulates NMDA receptors. And certainly withdrawals, you can have excess excitation. That can be an issue where the withdrawals cause someone to have higher blood pressure, higher emotional state, more anxiety. And then alcohol can affect the effects on the limbic system. So it can lead to more problems with decision-making and impulsiveness. And people with chronic alcohol use or alcoholics can have lower levels of endogenous endorphins. So less enjoyment of life, maybe continue to drink just to help give a temporary boost to the endorphins, but overall it has a negative effect on mood. And digestion, one drink or one ounce of alcohol takes about one hour to digest from mouth to excretion. And there's a small amount absorbed in the stomach, but most is absorbed in the small intestine. And the metabolism is the alcohol dehydrogenase turns alcohol into acid aldehyde. And then acid aldehyde is converted in the liver to acetic acid. And there's 10% renal excretion and 90% hepatic excretion. Then going back to the concept of recognizing the true risk of the drinking, just a couple of references here about this doctor from the University of Victoria's Canada Institute for Substance Use Research. I had a quote stating, risk starts to go up well below levels where people would think, oh, that person has an alcohol problem. And then the increased cancer risk is noted. And it's basically the oxidative stress from the alcohol and the metabolites that can damage the DNA of cells. And it can enable the out-of-control cell growth that creates tumors. And a little bit more about the metabolism. So again, the metabolites and oxidative stress are thought to be the main cause of alcohol-induced organ damage. Just the majority of the alcohol is metabolized in the liver by alcohol dehydrogenase. So when that process is going on repeatedly over time, that's where the liver damage can start and lead to hepatitis, eventual cirrhosis. So there's breakdown there. And also the cytochrome P450 system is partially involved with the breakdown of alcohol and acid aldehyde, which is the toxin to the body. So now screening, this is important. So there is a question on the Medicare wellness visit that it's trying to assess binge drinking. It has the questions about, have you had more than four in one sitting as a woman or five as a male? And then that's also on the health risk assessment that you can do for all general patients too. And this one, you gotta be careful. Some patients will incorrectly overstate how much they drink because they just read the answer. The answers can be zero, one day, two, three or four days a week. And so let's say someone circles one day a week and you don't think of, they've never had any issues with alcohol and you don't think of them as a drinker. You say, oh, you actually have four or more on a day or five or more? And they'll go, oh no, I just have one. So it's like, okay, well, you don't qualify as, that doesn't, that's not a positive test for binge drinking. So it just brings up the discussion and trying to assess the risk. Then you have the CAGE questionnaire. That's the next step. And then the Audit 10, which is a, if the CAGE is positive, then you go on to the Audit 10 and I'll show you the questions involved there. And so the CAGE questionnaire, have you ever felt you should cut down on your drinking? That's the C. Have people annoyed you by criticizing your drinking? That's the A. Have you ever felt bad or guilty about your drinking? That's the G. And have you ever had a drink in the morning to cure a hangover? So the eye opener. And you get a one if there's any positive tests or score or answers. And the score of two or greater is considered clinically significant. And then here's the Audit 10. So you could print off copies of this for use in your office if you do want a screen for this. And then, so it's 10 questions and the higher score are for the more higher levels of drinking and more risk. So the first question, how often do you have a drink containing alcohol? So if it's zero, never, you just skip the nine and 10. But let's say you answered one or two on these questions and your score was a 15. Then you'd see what the risk is. But there's questions in here about binging. So how many drinks containing alcohol do you have on a typical day when you're drinking? One to two, three or four. So that's when you're getting close to the binge, five or six, and your score goes up from there. And how often do you have six or more on one occasion? That could be even less than monthly is you attribute some risk to that. So the scoring, so one to seven would be considered low risk and eight to 14 is a hazardous or harmful alcohol consumption and 15 or more, you're probably looking at an actual alcohol use disorder. If you did the DSM-5 criteria survey, you would most likely have at least moderate to severe alcohol use disorder. So again, Audit 10 is a really good screening tool I would recommend using. And then just the DSM-5 criteria for alcohol use disorder, it's a problematic pattern of alcohol use leading to clinically significant impairment or distress. And you have to have at least two of the criteria that they'd be considered mild. If you have all 11, between six and 11, that'd be severe. And here's the criteria. I'm not going to read all of these, just a few of them. Like the most common one I see is when you talk about cravings, is someone having irresistible or constant cravings to use and that's considered a really strong criteria or I've used larger amounts over