A case study: identifying alcohol abuse in multiple sclerosis.
Article Type: Case study
Subject: Alcoholism (Identification and classification)
Alcoholism (Complications and side effects)
Alcoholism (Case studies)
Multiple sclerosis (Risk factors)
Multiple sclerosis (Case studies)
Patients (Alcohol use)
Patients (Health aspects)
Patients (Psychological aspects)
Patients (Research)
Author: Sammarco, Carrie Lyn
Pub Date: 12/01/2007
Publication: Name: Journal of Neuroscience Nursing Publisher: American Association of Neuroscience Nurses Audience: Professional Format: Magazine/Journal Subject: Health care industry Copyright: COPYRIGHT 2007 American Association of Neuroscience Nurses ISSN: 0888-0395
Issue: Date: Dec, 2007 Source Volume: 39 Source Issue: 6
Topic: Event Code: 310 Science & research
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 172597391
Full Text: Abstract: Limited information is available regarding alcohol abuse in people with multiple sclerosis (MS). Tools are available to assist clinicians in screening and intervention for alcoholism. Though the literature does not convincingly support that patients with MS are at a significantly increased risk for developing alcohol abuse, it may complicate symptoms or aggravate their underlying neurologic disease. This case study provides an example of an individual with MS whose condition is complicated by alcohol abuse. Further research may validate assessment tools in this population and examine the physiologic, psychologic, and neuro-immune implications of alcohol abuse on patients with MS.

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Alcohol, for the majority of individuals, is an enjoyable accompaniment to social engagements. Moderate alcohol intake of up to two drinks per day for men and one drink per day for women and older people is not considered harmful for the majority of adults and, in fact, is recommended to some degree for health promotion (Goldberg, Mosca, Piano, & Fisher, 2001). Still, alcohol-related problems occur for a large number of people. Currently, nearly 17.6 million American adults abuse alcohol or are considered alcoholics. Another several million more adults engage in at-risk behavior that could lead to alcohol problems. The risky behaviors include binge drinking and heavy drinking on a regular basis (National Institutes of Health, 2004). Binge drinking is a pattern of alcohol consumption that brings the blood alcohol concentration to 0.08 gram percent or more. Typically, this blood alcohol concentration corresponds to consuming five or more drinks for males or four or more drinks for females in about 2 hours (National Institute of Alcohol Abuse and Alcoholism [NIAAA], 2004). Heavy drinking is defined as consuming an average of more than 2 drinks per day for males and an average of more than 1 drink per day for females (Centers for Disease Control and Prevention, 2006).

Alcoholism is defined as the consumption of or preoccupation with alcoholic beverages to the extent that this behavior interferes with the alcoholic's normal personal, family, social, or work life. The chronic consumption of alcohol can result in psychological and physiological disorders. Adverse consequences of alcohol misuse can be life threatening. Increased risk for certain cancers can occur-especially cancers of the liver, esophagus, throat, larynx, and breast. Heavy drinking can also lead to liver cirrhosis, gastric disease, anemia, immune system problems, pancreatitis, brain damage, and harm to the fetus during pregnancy. Along with its impact on the health of the individual consuming increased alcohol, drinking increases the risk of death for others because of alcohol-related automobile crashes and homicides. Alcohol contributes to impaired social functioning, such as marital problems and child abuse. It can negatively impact occupational functioning, including schooling and employment (NIAAA, 2006). The physiologic, psychologic, and social impacts of alcohol can be addressed if the alcohol abuse is identified and an appropriate treatment plan is devised.

Alcohol abuse may occur with any medical or psychiatric condition. Whether these comorbid illnesses occur simultaneously or sequentially, one illness may complicate the other. Several medical conditions--including liver disease, cardiomyopathy, brain damage, cancers, reproductive disease, and psychiatric disease--have been associated with alcohol abuse (NIAAA, 2000). Patients with essential tremor (less often associated with multiple sclerosis [MS] as is cerebellar tremor) may find small amounts of alcohol to be effective in decreasing symptoms. As in the case that follows, alcohol may be used as a method of self-medicating depression and coping with MS.

Case Presentation

Susan was a 24-year-old Caucasian female who had been receiving care in the MS center for approximately 2 years. Initially, she was referred by an ophthalmologist for evaluation of optic neuritis. Her past medical and surgical history was unremarkable. She was single, living with a female roommate, and she denied cigarette smoking or alcohol intake. After a complete diagnostic evaluation that included magnetic resonance imaging of the brain, cerebrospinal fluid examination, serum review, and neurologic exam, she was diagnosed with MS. Interferon beta-la (Avonex) 30 mcg in weekly intramuscular injections for long-term management of MS was initiated. She was initially hesitant to self-inject; however, Susan demonstrated good injection technique and was motivated to participate in her healthcare regimen. Although she reported adherence, she continued to dislike self-injecting.

At a follow-up appointment, when accompanied by her mother, Susan confided that she felt "depressed" and anxious, especially regarding her diagnosis. She stated that her friends and family were very supportive. When her mother left the room, Susan stated she "did not want to worry" her parents by talking to them about MS. She expressed concern that her symptoms would return and be permanent.

Susan's exam was unremarkable; however, she had complaints indicative of depression as evidenced by depressed mood, hypersomnia, concentration difficulties at work, decreased energy and psychomotor disturbance (impaired capacity to work or study), and fatigue secondary to MS. Pharmacologic and nonpharmacologic treatments for depression were discussed and a selective serotonin reuptake inhibitor (SSRI) was prescribed. She was referred to a social worker to assess the possible benefit of talk therapy to improve her mood and coping skills regarding her new diagnosis. She was encouraged to call to discuss any issues she did not feel comfortable addressing with her parents or friends. She was advised to return in 1 month for follow-up regarding her mood and fatigue, or sooner if she developed new or worsening symptoms.

