HIV/AIDS

Note: Some medications mentioned in this chapter may not be available on the VHA National Formulary. Consult VA pharmacists for alternatives.

Background

Definitions

Alcohol misuse refers to the spectrum from risky drinking to alcohol dependence.

Risky drinking refers to drinking beyond recommended drinking limits (see below).

Alcohol abuse and alcohol dependence (also called "alcohol use disorders") refer to diagnoses based on problems patients experience as a result of drinking, and are defined by the DSM-IV-TR. Both abuse and dependence are maladaptive patterns of alcohol use that lead to clinically significant impairment or distress.

Alcohol abuse is a maladaptive pattern of use associated with 1 or more of the following:

• Failure to fulfill work, school, or social obligations
• Recurrent alcohol use in physically hazardous situations
• Recurrent legal problems related to alcohol use
• Continued alcohol use despite alcohol-related social or interpersonal problems

Alcohol dependence is defined as a maladaptive pattern of use associated with 3 or more of the following:

• Tolerance
• Withdrawal
• Alcohol taken in larger quantity than intended
• Persistent desire to cut down or control use
• Time is spent obtaining, using, or recovering from alcohol
• Social, occupational, or recreational tasks are sacrificed
• Alcohol use continues despite physical and psychological problems

Recommended drinking limits:

Based on the accumulated epidemiological evidence, individuals who drink beyond the following levels are at increased risk of adverse consequences of drinking (National Institute for Alcohol Abuse and Alcoholism [NIAAA]):

• An average of 2 drinks daily (14 drinks per week) for younger men; an average of 1 drink daily (7 drinks per week) for women or older adults (≥65 years)
• A maximum of 4 drinks on any occasion for men; a maximum of 3 drinks on any occasion for women or older adults

Note that safe drinking limits may be substantially lower for some patients, depending on factors such as comorbidities (eg, liver disease), pregnancy, and interacting medications.

A great number of people drink more than the recommended limits but do not meet criteria for alcohol dependence. These nondependent drinkers account for the majority of alcohol-related morbidity and mortality in the general population. All patients who misuse alcohol should receive focused medical attention and intervention.

Epidemiology

• 35-40% of HIV-infected patients in primary care settings have documented diagnoses of alcohol use disorder; many more might drink above recommended levels in ways that pose health risks.
• Alcohol misuse causes substantial morbidity and mortality. Medical conditions associated with alcohol misuse include alcohol withdrawal syndrome, hepatitis, cirrhosis, pancreatitis, thiamine deficiency, neuropathy, cardiomyopathy, hypertension, stroke, breast cancer, depression, and cancers of the oropharynx, larynx, and esophagus.
• Excessive alcohol consumption is the third leading preventable cause of death in the United States.
• Alcohol use is associated with:
  • 40% of all traffic fatalities (2000)
  • 20-37% of emergency department trauma cases (1990)
  • 66% of all drownings
  • 50% of all deaths from cirrhosis
• Alcohol use compounds the liver damage associated with hepatitis C and hepatitis B, and accelerates progression to cirrhosis.
• Concomitant use of alcohol and hepatotoxic drugs (including some ARVs and statins) may increase the risk of early and severe liver damage.
• The risk of pancreatitis caused by ddI is higher among patients who use alcohol chronically.

Evaluation

Screening

The VHA recommends universal screening to identify patients who misuse alcohol. Screening followed by brief counseling interventions or treatment has been shown to decrease drinking and improve health outcomes.

• Ask all patients whether they currently drink alcohol. Ask about past alcohol use, and about family history of alcohol-related problems.
• For drinkers, use the AUDIT-C screening questionnaire (see below) to assess for risky drinking (see above for recommended drinking limits).
• For drinkers, ask more specific questions to determine whether they fulfill criteria for alcohol abuse or dependence (see DSM-IV-TR criteria, above) and whether they have signs or symptoms of liver disease, psychiatric comorbidities, behavioral complications such as violent episodes, or other substance abuse.
• Goals for evaluation:
  • Determine whether the patient is drinking above safe levels.
  • Determine whether the patient has loss of control over the use of alcohol.
  • Determine whether tolerance, dependence, or abuse is present.
  • Determine whether adverse consequences of excessive drinking have occurred.

Management

Brief counseling with specialty referral as indicated can be effective in reducing hazardous drinking. Patients with alcohol use disorders may require comprehensive treatment programs that include the services of medical providers, psychologists, and psychiatrists to assist with comorbid psychiatric conditions, social workers, housing counselors, case managers, and substance abuse counselors.