a longer period of time so that progressive use, someone wants to cut down or quit, that would be definitely one of the criteria. Then here, going down to the ninth criteria, alcohol use has continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused by or exacerbated by alcohol. So that's when someone's aware of the problem, but they just are powerless to quit. So anyway, the criteria or the severity, mild two to three, the criteria are met, four to five is moderate, six or more severe. So some brief intervention that you can consider, just doing some supportive counseling in the office is important just to discuss, find out what the understanding is from the patient and what their motivations are. And then just track the number of drinks, let's say per week or per month. And over time, you can see if that number is changing or it's getting better, then you can talk about the progress they're making or any more progress they need. And then lab markers, I'll just reference the urine ethyl glucuronide or ETG. You can actually just do a urine dipstick. Those are about a dollar or less per dipstick. You can have that test in the office and that'll show if someone's had any alcohol in the last three or four days. So it's just a way to monitor. I sometimes do those along with 12 panel drug tests I do for my opioid use disorder patients or patients that are on medication assisted treatment. So the protocol for the alcohol use disorder is the patient may need detox. Inpatients for a high risk, you can do outpatient if it's considered lower risk, but that they may need inpatient care. Follow some type of protocol because you don't wanna have the severe withdrawal syndrome that can happen that puts the patient at very high risk. And then for long-term abstinence programs, the 12 step programs are still considered very effective and a lot of patients benefit from that. Alcoholics Anonymous, AA, that's a good program. Another term for it would be mutual self-help. So those can be the Alcoholics Anonymous or there's other ones too. Then encourage the patient to get a sponsor. They may need more in-depth treatment programs through agencies such as Catholic Human Services, which is my area or there's other agencies. And then sometimes a transition house can be needed. Let's say the person goes through a detox, a residential program, they may need to go into transition house after. Then there's medications you can use. The first line is naltrexone, which is an opioid blocker. So it's an opioid antagonist and it's something that will decrease the pleasure from drinking. It doesn't happen in all cases, but a lot of times patients will tell me, yeah, I just don't enjoy it anymore. It doesn't provide that same buzz or the same effect that used to. And so your goal is to reduce alcohol use. You're not gonna expect 100% abstinence, 100% reduction, but you should have less daily drinking and less days where they aren't drinking. And the dosing, it's an oral tablet, 50 milligrams, you take once a day, or you can get the monthly injection, which is 380 milligrams. It's an injection given intramuscular. And there's quite a big price difference between those. So if the person is responsible for their drug costs, you may wanna certainly shift towards the oral dosing as the better option, because the injection can be 1500 or more a month. They're both effective. I've seen both work really well. And they're both covered by insurances in most cases. So a second line treatment would be gabapentin. So it's been shown to be a safe and effective for mild alcohol withdrawal. So this may help where you don't need to use a benzodiazepine if the person's having more mild withdrawal symptoms. And it has been shown to be effective in lowering cravings, can improve mood, sleep that are associated with early withdrawal. So it's been shown to be effective associated with early withdrawal issues or early abstinence. And there is some risk. It's a scheduled medication. So you gotta be aware that there can be some abuse potential, but it's considered to be very low in patients without a history of drug use and when you're using it at therapeutic doses. And there's a good article from the Cleveland Clinic Journal of Medicine from 2019 that discussed that as a good option. Then this is an article from JAMA in 2014. I came across this when I was recertifying every year for my addiction medicine board. I have to look through at least nine articles and answer a bunch of questions, but this is one of the articles I chose to review, on gabapentin treatment for alcohol dependence. There was a randomized controlled trial that showed that it did lower the abstinence significantly and in a dose-dependent fashion. In the study for placebo, it was four percent abstinence rate in the 900 milligram group, so that was 300 milligrams three times a day. There was an 11 percent abstinence rate. In the higher dose, the 1,800 milligram group, there was a 17 percent abstinence rate. You're not looking at extremely high numbers, but it does make a difference and it could be effective in some cases. You can combine the two treatments. Let's say someone's on naltrexone, you could also have them on gabapentin as well to help improve the abstinence rate. Topiramate, another seizure medicine that's been shown to help in some addictive disorders. It's not FDA approved for alcohol use disorder, but it can be used off-label. Interestingly enough, topiramate has multiple indications, and one is for overeating. There's a diagnosis for sleep-related