"You need to create a new life, whatever that life is gonna be" - Managing Alcohol Use Disorder (Part II)

In this episode, Dr. Barenboim and Dr. Holt discuss the important role that medications and mutual support groups play in helping James maintain sobriety from alcohol.

Share your reactions and questions with us at  Speak Pipe . We might feature you on a future episode!

=== Outline ===

Chapter 1: Managing Alcohol Withdrawal in the Outpatient Setting

Chapter 2: Medications for AUD

Chapter 3: Recovery Group/Social Support

=== Learning Points ===

1. Although our training has historically focused on the inpatient setting, managing alcohol withdrawal in the outpatient setting is also possible. A sample regimen for this may be 10mg diazepam every 6 hours on the first day, then every 8 hours on the second day, every 12 hours on the third day, and then once on day 4.
2. Medications approved by the FDA in the treatment of alcohol use disorder include: naltrexone, acamprosate, and disulfiram. Disulfiram is considered a first-line medication. 
3. Successful treatment of AUD often requires trying lots of combinations of interventions, which can include medications and non-pharmacologic interventions such as mutual support groups or therapy. The diversity of support groups is growing, making them more accessible to patients; but patients may need to trial many different groups before finding one that “works” for them.

=== Our Expert(s) ===

Dr. Stephen Holt attended Columbia University’s College of Physicians & Surgeons and subsequently completed his residency training and Chief Residency at Yale's Primary Care Internal Medicine Residency Program before joining the program as an Assistant Professor. He currently serves as the Associate Program Director for Ambulatory Education in the Primary Care Program. His areas of interest include addiction medicine, medical education, and the art and science of physical diagnosis. 

=== References ===

1. Tiglao SM, Meisenheimer ES, Oh RC. Alcohol Withdrawal Syndrome: Outpatient Management. Am Fam Physician. 2021 Sep 1;104(3):253-262. PMID: 34523874.
2. McPheeters M, O'Connor EA, Riley S, Kennedy SM, Voisin C, Kuznacic K, Coffey CP, Edlund MD, Bobashev G, Jonas DE. Pharmacotherapy for Alcohol Use Disorder: A Systematic Review and Meta-Analysis. JAMA. 2023 Nov 7;330(17):1653-1665. doi: 10.1001/jama.2023.19761. Erratum in: JAMA. 2024 Oct 2. doi: 10.1001/jama.2024.11331. PMID: 37934220; PMCID: PMC10630900.
3. Garbutt JC, Kranzler HR, O'Malley SS, et al. Efficacy and tolerability of long-acting injectable naltrexone for alcohol dependence: a randomized controlled trial. JAMA 2005; 293:1617.
4. Skinner MD, Lahmek P, Pham H, Aubin HJ. Disulfiram efficacy in the treatment of alcohol dependence: a meta-analysis. PLoS One 2014; 9:e87366.

=== About Us ===

The Primary Care Pearls (PCP) Podcast is created in collaboration with faculty, residents, and students from the Department of Internal Medicine at the Yale School of Medicine. The project aims to create accessible and informative podcasts about core primary care topics centered around real patient stories. 

Hosts: Dylan Balter

Producers: Helen Cai, Josh Onyango

Logo and Name: Eva Zimmerman

Theme music and Editing: Helen Cai, Josh Onyango

Other background music: Asher Fulero, Dan Bodan, Penguin Music, Nathan Moore, Chris Haugen

Instagram: @pcpearls

Twitter: @PCarePearls

Listen on your favorite podcast platforms: linktr.ee/pcpearls

Transcript

[00:00:00] Dylan: Hi, welcome to Primary Care Pearls, a podcast made by learners for learners. Today,

[00:00:07] James: I like to play lottery scratch off, and the store, it's right next to a package store that I frequently used to go into. Now I walk by it, I don't even, don't, don't phase me. I don't even look at it. I just keep going, do my business at the convenience store, go.

[00:00:23] Dylan: We're continuing our discussion on alcohol use disorder with help from James and Tonya.

[00:00:29] James: I'm James Streater. Um, I'm a recovered alcoholic. Right now, today I'm 105 days sober.

[00:00:38] Tonya: I'm Tonya Robinson Streater. I'm married to James Streater and I'm pretty much here to support him through his journey of recovery. 

[00:00:49] Dylan: We'll also be joined by our faculty expert, Dr. Stephen Holt. 

[00:00:53] Dr. Holt: Hello, my name is Stephen Holt. I'm a physician. I'm board certified in Internal Medicine and Addiction Medicine and at Yale School of Medicine I direct the Addiction Recovery Clinic within our Primary Care Internal Medicine residency.

[00:01:08] Dylan: The interviews will be facilitated by Dr. Jessica Barenboim.

[00:01:12] Jessica: My name is Jessica Barenboim. I am one of the preventive medicine residents. My interest in the field of substance use disorder has been one that's been brewing for about 20 years. 

