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Alcohol

Elyssa Del Valle, M.D.Vice President and Medical Director

Elizabeth PfefferAssociate Underwriting Consultant

September 12, 2017

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Substance abuse is a complex topic and a common problem seen in underwriting and a medical problem dating back centuries

The two most common aspects of the problem in the U.S. today are –alcohol abuse and prescription opioid abuse

This presentation will concentrate on alcohol as a disease as well as a substance of abuse

Introduction and Overview

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Review the scope of alcohol abuse and it’s associated problems

Discuss the health effects, both unfavorable and favorable

Review tools for clinical screening as well as treatment

Present an approach to underwriting and classifying risk in individuals with these problems

• Distinguish at-risk use or abuse, dependence

• Explore the various definitions, tests and other criteria that help us make these decisions

• Look at a rational approach to ratings based on our assessment

• Case reviews

Goals

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Almost 75% of adults in the U.S. use at least some alcohol

One of most prevalent causes of advanced liver disease in US and Europe

Estimated 10-35% of alcoholics in US have alcoholic liver disease

About 1 out of every 10 deaths among working age adults is a result of excessive alcohol use!

About 40% of traffic fatalities are alcohol-related

85,000 deaths a year in the U.S. are alcohol-related

75% of the deaths attributable to binge drinking

The costs of alcohol problems in the U.S. were estimated at $250 billion in 2010

Most liver transplants are for those with histories of ALD and Hep C w/6,000 transplants performed annually in US

Scope of Alcohol-Related Problems

Sacks JJ, Gonzales KR, Bouchery EE, Tomedi LE, Brewer RDAm J Prev Med. 2015 Nov;49(5):e73-9. Epub 2015 Oct 1.Accessed uptodate.com 05/24/2016.

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Short-term

• Acute hepatitis: Associated with heavy alcohol use for 10-20 years

o Leads to cirrhosis

• Acute pancreatitis: accounts for about 30% of the cases of acute pancreatitis

• Esophagitis and gastritis with GI bleeding

• Alcohol poisoning (2200/year; 76% age 35-64, 76% men per CDC)

• Seizures

• Accidents

• Mental health problems

o Depression, suicide

o Domestic abuse

Adverse Health Effects of Alcohol Use

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Long term

• Hypertension and cardiovascular disease

• Stroke

• Cardiomyopathy

• Cirrhosis

• Chronic pancreatitis

• Gastroesophageal reflux disease (GERD)

• Brain atrophy secondary to acute and chronic encephalopathy from toxic effects of alcohol- Thiamine deficiency/ Vit B1 and B12/Folate deficiency

• Peripheral neuropathy- Thiamine deficiency/ Vit B1, B12 and Folate Vit B9 deficiency

o Can also be seen with bariatric surgery patients that do not take their supplements properly

Adverse Health Effects

So. Y MD/Phd. Wernicke Encephalopathy. Uptodate.com. Updated May 05,2015. Accessed 05/19/2016.

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Long term (continued)

• Osteoporosis

• Cancers

o Head and neck cancers (throat, larynx)

o Esophageal

o Liver

o Likely breast and colon

• Cardiac arrhythmias: atrial fibrillation or “holiday heart”

• Bone marrow suppression


Tetrault, JM, MD., O’Connor, PG, MD. Risky drinking and alcohol use disorder: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and

diagnosis.Uptodate.com.Last up dated 05/2016.Accessed on 05/19/2016.

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Worsens treatment of diabetes and other disorders

• Compliance and worsened blood sugar control

Interacts with many prescription medications (opioids, anti-epileptics, antidepressants, anticoagulants, antibiotics, beta-blockers)

• Decreases or prolongs effect of other medications

Poor nutrition and vitamin deficiency

Mortality reaches 80% with just 50% reduction of normal protein intake

Fetal alcohol syndrome in pregnant women


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Light to moderate drinking is associated with favorable cardiovascular outcomes

• Defined as 2 drinks/day for males and 1 drink/day for females

• Type (i.e., wine, beer, liquor) does not matter

• May increase HDL, reduce thrombosis and inflammation

• “French paradox”

Caution

• These benefits are modest at best

• The AHA does not recommend starting drinking for these benefits

• A true alcohol-addicted individual cannot drink without problems

Positive Health Effects

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This is the key to underwriting this impairment

• The bulk of this talk will explore the various definitions, screening tests, lab tests and other data that help to distinguish between moderate alcohol consumption, at risk drinking and alcohol abuse/dependence

• The definition of alcohol abuse sometimes relates to the perspective of the observer, clinician or underwriter; objectivity is important

oDefinitions are not always consistent

o “Standard drink” is 10-14 grams of ethanol: 5 oz wine, and 1.5 oz of 80 proof liquor, or 12 ounces of beer• Risk increases with increased consumption oIncreases risk for both short term and long term consequences

Distinguishing Harmful from Non-harmful Use/Abuse

Tetrault, JM, MD., O’Connor, PG, MD. Risky drinking and alcohol use disorder: Epidemiology, pathogenesis, clinical manifestations, course, assessment, and

diagnosis.Uptodate.com.Last up dated 05/2016.Accessed on 05/19/2016.