eating disorder, so you can use topiramate for that. For alcohol, it does show that it's somewhat effective. Improves abstinence, well-being, and quality of life in people with alcohol use disorder. The dosing, you start at 25 milligrams a day for a week, and then you go up by 25 milligrams on a weekly basis, and your target dose is 150 milligrams twice a day. Some third-line options, these disulfiram or anabuse can be an option. Patients take it, it can be an add-on to the naltrexone as well, just provides a deterrent. Now, there's negative reinforcement with this medication, because if someone does drink after they've taken it, they get some nausea, flushing, and feel pretty sick. Then camperol, Acamprosate is a medication that balances GABA and glutamate neurotransmitters, and it can be somewhat effective. May prevent relapse in 1 in 12 patients, so number needed to treat is 12. The cost and the amount of tablets a day can be a problem with compliance, but it can be an option for patients. But definitely, the first line is the naltrexone. Then baclofen, I threw this in here because I gave a talk on alcohol use disorder last year, and someone asked a question about what about baclofen, which has some evidence in certain trials that it works, but on average, it was considered to be no different than placebo. Baclofen at this point, I wouldn't recommend for alcohol use disorder. Now, I'll go over a first case study. This was a 73-year-old female who presented just about four months ago now. It seems like I've known her longer, but she was referred to me by Catholic Human Services therapist, and on her first visit, her daughter and her husband came with her. I asked her what's her reason for coming in, and she basically gave me the quote, I want to stop drinking, so that's certainly someone who's motivated. Her history, she'd been a social drinker for many years, probably 10-20 or more years, and prior to the pandemic time, she would have one or two per day, didn't really report having high levels of drinking. But then a couple of years prior to when I saw her, she did say her use has escalated, and she was now having more negative consequences to that. She's had multiple ER emergency room visits in the last couple of years when she would try to quit and would end up having what she thought was withdrawals, but it was really a lot of just anxiety, panic attacks, and so she had maybe seven or eight ER visits two years prior. She never had any inpatient treatments or legal consequences, so no DUIs, that can be a reason for people to quit, for sure, when they start having legal consequences. She's had some counseling, so that's been helpful. Her primary care doctor was prescribing her chlorodiazepoxide or Librium for the withdrawals. Certainly, that's an effective treatment for severe withdrawals. If the patient's in the hospital, that can be used, but it's a little bit risky, so I'll get into that a little bit later here. But her past medical history, pretty significant. A couple of different cancers, breast cancer, colon cancer, renal cell carcinoma, and certainly a mental health history, a little anxiety was reported. She's been on Alprazolam for years, taking one a day on average. Surgery, she's had several surgeries. She's a retired nurse and lives with her husband, so make sure to get the good history. Then I did the screening test, so her CAGE was positive. She would have had all four on that. Her audit score was pretty high at 22, and then she had nine out of 11 of the DSM-5 criteria, so that leads to diagnosis of severe alcohol use disorder. Then the physical exam, pretty unremarkable. Just in talking with her, she was pretty fixated on when she could take more Librium, if that was going to be needed, and she asked that multiple times. There was some over-emphasis on that in her case, and some anxiety related to that. I just talked with her, told her the risk and benefits of continuing that medication, and how there could be an addiction potential for that in the same way as alcohol. There's the assessment, her diagnosis, the continuous chronic alcoholism, F10.20. She does have an anxiety disorder, generalized, and then some induced by the withdrawals. When she would stop alcohol, she would have a heightened excitation or more anxiety. She's been on, like I said, the Xanax one-half to one tablet a day for 10 or more years. But adding the Librium, I think, was the higher risk. We were talking about that at length, on the need to stop that. She's got high blood pressure, and I would expect that to improve when someone stops drinking. Generally, you'll see the blood pressure reads get better. A little bit overweight, so we talked about how exercise and improved diet are going to help that. The plan, we talked about all the options, but naltrexone tablet was determined as what we're going to start. She's going to take one tablet a day. Also, let's say if someone's on opioids, this would not be a good option. If someone's on prescribed opioids, of course, you don't want to give them the antagonist. But there was no history or risk of that in this patient, so I didn't hesitate to start this. You can always do a drug test, certainly to verify if there is any opioids in their system before starting this type of treatment. Education, we review the risks of drinking. I talked about how it can cause hepatitis, memory loss, confusion, and falls. On the elderly, it's really important to lower that fall risk, and they'll sure be interested in hearing, and they don't want to have that