[00:01:26] Dylan: In the last episode, we discussed how to take a comprehensive biopsychosocial history with a patient, how to diagnose alcohol use disorder using specific criteria, and how to motivate patients towards change. This is particularly important as only about 7 percent of patients with alcohol use disorder receive treatment.

As frontline clinicians in the primary care setting, or even in the emergency department and inpatient settings, we can make a difference. During today's discussion, we'll move on to discuss the treatment options for alcohol use disorder, including medication options available, approaching community support groups, and how to put together a treatment plan from the vast menu of options.

Before we get started, Please know that this content is meant to be for learning and entertainment purposes only, and should not be used to serve as medical advice. If you or a loved one is suffering from anything discussed in today's episode, please be sure to discuss it with a medical professional.

Okay, with that, let's get started. 

Chapter 1: Managing Alcohol Withdrawal

Dylan: Let’s hear about alcohol withdrawal and how to identify which individuals are at risk.

[00:02:39] Jessica: Did you experience withdrawal if there were days where you did not drink or waking up in the morning with shakes, things like that?

[00:02:47] James: That's the the one thing I never had withdrawal. 

[00:02:50] Tonya: But his mood, the emotional part of it, he started, he started getting moody. 

Whatever changes his brain was going through and went through that journey, I mean, he would be crabby.

[00:03:04] Dr. Holt: In thinking about which patients are at risk, some of it's a little bit of a no-brainer. If somebody tells you they drink a six pack on the weekends, but that's it, they're not gonna experience alcohol withdrawal.

But for a patient who says they drink every day, probably in excess of five to 10 drinks per day, and have done so for, I'd say a minimum of three months. This is a little bit of hand waving again. Somebody who's just been on a bender while on a cruise ship in the Caribbean for 10 days and comes back home, they're not gonna go into alcohol withdrawal after 10 days of drinking too much.

So it's somebody who's really had sustained elevated alcohol consumption for for many months before they're gonna experience withdrawal

[00:03:45] Dylan: Dr. Holt makes an important point here regarding how to identify which individuals are at risk of developing withdrawal. This typically does not include rare binge drinking patterns regardless of how heavy those sessions are because it doesn't have the sustained level of alcohol exposure that lead to neurochemical remodeling, which serves as a prerequisite for withdrawal.

Despite James's pattern of drinking, it is a bit unusual that he never experienced true withdrawal, which we'll describe in a second, but it isn't uncommon for patients who give up a substance to experience a period of depressed or irritable mood as they adjust.

We learned in our last episode that alcohol is associated with release of endorphins and dopamine. For many patients for whom alcohol had consumed their lives,  they had likely also abandoned healthy that are associated with the release of these feel-good neurotransmitters: such as social connection, physical activity or hobbies, leaving alcohol as their primary way of dealing with stress,  or essentially experiencing happiness. So, it can take some time to adjust. Ok, enough about that. Let's return to discussing what the symptoms of alcohol withdrawal are. 

[00:05:13] Dr. Holt: The symptoms of alcohol withdrawal have been described for thousands of years. But basically it's characterized by initially there's just early withdrawals, which can just be feeling a little tremulous, a little nauseous, maybe a little headache, a little bit of dysphoria. And then that can progress to starting to have hallucinations, alcohol hallucinosis, which typically happens within 24 to 48 hours after the last drink.

And that's characterized by very vivid visual or auditory or tactile hallucinations that the patient knows are not real at this point. But then we transition to something called delirium tremens, which again has been described for a very long time, usually 72 hours after your last drink.

And that's where patients are exhibiting signs of psychosis. They're still having those hallucinations, but now they are starting to believe those hallucinations. They're basically profoundly disoriented. And those symptoms are accompanied by increased sympathetic tone. So your blood pressure's going up, maybe a little febrile, a little tachycardic.

And that's when folks start to get really at risk for seizures. Seizure risk is elevated throughout the withdrawal process, to be clear. But certainly it's at even higher risk in that several days after the last drink window. And it's when we're managing folks with DTs, with oftentimes the benzodiazepines, that's when there's also risks of aspiration, oversedation, which has its own attendant risks and complications.

Most patients who we see in our practice in primary care, if they are at risk for alcohol withdrawal, trying to manage them in the outpatient setting is ideal.

Many folks are just anxious about being in the hospital, and I've had so many patients who as soon as they wake up in the hospital, they bolt. They just don't wanna be there. They are accustomed to experiencing a lot of stigma when they're there. So trying to find a way to manage it safely in the outpatient setting is really the goal.

And there's a lot of evidence to support that you can safely do it, for the vast majority of cases.

[00:07:12] Jessica: So that is incredibly interesting to me because I have generally only been told that the most, the safest thing is to tell the patient to go to the hospital. So how does one manage a patient in an outpatient setting who's at risk of withdrawal?

[00:07:25] Dr. Holt: Yeah, this is really coming more and more to light in these past 10 years or so. But there's been data out there, data for years. Yeah, so the way that's done is in contrast to an inpatient detox where we typically use a symptom-triggered approach cuz we have the ability to check a person every four hours to see what their CIWA score is (the Clinical Indicator of Withdrawal from Alcohol symptoms scale).