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World Health Organization (WHO)

• Hazardous drinking – at risk for adverse consequences from alcohol

• Harmful drinking – alcohol is causing physical or psychological harm

National Institute on Alcohol Abuse and Alcoholism

• Men <65: >14/week or >4 per occasion

• Women <65: >7/week or >2 per occasion

• Men and women >65: >1/day

• Binge Drinking defined as drinking 5 or more drinks in men or 4 or more drinks in women within 2 hours

Definitions

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Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition(DSM-V) – Alcohol Use Disorder

• At least 2 of the following events in a year

o Recurrent use resulting in failure to meet major role obligations

o Recurrent use in hazardous situations

o Craving, or a strong desire to use alcohol

o Continued use despite social or interpersonal problems caused or exacerbated by alcohol use

oGreat deal of time spent obtaining alcohol, using it or recovering from its effects

o Drinking more or longer than intended

Definitions

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DSM-V – Alcohol Use Disorder

• 2 or more of the following events in a year (continued)

o Tolerance; increased amounts to achieve effect, diminished effect from the same amount

o Withdrawal; characteristic withdrawal syndrome for alcohol or alcohol or a closely related substance such as a benzodiazepine used to relieve or avoid symptoms

o Important activities given up or reduced because of alcohol

o Persistent desire or unsuccessful efforts to cut down or control alcohol use

o Use continued despite knowledge of having a physical or psychological problem caused or exacerbated by alcohol

Definitions

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AUDIT

• 10-question screen takes about 5 minutes

• Asks about patterns of use, amounts, frequency and any related problems

• AUDIT-C is an abbreviated form with 3 questions

CAGE – 4 questions

• Has anyone been Concerned about your drinking?

• Have you been Annoyed when criticized about your drinking?

• Have you ever felt Guilty about your drinking?

• Have you ever had a drink in the morning to steady your nerves or get rid of a hangover? (Eye-opener)

Clinical Screening Questions

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Michigan Alcohol Screening Test (MAST)

• Focuses more on alcohol dependence and problems associated with drinking

• A short version is available (SMAST)

• A geriatric version is available (MAST-G)

The National Institute on Alcohol Abuse and Alcoholism recommends the AUDIT

Most commonly we see either AUDIT or CAGE in APSs, but unfortunately we rarely see any screening questionnaires at all

Clinical Screening Questionnaires

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Gamma-Glutamyl Transferase (GGT)

• Very sensitive to alcohol use but not very specific

• Because of the non-specificity clinicians rarely use this test and tend to dismiss the result

Aspartate Aminotransferase (AST) and Alanine Aminotransferase (ALT)

• So-called liver function tests are also not very specific

• An AST/ALT ratio >1 is a red flag and much more specific for alcohol-related liver damage

Laboratory Tests

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Carbohydrate-Deficient Transferrin (CDT)

• Indicates the use of 50-80g of alcohol per day (5-6 drinks/day) for the preceding two weeks

• Very specific but variable sensitivity depending on lab, other underlying impairments, age and gender

• Sensitivity increases with elevated GGT

• Specimen hemolysis or delays in processing can result in false positives

• This is the only lab test currently approved by the FDA for alcohol screening

Hemoglobin-Associated Acetaldehyde (HAA)

• By-product of alcohol metabolism

• Most sensitive when associated with elevated GGT, AST or high HDL

• Not approved by the FDA

Alcohol Markers

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High-density lipoprotein (HDL) elevation

Mean corpuscular volume (MCV) elevation (usually mild, 100-108)

Smoking

Triglycerides elevation

MVR

Financial

Physical findings generally don’t appear unless liver disease is advanced

Insurance alcohol questionnaires

Other Findings

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Physical Findings of Advanced Liver Disease

o Stigmata of Chronic Liver Disease

o Ascites

o Gynecomastia

o Distended abdominal veins

o Facial telangiectasia

o Palmar Erythema

o Terry’s Nails

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Clinical Signs of Advanced Liver Disease

Encephalopathy

Esophageal Varices

Spontaneous Bacterial Peritonitis

CBC abnormalities: Low Platelets (< 160K), low WBC, Macrocytic anemia

Prolonged INR or Protime

Low Albumin

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Alcohol “criticism”

• Amount of alcohol reportedly used

• Actual recommendation to reduce or eliminate alcohol use

• May also be colored by the experiences of the provider and by the context of the situation

“Social history”