• Short-term goals: treating alcohol withdrawal as needed; encouraging abstinence and attendance at Alcoholics Anonymous or other counseling programs; engaging family and community support; ensuring adequate resources for housing, food, and income
• Long-term goals: sustained abstinence from alcohol use; recovery of self-esteem, health, and social functioning

Simple, office-based interventions can be made using the 4-A approach: Ask, Assess, Advise, and Assist.

• Ask about alcohol use, using AUDIT-C (see above)
• Assess for alcohol use disorders (see below)
• Advise all patients, even those with no reported heavy drinking, to stay within healthy drinking limits, keeping comorbidities in mind. Particularly for those with liver disease, there is no known "safe" level of alcohol consumption, and alcohol may be particularly dangerous for patients with HIV/HCV coinfection.
• Assist patients with brief interventions, pharmacotherapy, and referral for treatment services
  • Brief (<5 min) alcohol intervention (BAI) can be extremely effective for alcohol misuse. More information on BAI. Key components:
    • Aim to reach agreement on a drinking goal.
    • Let the patient lead the discussion; for example, ask patients (rather than tell them) how they think alcohol use affects their health.
    • Aim for a nonjudgmental atmosphere, using open-end questions and eye contact.
    • Give choices in the discussion rather than force topics on the patient. For example, ask about stressors and how alcohol use fits in with these.
    • Remember that patients vary in their degree of readiness to change.
    • Patients need to understand the importance of change, to have a sense of confidence about their ability to change, and to have a support system.
    • Avoid lecturing or cheerleading; if it happens, take a step back and ask an open-end question such as "What do you think of this?"
  • Referral to Alcoholics Anonymous is helpful to many patients; AA meetings are held worldwide, and information is available at www.aa.org.
    • The Drinkers Check-up website offers a self-evaluation tool and information on cessation: www.drinkerscheckup.com
• Reinforce and reevaluate intervention messages at each visit.

The following is an algorithmic representation of screening and intervention using this approach from the NIAAA.

Alcohol Misuse: Screening and Intervention Algorithms

(See PDF) Adapted from NIAAA Pocket Guide

When to Refer

Most patients with moderate or severe alcohol misuse should be referred to specialized alcohol or substance use disorder treatment services. Patients with comorbid conditions that are adversely affected by alcohol, such as HCV infection or depression, may need treatment even if they do not meet typical criteria for alcohol use disorders.

Patients in withdrawal (tremors, sweats, anxiety, disorientation, or visual, auditory, or tactile hallucinations) should be referred to an emergency department for immediate evaluation and treatment, and should be referred to a detoxification program if available.

Pharmacotherapy for Relapse Prevention

Although pharmacotherapy may help to prevent relapse, multimodal treatment that includes medical therapy with or without behavioral therapy may be more effective.

Note: Caution should be used, as no trials have demonstrated the safety of these medications in HIV-infected patients who are receiving ARVs. Although it is expected that the efficacy of these medications will be similar in patients with and without HIV infection, increased monitoring for adverse effects should be exercised until more data are available.

A randomized controlled trial involving HIV-uninfected patients compared various combinations of medical management, medication, and behavioral therapy for treatment of alcohol dependence in recently abstinent patients. The study showed that:

• All treatment groups had substantial increases in the percentage of days abstinent from alcohol.
  • The highest percentage of days abstinent (77-80%) was seen in 3 treatment groups: patients who received naltrexone (100 mg QD) + medical management (9 sessions with a health care professional), naltrexone + medical management + a combined behavioral intervention (CBI) (20 sessions), or medical management + CBI + placebo pills.
  • Patients who received CBI alone (no medical management or pills [whether placebo or naltrexone]) had the lowest abstinence rates.
  • Acamprosate was no more effective than placebo.
  • Treatment effects largely dissipated after 1 year; thus ongoing monitoring is important, and treatment of relapse may be necessary.

References

• AIDS Education and Training Centers National Resource Center. Recreational Drugs and Antiretroviral Therapy. In: Clinical Manual for Management of the HIV-Infected Adult; July 2006. Accessed December 10, 2008.
• American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Text Revision, 4th Edition. Washington, D.C.: American Psychiatric Publishing; 2000.
• Francis H. Substance abuse and HIV infection. Top HIV Med. 2003 Jan-Feb;11(1):20-4.
• National Institute for Alcohol Abuse and Alcoholism. Helping Patients Who Drink Too Much: A Clinician's Guide. 2005. Accessed December 10, 2008.
• VA/DoD Evidence-Based Clinical Practice Guideline Working Group. Management of Substance Use Disorder in the Primary Care Setting. Washington, D.C.: Department of Veterans Affairs, Office of Quality and Performance; September 2001.