In the outpatient setting, we don't have that degree of monitoring. So instead we use a fixed dose taper. And the data supports that you can really use either a benzodiazepine, generally a long-acting benzo like diazepam or chlordiazepoxide. Or there's also really good data for the use of gabapentin and or carbamazepine. That’s another one that I think folks don't use it often because we're not as comfortable prescribing it in general, but data head-to-head trials, looking at gabapentin compared with a long-acting benzodiazepine find that they are equally good at completing alcohol withdrawal management.

They're equally good at preventing complications. It actually looks like gabapentin may be superior in terms of having less sedating effects than something like Diazepam. But in terms of seizure risk or getting DT, because those things are so rare in the outpatient appropriately-screened patient there's no data to show that being on a benzo or gabapentin has any difference in risk for those complications.

It is worth mentioning that, when a person goes to the hospital for ambulatory, for when a person goes to the hospital for alcohol withdrawal, the completion rate is very high. Most people, if they go to the hospital, they're gonna stay there until they're done getting through withdrawal, unless, like I said they bolt or or what have you, or pass away, God forbid.

So success rates are very high on the order of 90 to 95%.  In the outpatient setting,  even in appropriately screened patients, the success is probably closer to around 60%. But that's not because some terrible complication occurred. It's because guess what?

There's still alcohol around. So there's just a chance that after three days of this um, this fixed dose taper plan the patient just couldn't deal with it anymore and started drinking again, or somebody showed up with some alcohol, whatever it is. So it's, it's obviously, it's an uncontrolled environment outside of the hospital, so the success rates aren't as good, but despite that, the benefits are great.

It's a dramatic reduction in healthcare dollar-costs, obviously. And from a patient-centered perspective, patients would generally prefer to do it if they can safely outside the hospital. Just to say the regimen real quick, it's basically 10 milligrams of diazepam Q6 on day one. So four times day one, three times a day two, two times a day three, and then once on day four. So basically a 4, 3, 2, 1 taper. And we typically provide like five PRN doses of diazepam to be taken as needed. If you're using Gabapentin, you just substitute that 10 milligram diazepam tablet with a 300 milligram Gabapentin tablet.

But otherwise it's the exact same regimen.

[00:10:32] Dylan: In summary, alcohol withdrawal symptoms can range from mild tremors and nausea, to visual and tactile hallucinations, and, in its most severe form, hallucinations associated with delirium, often termed delirium tremens, which can sometimes precede potentially fatal seizures. These symptoms can develop when someone who has had consistent and excessive use of alcohol cuts down or stops abruptly.

While inpatient withdrawal management is often seen as the safest option, outpatient management with medications like benzodiazepines and gabapentin is increasingly being recognized as a viable alternative. Success rates of outpatient management may be lower due to the uncontrolled environment, but it offers significant benefits in terms of cost reduction and patient preference. 

All right, so we've screened our patient for excessive alcohol use using tools like AUDIT-C or CAGE, diagnosed them with alcohol use disorder using the three C's, and engaged in a brief intervention through motivational interviewing, all of which we discussed in our last episode.

Your patient is now ready for change. but they feel they need additional support given that they've tried and failed in the past. What else can we offer them that could significantly decrease their risk of returning to use?

Chapter 2: Medications for AUD

[00:12:02] Jessica: So currently there are three FDA approved medications for alcohol use disorder. Is that correct? Could you tell us about them and a little bit how they work for alcohol use disorder?

[00:12:13] Dr. Holt: Sure. I'll start with naltrexone. There's an oral form, which is just one pill once a day. Super easy, tolerated, minimal side effect, a strong safety profile. And then an injectable formulation that is a 30-day extended release formulation injected intramuscularly into the upper outer quadrant of the buttock.

[00:12:32] James: Well, basically when I first took the shot the first time after a couple of days, I mean, it didn't even phase me. Um, I like to play, uh, lottery scratch off, and the store, it's right next to a package store that I frequently used to go into. Now I walk by it, I don't even, don't, don't phase me. I don't even look at it. I just keep going, do my business at the convenience store, go the first time I took the shot for 30 days, but then when the shot wore off and I started drinking again and I wound up back in the hospital.

[00:13:04] Tonya: The first time when he was in the hospital, they gave it to him in an injection format and it worked perfectly and you have to get the injection every 30 days. The problem with the process and the system, they get you a counselor, you speak to the counselor, they get you on a path of recovery, but then they forgot the insurance of how it worked.

So when he got out of the hospital, oh, you could get that injection from your primary care and couldn't get the injection that way. The program that they set him up, couldn't get the injection, they had all these hurdles with more doctor's appointments, and the injection only lasts 30 days. So after a while, my husband can be somewhat impatient. After a while he stopped worrying about it. The injection wore off, and that caused him to lapse to drink.