happen. Follow-up, she'd started on naltrexone every day. She thought it was helping. She was still having drinks on a few days, not every day, whereas prior, she was drinking every day. She's not having the cravings, and she was able to abstain from drinking at a holiday party, so that was a big thing. Even in a setting where everyone was drinking, and that would be a trigger in most cases, she said she didn't have any, and her family was supporting her too, so that was key. The alcohol had been removed from the home, and for the most part, that's another step. She's feeling better, feels less unsteady on her feet, and is thinking more clearly, and not as anxious overall. In the beginning, I tend to have people come in for close follow-up. In this case, we're doing telehealth. First visit was in-person, then we did a couple of telehealths, and then we're able to have extensive discussions over the phone, and I did some counseling over the phone too. She was still taking naltrexone and thought it was helping. She was down to about one or two drinks a week, but still the habit of having these shooters was there, so we talked about how getting rid of even that last bit was important, and she agreed. Again, I'd avoided alcohol over the holidays. She's more active going to the senior center for exercise classes, and still has more energy, and it's not taking liberty. So three months later, so this is just the last few weeks I saw her. She's not had any alcohol for more than two weeks, and really, it seemed like she's on the path to have full abstinence now. Still is taking Xanax, so I think the benefit is outweighing the risk still, but we're just going to continue to monitor that, and hopefully eventually limit that. At this visit, the question of depression came up, and then so she had a PHQ-9 score that did indicate depression, and that was going to lead to further treatment. She had never been on any SSRIs or antidepressants before, so that was the discussion we had, and with the diagnosis of depression, her PHQ-9 score was 12, so that's something I'll check again in a couple months, and she's been taking ezetalepram or Lexapro one a day, so I've had some follow-up since then, and it seems to be helping. So that was a case of just an elderly woman, you know, 73 years old, starting on medication for alcohol use disorder. So the next case study, this is a patient with chronic pain, so I saw him first about 12 years ago now, and he had been seeing another doctor in the practice who had left the practice, so then he came to see me for an initial visit, and the complaint was chronic left knee pain and pain from plantar fasciitis, so he just had this chronic knee pain issue, and had surgery, injections, but had been on opioid pain medication for several years because he wasn't getting enough relief from the NSAIDs or the other non-medication treatments, also taking amitriptyline at night. So a little more history, half a pack a day smoking, no alcohol use, self-employed landscaper, he was winding that part of his life down, but it was still pretty active with that, no significant family history at all, and then for any patients where I'm considering opioid prescribing or they're on opioids, I like to get what's called a Dyer score, it's a good screening tool to see if the person is appropriate for opioid prescribing. So Dyer, I'll show you the score there, here's the survey you can have the patient do, so Dyer is an acronym for diagnosis, intractability, risk, and efficacy. So do you have a proper diagnosis, which would be something like significant arthritis or degenerative disc disease or spinal stenosis, intractability, has the problem been continuing despite other treatments, risk, do they have chemicals, dependency issues, reliability issues, social support issues, and then efficacy, does the medication actually help them improve function. So the higher score for each question, the more appropriate it can be to prescribe opioids, so the score anywhere from 7 to 21, and this patient, he did have a high enough score, I believe, to warrant prescribing. So pain management, so this is where there was a change in the pain management regimen that led to him needing more short-acting medication that led to the increased tolerance and eventually a problem. Partly this was because the OxyContin coverage was reduced and other options weren't as effective. And the tolerance was built up, when this switch was made to MS Contins, a long-acting morphine and short-acting oxycodone, his tolerance and use of tablets would build up to the point a few years later, the diagnosis of opioid use disorder was made, so moderate opioid use disorder. And I'll show you the DSM-5 criteria, and he fit about five of those, five of the 11, so it was a moderate opioid use disorder. So the decision was made for that patient to go on, instead of a full agonist opioid, we switched to the partial agonist opioid, buprenorphine naloxone, which is used for opioid use disorder, and one of the benefits to it can help with pain. At the follow-up, he said his pain was worse, but he was feeling better and glad to be off opioids, so less sedated and more energy. So here's the opioid use disorder criteria, and what this patient meant was, he met the criteria, taking more opioid drugs than intended, wanting to control, wanting or trying to control use without success, so he wanted to stick to the four tablets a day that he was on, but he ended up getting on six, seven, and would run out early with that change in the