• Often will give information on smoking and alcohol use

• Also may note marital status and employment status as well as socio-legal problems

APS

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Social and employment effects

Family history

Financial problems

Legal problems

Driving problems

Other Considerations

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Medical Conditions Associated with Problematic Drinking

Medical issues/associated impairments

• Hypertension

• CAD

• Liver disease/hepatitis

• Neuropathy

• Diabetes

• Depression

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Alcohol Withdrawal

Shakiness, Sweating, Loss of Appetite

Agitation, Restlessness, Irritability

Nausea and Vomiting

Tachycardia, Tremor, Disorientation, Headache, Insomnia, Seizures

Can begin as early as 2 hours after last drink

Delirium Tremens (DTs) characterized by confusion, tachycardia, fever and with death rate up to 5%

Life Threatening condition that requires urgent medical treatment

Symptoms

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Detoxification

In-patient vs. out-patient

Behavioral counseling/addiction specialists

Support and accountability groups

• 12-step programs/Alcoholics Anonymous

• Faith-based and culture-based organizations

• Optimally lifetime attendance

Medications

• Disulfiram (Antabuse)

• Naltrexone

• Acamprosate (Campral)

• Off label— Topiramate (Topamax), Valproic acid (Depakote)

Treatment

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General approach

• No single finding or test will give us the means to properly risk-classify these individuals

• We need to look at all the available information

Consider amount of alcohol used

Consider the pattern of alcohol use or abuse

Consider gender

• While more men have alcohol problems than women, women are more susceptible to the effects of alcohol

Consider the other factors involved

RatingCurrent use

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Alcohol use

• Can include intermittent or “social” drinking

• Usually low-risk if driving not involved and no other problems are associated

Alcohol abuse without dependence

• Excessive consumption and often has associated social and legal problems

• Requires a rating

Alcohol dependence

• Definite excess consumption with significant mental and physical problems

• Highly rated to decline

Patterns of Use and Abuse

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“Binge” drinking

• Drinking to the point of drunkenness or obvious intoxication

• Amount depends on build, gender and tolerance and is difficult to quantify

• Up to 1/6 of adults in the U.S.

• High risk, usually requires additional debits or decline depending on frequency of binges and amount of alcohol used

o Accounts for ½ of the 80,000 deaths in the U.S. attributed to alcohol

o Arrhythmias/myocardial infarction

o Accidents and suicides

o Alcohol poisoning

o “Blackouts”/amnesia

Patterns of Use and Abuse

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Consider years of abstinence

Consider relapses

Consider any current drinking

• With history of dependence and any current drinking generally an offer cannot be made

Association with other substance abuse (polydrug abuse)

• Generally we cannot make an offer unless there is a long history of successful abstinence

o Look for both street/illicit drugs and drugs that are prescribed

Recovery

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Cross-addiction

• Other drugs

• Alcohol

• Very high risk/decline

Recovery

• Generally long-term recovery is not achieved without an initial in-patient treatment regimen followed by continued counseling and support group attendance like Alcoholics Anonymous

• Generally long postpone period before consideration is possible

Ratings

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Alcohol is an ever-increasing problem encountered by underwriters, with significant mortality implications

Distinguishing appropriate and inappropriate use is the key to underwriting these individuals

A number of factors identify inappropriate and high-risk use, and these cases are generally rated or declined

Recovery is possible, but postpone periods are required before we can reconsider

Summary

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40 yo male for $500K.

DUI 1/11, 3/11. Was going through a divorce at the time, underwent counseling and now only drinks an occasional beer.

LFTs and CDT are normal.

MVR shows failure to yield right of way in 8/15

Case 1: Std, Mildly substandard, Moderately substandard, Highly substandard, RNA

Cases

Case 1

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33 year old male smoker for $2 million

For his 33rd birthday in 6/16 he had 25 drinks, passed out, woke up the next morning with abdominal pain that continued several days and he went to his doctor

His wife told him he had been wrestling

Doctor attributed pain to minor injury or gastritis

On alcohol questionnaire he reported 3 drinks on Fridays and Saturdays

Case 2 : Std, Mildly substandard, Moderately substandard, Highly substandard, RNA

CasesCase 2

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32 year old male, $500,000: smoker pack/day x10 years, Ht-5’7”, Wt=150# (stable), BP=119/74. Hx of mild hypertension, mildly elevated cholesterol, and mild depression/anxiety. Current meds Benicar HCT 20 mg/d, Simvastatin 20 mg/d. Habits: 2 drinks 1-2x per week. MVR: speeding ticket dismissed 2 years ago.