[00:14:06] Dr. Holt: So naltrexone going back to what I was saying about how alcohol also triggers the release of endorphins from your pituitary and your hypothalamus; if you can block the rewarding effects of those endorphins, then you will hopefully uncouple the relationship between drinking alcohol and experiencing pleasure or reinforcement. And while initially it may be counterintuitive to use an opioid antagonist, naltrexone, to treat an alcohol problem, when you keep in mind how the neurochemistry works, how endorphins can actually drive the the reinforcement of alcohol consumption, it makes sense that naltrexone will turn out to be an effective pharmacotherapy. It was initially FDA-approved for opioid use disorder, but then subsequent post-marketing research found that it actually was quite effective for alcohol use disorder.

When we think about how effective it is. All three of these, or again, four of these medications are all pretty equally effective. So we'd like to use the term number needed to treat. That is how many patients do you have to treat with this medicine in order to have an important outcome like preserving, 30 day abstinence or 90 day abstinence, or a reduction in the number of heavy drinking days.

And we know that naltrexone and acamprosate and disulfiram all have similar effect sizes. Again number needed to treat kind of data. Compared with so many medications that we don't even hesitate to prescribe, things like SSRIs they're actually these medicines are dramatically more effective than things like statins or DVT prophylaxis. All these things that we take for granted. These medications for alcohol use disorder are actually more effective than those things when we look at the those relevant outcomes.

I've had patients who've been getting it every month for a couple years. So it seems to be tolerated ,and of course there is a potential for an injection site reaction with some swelling, pain, discomfort rarely like real complications like a phlegmon. That's one of the thousand or less kinds of phenomenon.

But generally these medications are very well tolerated. Naltrexone can cause a little nausea for the first couple days just as your body's getting used to it. Headaches, I've occasionally had to stop naltrexone because people had headaches associated with it for unclear reasons, and they're safe in advanced liver disease. Initially there were reservations about using it in folks who had cirrhosis, but nowadays naltrexone is viewed as quite safe in terms of hepatotoxicity risk.

So acamprosate, also known as Camprol also has been around for decades.

This is where one can get a little hand-wavy, but it's basically believed that it stabilizes the GABAergic and glutamatergic neurotransmitter systems. Exactly how that happens. Again, I, if you could see me waving my hands, you would see me waving my hands about how it works exactly.

And it's very useful in somebody who has decompensated cirrhosis because it's not cleared by the liver. It's the only one that is renally excreted. So it's super safe in that regard. But it is a lot of pills. It's actually two pills, three times a day. Again, compared with naltrexone once a day.

And then the last one, it turns out, is one of my favorite medications. I really view it as the unsung hero of the alcohol use disorder space. And that's Disulfiram also known as Antabuse.

[00:17:21] James: When the shot wore off and I started drinking again and I wound up back in the hospital, we revisited this, this subject again and they brought up the other pill. And they said that that would make me horribly sick if I chose to drink while I'm on these two medications and they said, you gotta be very serious because with your, uh, health, this could be dangerous if you were to drink while taking these two medications.

And I said, let's do it. Let's do it.

[00:17:49] Dr. Holt: It's been around since the forties. So this is an old medication, decades of safety data. And a lot of times it was initially studied in randomized controlled trials, but subsequent stuff has shown that's not a great study design for a deterrent medication. So when they started looking at open labeled studies, it actually was found to be extremely effective.

And it's regarded as a real first line treatment, if you look at any of the more recent meta-analysis and review articles on the subject. So disulfiram works by inhibiting one of the enzymes in the metabolism of alcohol leading to the accumulation of acetaldehyde, it’s like getting an instant hangover. It's a very potent toxin in your body that causes diaphoresis, flushing, headache, nausea, vomiting, really unpleasant symptoms. And so you take this pill every day, and if you don't drink alcohol, you're great, you're fine. But as soon as you drink, even just a few sips, really for some patients, if you just drink a little bit of alcohol this acetic acid level builds up and you have a really bad afternoon.

It's not dangerous per se, but it is a really unpleasant thing to do. I have found that many of my patients, as soon as they take disulfiram in the morning, they're liberated from their cravings because so much of addiction is about this constant hourly internal debate with yourself. You shouldn't drink, it's bad when you start drinking, you can't stop yourself.

But boy, that package store is right there. My friend's coming over, it's the anniversary of somebody's death. I wanna drink. You're in this constant battle. Once you take your Antabuse in the morning, the battle's over. Alcohol can't win.

[00:19:23] Jessica: What prevents you from not taking the disulfiram in the morning? Meaning if you didn't take it that morning, you could potentially drink that day. 

[00:19:33] James: Just thought process. First thing I do in the morning, I have a nightstand on the side of my bed. First thing I do when I get up, I take those two pills before I take my other pills.

[00:19:45] Jessica: Do you think having the support of your wife Tonya, has been integral to you taking that medication every day? 

[00:19:53] James: Absolutely. 

[00:19:55] Tonya: Well, the one thing that I won't do is, I'm not gonna handhold him and monitor his pill taking for two reasons why. It's a journey that we're both going together, but he has to be the pilot.