regimen. And knowing, going down the list, he did build up a tolerance and withdrawals, he didn't have the craving necessarily, but he'd met enough of these criteria to get to the diagnosis. So anyway, we're forwarding ahead several years, he started having more back issues from lumbar degenerative disc disease, and radiculitis, he didn't end up needing surgery, had injections, but it was, really never went back on the full agonist opioids, and he was happy about that. His dose has been pretty stable, pain control was pretty good, you know, some reduction in his life activities, he wasn't doing as much of his hobbies, woodworking, he's serving as a caregiver for his wife, and then fast forward to this year, within the last year, he's ended up having another back surgery, he's going to PM and R clinics for injections, but still doing well with the buprenorphine naloxone medication. And this is a flow sheet that you could reference, just for opioid tapering, and it gives you some options too, like you don't want to just discontinue someone without a lot of thought, because it can lead to lots of disruption in their life, poor functioning, suicide risk can be very, very high if someone's pain is out of control, and they've been used to taking something, they were just cut off. So, if the benefit outweighs the risks, you can just continue prescribing, if the risks are starting to outweigh the benefits, where there's some indication of opioid use disorder, you can start tapering, or there's an option too, if they meet criteria for opioid use disorder, transition to the buprenorphine. And this slide's a little outdated, because it showed the X waiver is required, it's no longer required for the buprenorphine. So, this is a good flow sheet, and it gives you some options in terms of options in terms of not just cutting someone off from opioids, but potentially switching to buprenorphine, and also just making sure you're really out, you're balancing the risks versus benefits, and the impact on the patient's quality of life. So, I'll end with a serenity prayer, certainly is something that's said every time at an Alcoholics Anonymous or Narcotics Anonymous meeting, but use it as a guide, sometimes you got to remember that you're not going to change everything, but make sure you try your best, and have the wisdom to know the difference. So, God grant me the serenity to accept the things I cannot change, courage to change the things I can, and wisdom to know the difference. And thank you very much, and I've been looking at the chat, see if there's any questions. Well, we're going to have, we've got a couple of questions on the floor, Dr. Best, I'll relay them to you. Sure. Dr. Canton? Yes, sir. Uh, Dave Canton. Uh, several years ago as the C. M. O. For an F. Q. H. C. We decided to undertake a review and kind of, uh, reset on our opioid prescribing. And through through that process, we started screening people. We had an individual who basically admitted he was selling his narcotics. So they said, Okay, well, we can't prescribe for you if you're just gonna sell them. And he said, Well, how about Mrs Jones, Mr and Mrs Jones? They're my neighbors. Well, they were patients of ours, too. And I'm making up the names. And they were a 70 year old couple. And the provider said, Well, what do you want about them? Yeah, I know them. They're good people. They just like the story you presented with the D. J. D. He said, Well, they're selling theirs, too. So when they came in for the for their next appointment, they were confronted and they admitted to Yeah, they were selling. That was kind of their adjunct income. Could you speak to? I mean, we don't typically think of 70 years old 70 year old people as being drug dealers, if you will. Can you speak to that sort of approach and and mindset and how to deal with that? Yeah, that is. That's definitely a challenging situation. It could be kind of shocking to hear. But then I think the key is when you get a report like that, you act on it in terms of, you know, having the patient come in for follow up, do a med count. That's why I drug test all my patients that are on any kind of opioid prescription. And, yeah, there's some inconsistencies that that's where you can go back to this flow sheet. And, you know, where the risks outweigh the benefits. That's where you can discontinue the use. And but again, it is challenging. It takes a lot of effort on our part, the doctor in the clinic. But the drug testing is the big thing you want to do there is make sure you get a in office drug test. So you have the results while they're still there. And then you can assess if there's any inconsistencies there. And then realize to you may you may get reports that are bogus as well. Sometimes I've had this happen where someone called and said, Oh, yeah, these people are selling their meds. And then you you just check up on it, you have the person come in for a med count. And hopefully, if they're all consistent there, you can say, well, someone was trying to sabotage your care. But you do want to follow up on those type of reports with a med count. This certainly discussion with patients and drug testing. Thank you. We we have a question from the chat. Yeah, this one's about ketamine assisted psychotherapy in treating alcohol and other substance use disorders. So that I just read about this recently, it is pretty high. There's more treatment going on, but it's off label. And certainly you got to be aware of the risks of ketamine, which is a dissociative anesthetic. And so it