5/15 Lab: Hgb=15.3, MCV=92.5, WBC=7,300, plate=178,000, A1C=5.5, chol=176, HDL=48, LDL=100, trigs=140, bili=0.6, ALT=34, AST=28, GGT=101, albumin=5.0, Hep B, C-neg, HOS cot >1.00 mcg/ml

Followed by AP for over 12 years: 11/04 drank <1 beer per day; 11/11 drank 6-7 beers per day


CasesCase 3

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33 year old male, $1,000,000, NS, Ht=6’1”, Wt=180#, BP=117/67. Investment management. Alcohol use is 2 glasses of wine per week. In questionnaire admitted to 5 or more drinks (binge) once every five years. His only chronic illness is gout and his only medication is allopurinol 300 mg/day.

10/12 acute attack of gout, admitted to 4 drinks per week, uric acid=8.1 mg%, ALT=21

5/14 acute attack of gout, uric acid=8.6 mg %

3/15 acute attack of gout after a wine country trip-usual treatment-colchicine and allopurinol

2/15 ins lab: bili=1.0, AST=14, ALT=17, GGT=15, alb=5.0, CDT (+), HAA=10.6 (<10.5), chol=203, HDL=87, LDL=103, trigs=62

Case 4, Std, Mildly substandard, Moderately substandard, Highly substandard, RNA

CasesCase 4

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50 year old male, $2,000,000, NS, Ht=5’9”, Wt=165#, BP=128/82. Med hx is unremarkable except for cholesterol elevation. Medications he takes include Simcor 20 mg/day and Klonopin 1 mg at bedtime. He admitted to drinking beer or spirits 1-3 drinks 2-3 times per week. Extensive APS revealed no alcohol concerns or problems possibly related to alcohol use.

3/16 ins lab: bili=0.53, AST=33. ALT=38, GGT=102, alb=4.8, CDT (+), chol=215, HDL=63, LDL=114, trigs=193


CasesCase 5

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55 year old male, $590,000, NS, Ht=5’11”, Wt=228#, BP=156/101. He admitted to having high BP and abnormal lipids. Medications included Lisinopril 10 mg/day and Lipitor 10 mg/day. He drinks two wine or beers two times per week.

5/16 ins lab: bili=1.0, AST=26, ALT=34, GGT=54, alb=4.9, chol=193, HDL=58, LDL=91, trigs=216

6/14 cardiac evaluation due to age and risk factors: echo-mild LVH (no measurements), LV EF=60%; TM-1-1.5 mm ST depression, short episode of NSVT (number of beats unknown), perfusion scan-normal, LV EF~50%, went 7:44, BP to 240/140; heart cath-minimal CAD (no report)

8/14 4-6 beers per day; 12/12 normal PE captain’s exam for scuba diving


CasesCase 6

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39 year old female, divorced, $300,000, NS, Ht=5’1”, Wt=108#, BP=106/69. She admitted to a hx of prior antiphospholipid antibody syndrome and in vitro fertilizations. Her current medication is Lo-estrin BC pills. She admitted to drinking alcohol 2 drinks 3x per week.

MVR showed a DWI in 11/10 with a BAC=0.18 and successful completion of an alcohol clinic course program.

5/16 ins lab: bili=0.6, AST=21, ALT=19, GGT=33, alb=4.2, chol=180, HDL=83, trigs=65.

Review of APS revealed atypical chest pain 9/14 and a normal echo. She also was noted to have some insomnia and sweating at night, chronic, not severe.


CasesCase 7

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54 year old male with hx of alcoholism. He was admitted in 2014 for upper GI bleed due to esophageal varices.

Last OVN noted reported abdominal pain and bloated abdomen. His wife reported declining memory. PE noted distended abdomen with fluid wave. He had stopped drinking after the GI bleed

Most recent labs include CBC with WBC 4.7, Hgb of 12.1 with MCV of 110 and platelets of 120K. LFTs revealed AST of 22 and ALT 10 with albumin of 3.3.

Case 8: Std, Mildly substandard, Moderately substandard, Highlysubstandard, RNA

CasesCase 8

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Wilson, JF, et al.; “In the Clinic – Alcohol Use.” Annals of Internal Medicine,3 Mar 2009.

Tinsley JA, Finlayson RE and Morse RM. “Developments in the Treatment of Alcoholism.” Mayo Clinic Proceedings 1998; 73:857-63.

Holt, JB. “Vital Signs: Binge Drinking Prevalence, Frequency and Intensity Among Adults – United States, 2010.” MMWR Jan. 13, 2012. 61(01):14-19.

Quick stats MMWR 1/9/15 64(01); 32.

USA Today, “Campus Rivalry,” July 12, 2011.

Jones, DE et al. “Pharmacotherapy for Adults with Alcohol-Use Disorders in Outpatient Settings.” JAMA 2014; 311(18): 1889-1900.

So. Y MD/Phd. Wernicke Encephalopathy. Uptodate.com. Updated May 05,2015. Accessed 05/19/2016.

Bibliography

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Questions?

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