And I literally stepped back and said, you got your own routine. Just do it. Because if you start micromanaging someone's life, knowing that they know that they can die and they're not willing to do it themselves, it's not gonna matter anyway.

[00:20:34] Jessica: James I believe is on naltrexone and disulfiram together. Now he happens to be in an obviously very beneficial, unique situation where he has a lot of support in his wife who encourages him to take his medications every day.

So do you feel this medication would be as successful in somebody who does not have that kind of daily support? 

[00:20:55] Dr. Holt: Yeah, that's a great comment. James has found the combination of disulfiram and naltrexone to be really effective which is great. But there's no question that there's some folks for whom I'm probably not gonna recommend disulfiram for one of two reasons. One, if somebody's just trying to cut back on their drinking, obviously we can't use disulfiram cuz they're not willing to go for abstinence.

But number two, someone who's very equivocal about their drinking, not necessarily very motivated, unstructured in their home environment, maybe even un-domiciled. The commitment to take disulfiram is most likely gonna be carried out for somebody for whom it's high stakes, has an immediate present support network person.

Maybe it's a parent, maybe it's a son or daughter, maybe it's a significant other. And again, for somebody who's committed to complete abstinence, somebody who's acknowledged that once I have a drink, I can't stop. That's somebody who may do better with disulfiram when you put all those things together. In his case, yeah, he was really a perfect example for it.

[00:22:00] Dylan: In summary, naltrexone, acamprosate, and disulfiram are the three FDA-approved medications. Naltrexone, available in oral and injectable forms, works by blocking the rewarding effects of alcohol. Acamprosate is believed to stabilize neurotransmitter systems and is safe for patients with liver disease.

Disulfiram, Dr. Holt's favorite, acts as a deterrent by causing severe discomfort if alcohol is consumed. While all three medications are effective, disulfiram's success relies heavily on patient commitment and a strong support system. Despite these medications being FDA-approved, it's important for providers to be aware that patients can still run into issues obtaining them due to variations in insurance coverage. 

[00:22:52] Tonya: I feel that, um, Dr. Holt and the programs and the people that work there are extremely supportive and caring. The only concern that I had was the bureaucracy of insurance companies.

It's very easy when something simple doesn't fall into plan, like your insurance covering things. Do you have enough money? Because on one of the shots, we paid the $400 copay. Because his life was more important than $400 until we could have plan B.

And to pay out so much out of the pocket is just ridiculous. I put my foot down to my husband, I put my foot down to the doctors, and I put my foot down to Dr. Holt that if we're gonna go through this again, before he left out of that hospital, I had to know every, every step, every obstacle, where we are getting the prescriptions, how much it's gonna cost.

[00:23:55] Dylan: In this case, Tonya was an incredible advocate for her husband when they began running into issues. But for others who don't have that kind of support, these insurance barriers can lead to significant diversions off the road to recovery. It's important for practitioners starting new medications for a patient to consult with their local pharmacy or check state insurance formularies to limit excessive out of pocket costs.

So James is now continuing his naltrexone and disulfiram and working towards sobriety. Let's check in with Dr. Holt on what else we should be monitoring for as a part of our comprehensive care.

[00:24:36] Jessica: What might be some best practices for monitoring some of the health risks that you mentioned earlier that are associated with excessive alcohol use? Especially in the primary care outpatient setting.

[00:24:48] Dr. Holt: Yeah, it's a good question, sort of thinking about monitoring our patients. For opioid use disorder we're frequently doing a lot of monitoring, a lot of urine drug screening. We're checking for HIV and hepatitis C every year. Keeping an eye on liver function tests, those kinds of things.

For our patients with alcohol use disorder, we make sure that they're vaccinated against hepatitis B and sometimes hepatitis A. And we do take a look at LFTs just to have a baseline somewhere in the system, but we're not routinely checking anything, honestly, over time. We check in about complications of alcohol use disorder periodically.

We're certainly keeping an eye on their blood pressure and symptoms or signs of cirrhosis or, more advanced liver disease. But I have to say it's not a big part of our weekly visits or part of our visits. Whenever we see patients we're really focused on how we get that alcohol consumption down.

I could think of a few patients who, dementia starts to set in if you're really unsuccessful with somebody for a long time. And that's sad to see. So once you're at that point, then you're sorting to transition from working on helping to cut back on the alcohol, towards working on how do I make sure this person is safe. How do I get other support systems into place to support this patient?

[00:26:04] Dylan: Importantly, the road to recovery is rarely traveled alone. The fire of addiction is often fueled by isolation, and healthy support systems act as a damp environment that simultaneously make it more difficult for those flames to rekindle, while also allowing for healthier habits to grow and flourish.

Let's learn more about how to encourage patients to find, build and sustain these support structures through loved ones and recovery groups.