says here, yeah, treatments prevent increasingly prevalent in Texas and other states. So I think it's pretty risky. I've had one patient that benefited from that for her resistant depression. Again, it was something she did on her own. And is getting treatment there. But I would think of it as a way it's kind of like doing electroshock therapy for depression, it might be effective in resetting the brain chemistry. But I think it is pretty high risk. And I personally have not been recommending it. And it, to my knowledge, is still off label and not a done deal in terms of being effective for alcohol and substance use disorders. Because patients may have a if they have substance use disorder to begin with, adding this type of potentially addictive medication would not be effective, in my opinion. Hey, Dr. Best, Al Phillipi here. A great talk. Thank you. In the first case, yeah. In the first case study, why were you recommending that she stop Librium? Partially because she was already on one prescribed benzodiazepine. And I think I think she was using it. She was getting actually 90 capsules at a time. So there was a large quantity being given. So I just thought it was a high risk for her to still have those. So I actually recommended she dispose of them. Because in addition to the short acting benzodiazepine, Alprazolam to have the long acting really was was a problem. And I think it was just because she was already on a benzo that presented a risk. She she had controlled her use over years and years. So I wasn't you know, saying she had to discontinue it altogether. But definitely, I think it was a high risk. And it wasn't being it wasn't clear on why she was using it was because her complaint of withdrawals really this would be even 10 days after she had used. In some cases, she would say, Oh, I'm having withdrawals again. I was like, Well, not exactly. You're, you're fully detoxed off the alcohol. I think your anxiety disorder is what you're having more than anything. Not so. Yeah. So you're, you're not totally against the use of benzos. It's just, it was the combination. Right? Yeah, exactly. And, and just the number like this happens all the time when patients have a medicine cabinet with unused meds, it's better to just get rid of those and not have a risk because that in at her age and with her other medication use, I think it was a pretty big risk. Hi, this is Naomi Reston. Great talk. Thank you. Did you find? Do you find that it's especially hard to get patients off Xanax? In my experience over the years, they really cling to that. Yeah, I experienced more so than other benzo diazepam. Yeah, I think it is it is an issue. You know, a lot of times I'll try if, if they're going to continue to require a benzodiazepine because of severe anxiety disorder, I usually try to switch to Klonopin, Klonazepam or Lorazepam, which can be considered a little bit safer. So you can try the, the, you know, try to transition to a different benzodiazepine, use one of the conversion tables to do that. But if there is a failed conversion, then, you know, certainly keep monitoring it and, and making sure the benefits outweigh the risks. And with my hospice care, we would always have people on Lorazepam, which seemed to be better tolerated. And it was very effective for the, you know, air hunger issues with people with were near death, and also with people had severe mental challenges or anxiety. So I, you know, if they're on Alprazolam, you can try to switch into Lorazepam or Klonazepam, those would be better. But again, realize sometimes, yeah, you're right, people are set in their ways. They're they've been using us for 20, 30 years. And you got to pick your battles there. We have one last question. Hi, Dr. Best. This is Jen Benikasa. My question is more about for like long term accountability. I don't remember if you mentioned it, but for either of the cases for like Alcoholics Anonymous, do you, did you recommend it for you know, either either of the two cases? Or is it as long as they seem to have a good social support? Then you're like, okay, then we'll go with that instead of, you know, having maybe an outside accountability to really keep them accountable. Yeah, I think I usually just make the recommendation, but I'm not mandating it. And I think I try to find something whatever works for the patient. So for the woman, the 73 year old, she was already going to, you know, counseling, and was well established there. So I think adding more wasn't a huge priority. And it's basically patient centered systems of care is what I follow. It's like what works the best for their function and their their life. Then the the patient who had the who was transitional from the opioid, full agonist opioid to the buprenorphine. I think he had good social support. I believe for a time he might have had some counseling, but long term, it's not something I was mandating for him. Or even I would just ask, you know, what's what's helping you stay, stay on track, what's helping your, your mood and your your quality of life. So you try to find out what what they're doing, how what their family situation is, what their environments like. But I'm not mandating the Alcoholics Anonymous or any specific recovery support. But you do want to mention it and certainly bring it up again if there's a problem. Well, thank you very much.

Dr. David Best

addiction medicine

substance use disorders

opioid crisis

alcohol use disorder

elderly addictions

CAGE questionnaire

DSM-5 criteria

naltrexone

personalized treatment