Dr. Turck:
Addiction has been a crippling health crisis in the U.S. for decades now. And the rates of alcohol dependency in particular may worsen as the COVID-19 pandemic continues. In fact, recent studies are already reporting increased alcohol consumption. So, what do we as clinicians need to know about screening and treating this growing patient population?
Coming to you from the ReachMD studios, this is COVID-19: On the Frontlines. I’m Dr. Charles Turck. And here to talk about challenges in screening for alcohol dependency and how we can overcome those barriers to getting our patients the best treatment is Dr. Alberto Augsten, a board-certified clinical toxicologist and Clinical Pharmacy Manager at Memorial Regional Hospital in Miami, Florida. Dr. Augsten, welcome to the program.
Dr. Augsten:
Oh, thank you for having me, very happy to be here.
Dr. Turck:
Well to start us off, Dr. Augsten, would you paint us a picture of where we are now as a nation in terms of addiction and alcohol dependency as a result of, or at least coinciding with, the COVID-19 pandemic?
Dr. Augsten:
I think you painted the picture rather well at the start of the program. I think for the majority of the United States having gone through this pandemic, we all assumed that we would be seeing upticks in individuals suffering from a variety of substance abuse disorders, whether it’s opioid related, stimulant related, and in this instance, alcohol use disorder. Obviously, one of the biggest challenges we have is getting data that’s recent and updated and can really account for what we’re seeing and that’s probably the biggest challenge. Really knowing what’s happening in real time.
From the preliminary data that we’re seeing, over this past year, secondary to COVID, we are understanding that there is an increase in individuals with alcohol use disorders. The specific data is still coming out but we’re looking at in a range of an increase of approximately 30%. And what’s complicating matters is not only are we seeing this increase in a lot of the patients during this pandemic, but really there has been a coinciding decrease in access to programs. So, you’re really looking at a perfect storm of matters.
And then just alone understanding that whenever you’re discussing individuals who are suffering from, substance use disorder, whether it’s an opioid related stimulant, and in this case, alcohol, many times we’re talking about co-occurring disorders., And when we’re discussing co-occurring disorders to familiarize oneself, these are individuals that not only have a substance use disorder, but also have maybe something psychiatrically that they’re dealing with. Sure enough, many individuals are co-occurring with depression, maybe an anxiety, and that’s exactly what we saw during this pandemic. We saw rates of anxiety go up. We saw rates of patients exhibiting depressive symptoms go up. So, you really have a perfect storm at this point in time in saying we have these individuals that are suffering from alcohol use disorder, these co-occurring related disorders and a diminished access to care, and I’d would say now is the time to act really, hopefully engage individuals into treatment.
Dr. Turck:
You mentioned a diminished access to care so I thought I would ask what are some of the screening challenges spurred on by the pandemic that you’ve encountered or observed?
Dr. Augsten:
Great question. And I think traditionally the challenges specific to screening have always been an issue, specifically when you’re talking about alcohol use disorder. And there is a lot of discussion related to individuals who maybe fall in the in between. You know, is this somebody that truly has an alcohol use disorder, maybe there is this gray area that they’re consuming more than low-risk and they’re an intermediate risk. I think from my perspective, coming from a large healthcare system, we’re talking about a healthcare system that pertains to one million residents in south Broward County in which we have very, very busy emergency departments, over 130,000 patient visits per year in the primary one, you are aware and you realize that screening is very difficult and very challenging. You need tools and instruments to be able to screen for an individual to say, ‘I have identified somebody who may have an alcohol use disorder or who may require further screening.’
So one of the things that we have implemented is the use of a neat screening tool which has been around for many, many years; it’s the AUDIT-C and it allows one to really identify an individual that would require further screening. And if an individual is deemed to be , a certain score in the AUDIT-C, that triggers a full audit screening from one of our clinicians to see if maybe there’s something that we can offer this individual and engage them into treatment, secondary to their alcohol use disorder.
Dr. Turck:
Now in addition to that tool, have there been any other changes in protocols that you have implemented during the pandemic?
Dr. Augsten:
You bring up a very good question. And I think for the folks listening, I think everybody got creative. Everybody used what we had in front of us, we used approaches by telehealth, telepsychiatry screening. We did the same thing, which is figure out ways that we can engage patients, figure out ways that we can use technology to not only engage them and to screen them and to hopefully link them between service providers, which was extremely challenging during the pandemic. And from our perspective, one of the greatest challenges that we saw was that many of the patients who presented, whether it was an alcohol use disorder or in general any substance use disorder, if these individuals presented to our primary hospital in Hollywood, Florida, which is our main hub, the majority of them were rendered in that location. However, our sister sites weren’t predominantly accustomed to identifying and screening and transitioning patients into substance use treatment and things of that nature. So we used telehealth, telepsychiatry to link those individuals, meaning individuals that presented to other areas in the healthcare system to identify them and link them with clinicians in our primary site with the goal, hopefully, to transition them into our services.