 Chapter 3: Recovery Group/Social Support

[00:26:36] Dr. Holt: When I think about community programs--and I generally lump them into one term called mutual self-help programs--20 years ago, let's say, there really was only one option. There was just AA - Alcoholics Anonymous. It's been around since the forties, founded by a doctor and a lawyer actually.

And that was the only kid on the block, really. And, there's some hangups with AA. There's an informal culture that tends to favor complete abstinence, not just from the substance, but also from treatments. There's like this sense that if you're not, especially for someone who's on methadone for opioid use disorder, if you're on methadone, you're not “clean”, you're not really out of the woods.

And the same thing if you're on Naltrexone or disulfiram what have you for alcohol, then maybe you're not really living cleanly. And so while that's not officially part of the bylines of AA, AA is a sort of a loose organization, but it does have a, not really a code of conduct, but at least a code of beliefs.

And they do officially state that medications are okay for the management of substance use disorder. But just because that's what the official line is from AA, that doesn't mean that veteran AA members who've been there for decades don't still have a little bit of that messaging.

So I do think that can be tricky for folks. And of course, it is also a very religious organization. There's, I've been to many AA meetings and some of them start off by literally going through the Lord's Prayer. And of course, one of the the 12 steps does involve turning yourself over to a higher power, so that could be a turnoff for a lot of folks who really would prefer a secular kind of venue.

So the good news is that over the past 20 years, like I said, there's been this explosion of different options out there for mutual self-help groups. And I really stress to all patients that I have in my addiction clinic that you can't get through or get over your addiction and sustain your recovery by living in a vacuum.

If you're just sitting at home wallowing in your cravings, there's no way you're gonna be successful. You need to get out and be a part of a community. And so now that there's so many options, you will find your community. Maybe it's something like Refuge Recovery, which embraces more Buddhist principles.12 step yoga, obviously it's very, it's got a physical component to it. There's groups that are focused on women in particular. There are groups that are focused on medications for substance use disorders. So they explicitly embrace the use of medications. There's the Phoenix, which is a group of people who get together and they do cool outdoor nature activities or hiking or biking or things like that, which is a great way to build community.

I still completely support AA and I refer folks to AA as well. But I usually now print off a list of a whole bunch of options with some descriptions, and I encourage patients to find something: between now and your next visit, I want you to have tried a couple of these things out, and keep trying until you find something where you feel like these are my people.

There's so many different forms of behavioral support in addition to the mutual self-help groups that we mentioned, of which there are, like I said, an increasing number of options. There's also Motivational enhancement therapy. There's cognitive behavioral therapy, just simply one-on-one counseling.

And in whatever model that counselor works in, there's intensive outpatient programs. Obviously there's just engaging with our own addiction treatment clinic and seeing a patient every week. 

[00:30:01] James: I go to these Tuesday meetings where there's a group of people with different substance problems and we all talk, um, relate to the problems.

You know, how, how did you do in the last week? And, you know, sad to say, some of the people, they relapse or they can't stop. And when they come to me, I'm the only one that says, I'm fine. I feel good. I haven't drank in so and so days. I don't even think about it anymore.

[00:30:33] Dr. Holt: You know, I'd just like to remind folks that if something doesn't work out, if this fails, if this option didn't work, don't abandon ship. Keep coming. We'll find something that does work. We'll figure out what works for you, your schedule, your values, whatever it is. We just gotta keep working at it.

[00:30:50] Dylan: Most people are familiar with Alcoholics Anonymous as a useful mutual support group that's ubiquitous and free to access, but some may not find some of its traditions, such as the religious assertions, appealing.

If your patient goes to an AA meeting and doesn't find it helpful, it's important to continue working towards other forms of support that will be more suitable to their preferences and needs. Now, outside of these formal support programs, some patients may find important social support from people that are already in their lives. 

[00:31:24] Jessica: James, would you say you were unwilling to make any changes until someone you loved, Tonya, came into your life? 

[00:31:32] James: Yes. like I said, I've drank all my life. I've had other, other relationships and I drank during those. Tonya really stood out, very focused, very, very sincere, and I could see that it's all, all love. And she wasn't doing it just to just to be doing it. She was doing it because she wants to see us together for a long time. And I respect that. 

[00:32:00] Tonya: I came to the meetings with him every Tuesday to support him. And I also needed to understand everyone else in this meeting to see different people from different perspectives and how this, these types of substances affect them, affect their families. I wanted to understand the why, because when you're, when you're too close to someone, you know your emotional story.

But when you're looking at other people and their stories, the window opens up and you have a better understanding. I wanted to understand the why. I understood the why. He now became stronger. The more he became stronger and independent from this substance abuse, the more I started pushing back. I started giving him his independence and letting him do things on his own.

He's now starting to get more independent without me. So now Tonya's gonna focus on Tonya. I gained, what, 70 pounds, you know, my health started to get a little wacky, so I'm now making myself the focus.

I always ran running, uh, jogging was my therapy. Um, it always has been for most of my life. I wanna get back to me. I wanna get back to my running. My running is my mantra and I wanna get back to my health and that's my focus. Because he's getting stronger now. He doesn't need me as much to lean on. 

[00:33:33] James: You're right, you're absolutely right.

[00:33:34] Dylan: It's clear that Tanya was, and continues to be, a foundational pillar of support for James throughout his recovery process. I love how Tanya opens up here and allows us to better understand one of the reasons why she was able to stand firmly by James' side through the ups and downs of his addiction.

Going to those recovery meetings helped her better understand the nature of addiction, preparing her for difficulties ahead, and allowing her to empathize with his struggle. Secondly, it's also interesting to see how that understanding helped shape how they approached boundaries and autonomy for James's actions.

Lastly, it's so important what Tanya is saying here about self care. There are phases when she needed to be more active in James's life, but also realizing when it was time to step back and focus on herself.

These may demonstrate some key lessons on how loved ones can sustain and even deepen relationships with the people in their lives struggling with addiction. This is a positive example of how people closest to our patients can be a source of support, but there are times when other loved ones can themselves be a trigger.

[00:34:53] Tonya: Everybody was just common, in his household on family functions to be drinking. And when he would try to sort of cut back or reserve the family, sort of like, it's just a normal, come on, let's drink. There's nothing wrong with it.

[00:35:12] James: I talked to my mother about that a few times and she says, oh, come on baby, you're not an alcoholic.

You get up, you work every day, you work hard, um, you know, if you wanna enjoy a drink, have a drink. Just recently when I really gave it up, I went over to a family function and people got, um, a little, I don't know how, how would you say that?

[00:35:34] Tonya: They're now seeing someone new and they don't know how to approach him. So they all didn't wanna drink. Um, his mother has a full bar.

He came prepared. The thing I love, what he did was he doesn't drink gin with tonic water, lemon and lime or club soda. He now has club soda with lemon and lime or and tonic water with no alcohol. And he makes it a project to make these non-alcoholic beverages so he can have a little routine. And they didn't know really how to deal with it. And he had to tell them, if you wanna drink, go ahead. I'm not. And I think when he announced that, then they all went for the bar, but they left him alone.

He has a best friend that's an alcoholic. He's now seeing a mirror of someone else from the outside. You should share that. 

[00:36:33] James: I went to go visit him cuz we've been friends for nearly 50 years, almost like best friends. And um, he still drinks and he drinks heavy and he's not working right now. I went to go visit him for the first time in, shoot. It's been like two years or so, that I've actually stopped over to see him. Because we talk on the phone all the time or text each other.

[00:36:57] Tonya: His phone calls when he calls him, he's completely drunk. You know how he talks about his significant other. It's always very toxic. And you know, my husband is seeing this for the first time.

[00:37:14] James: And the first thing he does when I get over there, he has a bottle. He said, you want a drink? I said, Tommy, you know, I stopped drinking. And he, oh, I'm sorry, I forgot. Um, you want a soda? I got soda. I said, no thank you. I'm okay.

[00:37:27] Tonya: He's seeing someone going through this journey and he wants to support, he wants to help and to be this advocate now who's saying you can do it, and being supportive. How does that hat feel? 

[00:37:40] James: Feels great. Feels, feels great.

Chapter 4: Closing Thoughts

[00:37:43] Jessica: what do you find to be, I guess, the most challenging aspect of treating or attempting to treat patients with alcohol use disorder in the primary care or outpatient setting?

[00:37:56] Dr. Holt: it's folks who I've been taken care of for many months, and I've exhausted my menu that I was referring to before and I can't seem to break the pattern and it's just a little bit demoralizing when that happens, and it's not a lot of people, it's a small number of people. I feel like we really do make headway on certainly more than half. Probably two-thirds of our patients we're able to make progress with. But there'll just be some folks who, no matter what we do that just, they keep coming back.

But they're still drinking at amazing levels. They're self-destructing in different ways. They've started to have issues with work. They've started to have issues with their significant other leaving them. They've had their first DWI. Now they've got a parole officer. Now they're looking at jail time.

It's just it's hard to watch that cuz in the inpatient setting you see people for a snapshot of time. And you may never see them again. But when you're, when you've got a close relationship with a patient who trusts you I imagine it's, like an oncologist just watching a patient with stage four lung cancer just deteriorate right before your eyes over the span of months to years.

And that's, it's just hard, because you love these people eventually. You just create such a close bond with them because they may never have had a clinician trust them or pay attention to them or care about them before. And when you finally do, it can really be hard to watch that decline.

[00:39:24] Jessica: That is no doubt one of the most difficult aspects of working in healthcare in general are watching patients that we feel that we cannot help at a certain point.

What do you feel is the most, or has been the most rewarding aspect? 

[00:39:36] Dr. Holt: Yeah, it's the flip side. Mr. Streater and his wife, when they had their first maybe seven days or 14 days of sobriety, I should say, when he had his first one or two weeks of sobriety and she came to almost all his appointments. They were elated,  um, and surprised.