Dr. Turck:
For those just tuning in, you’re listening to COVID-19: On the Frontlines on ReachMD. I’m Dr. Charles Turck, and I’m speaking with board-certified toxicologist and Clinical Pharmacy Manager Dr. Alberto Augsten about the growing numbers of people affected by addiction and alcohol dependency in the U.S.
So now that we have a better understanding of how we might optimize screening for alcohol dependency, Dr. Augsten, would you talk a bit about the different types of programs available that address, manage, and treat alcohol dependency?
Dr. Augsten:
Absolutely. Many folks are familiar with the traditional, people call it the shared model, which invokes abstinence. The challenge isn’t to get to this model in where a patient would approach recovery from an abstinence perspective is the intermediate phase, the phase of transitioning is extremely challenging. And obviously for those folks familiar with alcohol use and intoxication or withdrawal, we are well aware that the in-between phase and the withdrawal risk associated with somebody suffering from alcohol use disorder, we want to ensure that they don’t have any consequences from, stopping the alcohol use. So obviously the consequence is secondary to withdrawals, which could be seizures, and in some severe cases can result in significant delirium and risk to the patient.
But the real key component here is we always look at it from the perspective when we’re transitioning somebody from any compound to one in which we hope to get them off. We’re looking at the physical and psychological related risks. The physical risks we want to say, ‘I want to ensure that when this individual is transitioning from the moment that I’m starting treatment to the moment that I get them to the next level, where hopefully they’re off, I’m ensuring that the physical withdrawal risk is addressed.’ In this instance, physical withdrawals from alcohol use we know seizures is a high risk, but it can be precipitating even anxiety, things that I mentioned earlier. We’re talking about individuals with co-occurring disorders. And if you can image an individual who has now self-medicated with alcohol and they have an anxiety disorder, the moment you’re transitioning them, and anxiety starts to increase, it’s gonna lead to a high-risk of failure and relapse. So the physical component is extremely, extremely important in the initial phases.
Thereafter, really we’re looking at the psychological piece. And we know that the psychological piece is extremely challenging. This is where if we’re linking individuals in programs or allow them to address and identify causes and maybe reasons why they’re using alcohol and maybe that’s leading to an identification of somebody who has a psychiatric underlying disorder. But at the same time, that phase is crucial because we know that the psychological piece associated with addiction is what brings individuals back into re-using and having a risk of a relapse. So, all those factors play a role as we transition individuals from the first level into the next level of care.
Dr. Turck:
Are there another practical tools that you can recommend to aid the referral and transition process in getting patients to appropriate treatment providers?
Dr. Augsten:
Yeah. Every, city hopefully has programs that offer services for these individuals. From my perspective, we’ve done a very good job at identifying and addressing not only alcohol use disorder, but opioid use disorders, and many of the challenges that you run into is finding programs that are suitable for patients. You’re going to run into patients obviously that have access to care, have insurance, and then those that don’t. So really identifying the programs that can address the needs of our community. So, finding these programs that if I have an insured patient or uninsured patient, I can send them, and they can receive help. Then ensuring that we have the means and ability to address the intermediate phase, like I mentioned, the physical withdrawals, leading to psychological withdrawals, and then there are a variety of pharmacotherapy regimens that are available. We know that historically there are medications available that help with individuals that are suffering from alcohol use disorders, where there’s some medications that work by causing individuals to have a negative reaction to alcohol. So even if they did consume alcohol, it would cause them to get nauseous and vomit. There are other medications that strictly work on the reward pathway and have some mediating effects on that pathway. And then lastly, there are even newer medications that are injectable in formulation that work on opioid receptors because one of the things that we are aware now is that alcohol can trigger and release naturally occurring endorphins actin opioid receptors, so there are these agents now that block these opioid receptors and are actually available in an injectable formulation that last a whole month. And this medication hopefully in the right individual will block any euphoric effects related to alcohol use. So, there’s plenty of things that we can do. Really the key here is the identification and really engagement into treatment.
Dr. Turck:
Now we’re almost out of time for today, Dr. Augsten, but before we close, I thought I would see if you had any other final thoughts or key points about medication or the role of medication for alcohol dependency that you’d like to share with our listeners?
Dr. Augsten:
I think that there’s a lot that can be done. I think one of the things that we should be aware of is historically and this continues to be a problem is really identifying these individuals remains to be the biggest hurdle. Identifying that we have individuals in front of us that we’re treating that may actually have an alcohol use disorder and we’re not aware of it. They’re functional, maybe there aren’t any signs in their laboratory assessment and their liver profile, but they are actually suffering from some form of alcohol use disorder. So really here the key is the identification of these individuals.
Dr. Turck:
Well given the increase prevalence of alcohol dependency we’re seeing amid the COVID-19 pandemic, I want to very much thank Dr. Alberto Augsten for joining me today to talk about how we can better screen and treat patients with a disorder. Dr. Augsten, it was great having you on the program.
Dr. Augsten:
My pleasure, thank you.
Dr. Turck:
I’m Dr. Charles Turck. To access this and other episodes in our series, visit ReachMD.com/COVID-19, where you can Be Part of the Knowledge. Thanks for listening.