I got the sense that every day was like a new discovery for them, somehow. Because he had been intoxicated for such a long time,  when I saw the two of them in the office, he told his story and then she started telling her perspective of his story and she just started crying, saying how concerned she was that he was gonna slip up again, that he was gonna, not slip up, relapse hard again.

And that she was just so terrified of that because she'd seen it innumerable times before that. And so then two weeks later to have him still sober. Longest period of sober in, gosh, a decade. I'm not sure how long it had been. And to see how excited they were. And then to have them come to the group, because they started coming to our group visits, which we have with our clinical psychologist facilitates them and they would just be gushing about how amazing it is to be sober again.

[00:41:00] Tonya: You need to create a new life, whatever that life is gonna be, and take small steps, obtainable steps, you know, little write down each step of something new you wanna do.

And I've told him we don't have to do it in a big way, but I want him to find a new you. Find something new in this because everything led to alcohol. Going to a sports bar, every dinner, every place all the people in his life led to always having a cocktail. And I told him, our lives are not in these four walls.

We have to find new adventures, new hobbies, new things that's going to create a new life.

[00:41:54] Dr. Holt: Again, for him to be sober again and for her to be bearing witness to it. And there was this moment, I remember maybe three weeks in where there was some insurance snafu where he couldn't get his naltrexone and the terror that, that they were, that they conveyed when you went in the room and told them this as if, without this medication the whole thing was gonna unravel like a house of cards.

It just highlighted how important his sobriety was and how precious it was - that he had this new gift of himself. His personality, his ambitions, his commitment to his relationship, his re-entering into himself. But it was still like, boy if we don't have naltrexone, this whole thing's gonna fall apart.

And of course we, we turned out, we figured out how to make it all work and everything's fine. But seeing patients light up like that come out of themselves, seeing their brains wake up, folks who've been hooked on cocaine or opioids or alcohol or whatever it is, or PCP for that matter, it can take weeks to months for their brains to really recalibrate and to see their personalities come back out again.

It is, it's so rewarding, it's so gratifying, so fulfilling. And they are the most insightful and oftentimes the most grateful population of patients to take care of. And that's certainly what gets me going.

[00:43:13] Jessica: So you've been doing so well for over a hundred days. And I guess my last question will be where do you guys see yourselves in another a hundred days? 

[00:43:24] Tonya: In Maui. I wanna go to Hawaii. 

[00:43:29] James: We're trying, we're trying for this year. 

[00:43:32] Tonya: I, I, only thing I'm not is packed. See, he's never, he's never traveled except for maybe to go to Boston or New Jersey. He's never experienced the world and I've experienced the world and that's just because his family's comfort zone is Connecticut. And I want him to go out and experience the world in new eyes and see and taste so many different things.

And I said, we're gonna start with Maui.

[00:44:09] Dylan: What a privilege to witness the love between our guests, James and Tanya. As we learned from our first episode, it was James’ love for Tanya that finally moved him from a place of apathy about his increasingly dangerous alcohol use to a commitment to sobriety. And it is Tanya's love for James that motivated her to advocate for him to obtain his medications in a timely manner and root for his sobriety so that he can experience the world in new and wonderful ways.

While substance use disorders are often stigmatized and lead to a cycle of shame and isolation, it's encouraging to see how love and empathy can break this cycle. We hope they enjoyed their trip to Hawaii.

 Here are some notes I took away from our second episode, and I hope you did too.

First, alcohol withdrawal can range from mild, like tremors and nausea, to severe symptoms such as delirium, hallucinations and possible seizures.    It's important to identify who is  at risk of developing withdrawal before starting treatment and consider management in the outpatient setting, when appropriate to do so,  

Second, there are several FDA-approved medications that have been shown to be very effective in the treatment of alcohol use disorder.  This includes medications like naltrexone, acamprosate and disulfiram.  

Third, successful treatment often involves a combination of medications and social support through mutual support groups or therapy.

And lastly, a patient's personal social support network can lead to complex interactions which at times can help sustain a patient in their recovery journey or act as triggers towards returning to use. Engaging in therapy or self reflection can help patients identify how their social connections or isolation may be affecting their use patterns.

This brings us to the end of our alcohol use disorder series. We hope you enjoyed it. This series was made possible by contributions from our patient and his wife, James and Tonya. Dr. Jessica Barenboim, who served as our interviewer, and Dr. Stephen Holt, who served as our faculty expert and provided peer review for this series.

Special thanks to our producers, Helen Cai, Daniel Wang, and myself, Dylan Balter, as well as our faculty advisors, Dr. Joshua Onyango and Dr. Katie Gielissen. 

Be sure to follow us at PCPearls on Instagram or PCarePearls on X, where you can expect to get sneak peeks, additional learning content, and the most up to date details on show release times. And please rate and review our podcast wherever you listen to help others find this content.

If you enjoyed this episode, please share with others who are excited about primary care or friends who'd like to learn more about the health conditions we discussed today. Thank you for joining us. Farewell from all of us at the Primary Care Pearls Podcast.

We'll catch you in the next one.