Susan titrated up on the SSRI after 1 week, as directed, and started seeing a social worker weekly. Within 1 month she reported significant improvement in her depression. She also began looking for a new job. She was stable in her course of care and was seen approximately every 3-4 months for more than 1 year.

At a routine follow-up visit 16 months into her care, Susan reported she had been feeling well. Her mood had been stable on medication, and she was seeing her therapist weekly. She stated her alcohol consumption was two glasses of wine or margaritas three times during the week and five vodka drinks on Friday and Saturday evenings. This pattern had been ongoing for nearly 1 year. She denied any impact of her alcohol use on work. Susan described herself as "social." She enjoyed going out with her friends to meet men. She described how she always went home with her girlfriends, although she did not always remember leaving the establishments or how she got home. Further discussion revealed episodes of blacking out during drinking that had occurred two times in the previous 8 months. She described these events as having "no recollection of leaving one bar and heading to the next." She discussed waking up at home the next morning, still wearing her previous night's clothes; this had occurred a few times during the preceding 6-8 months. She said that most of her friends drink alcohol frequently, and it would have been hard for her to stop. She stated she wanted to cut back and thought she might have a problem.

Susan's MS symptoms and exam had been stable on injectable therapy, and her mood improved on medication and with talk therapy. At that time, she presented with possible alcohol abuse for approximately 12 months, complicating her MS picture.

A Closer Look at Alcohol Abuse

Alcohol abuse is described in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition as individuals who drink despite recurrent social, interpersonal, and legal problems as a result of alcohol use (American Psychiatric Association, 2000). An estimated 17.6 million American adults (8.5%) meet standard diagnostic criteria for an alcohol-use disorder. Alcohol-use disorders include (1) alcohol abuse, a condition characterized by recurrent drinking resulting in failure to fulfill major role obligations at work, school, or home; persistent or recurrent alcohol-related interpersonal, social, or legal problems; and/or recurrent drinking in hazardous situations, and (2) alcohol dependence (also known as alcoholism), a condition characterized by impaired control of drinking, compulsive drinking, preoccupation with drinking, withdrawal symptoms, and/or tolerance to alcohol (NIAAA, 2006).

Effective screening tools exist to assist practitioners in recognizing alcohol-use disorders. Tools include the 4-item CAGE tool and either the 10- or 3-question Alcohol Use Disorders Identification Test (AUDIT). The CAGE is a very brief questionnaire for detection of alcoholism. The AUDIT is a screening tool designed to identify individuals with hazardous and harmful patterns of alcohol consumption (Babor, Biddle-Higgins, Saunders, & Monteiro, 2001). These screening tools enable the clinician to identify individuals who may benefit from alcohol-related interventions or referrals (Bush, Kivlahan, McDonell, Fihn, & Bradley, 1998). All patients should be screened annually for alcohol use (Babor et al.).

The National Institute on Alcohol Abuse and Alcoholism has outlined guidelines for alcohol treatment. The screening tool can be seen at www.aann. org and also is available on the NIAAA Web site.

Alcohol Abuse and MS

A review of the literature regarding alcohol abuse revealed a paucity of information with regard to MS. Prior to results published in 2004, rates of alcohol or drug abuse had never been examined in a large sample of MS patients. The rates of alcohol problems were comparable to those seen in primary care settings, and therefore, clinicians were advised to consider routine screening for alcohol or drug abuse. The study findings suggested that younger, employed, less disabled, and depressed patients are at higher risk for alcohol abuse compared to other MS patients and should be routinely screened. In addition, alcohol can magnify motor and cognitive impairments in patients with MS resulting in greater harm (Bombardier et al., 2004).

Alcohol abuse is also associated with depressive symptoms in patients with MS (Bombardier et al., 2004). In light of the increased incidence of mood disorders in patients with MS, clinicians should be alert to the possibility of alcohol abuse in this population and be prepared to provide information on referrals and interventions available (Bombardier et al., 2001; Quesnel & Feinstein, 2004). In addition, some patients with MS report a nonpermanent increase in their neurologic symptoms while or shortly after drinking alcohol (National Multiple Sclerosis Society, 2006), suggesting that people with MS should be counseled about minimizing alcohol intake.

Case Study Resumed

Susan discussed concerns regarding her alcohol consumption, such as health implications (both physical and emotional), along with safety concerns in the presence of her mother. She agreed that she had a problem and stated that she wished to address it. We discussed potential options including one-on-one therapy and group therapy, such as Alcoholics Anonymous (AA). She was encouraged to discuss this problem with her therapist. She felt comfortable doing so and agreed that her therapist would support her. Susan was advised that she could contact either me or the social worker at the MS center with any questions or concerns. At the end of the extensive discussion regarding substance abuse, potential complications, and counseling options, she reported that she was going to think about her options and talk to her therapist. Susan agreed to call with a progress report or have an office visit sooner if symptoms worsened or if there was an increased concern regarding her alcohol abuse. We maintained e-mail contact. She was in counseling and improving until her next visit. In the interim, I discussed her case with the social worker on staff at the MS center and requested updates from the social worker when she had contact with Susan.

Two weeks later Susan informed me that after meeting with her therapist and with the encouragement and support of her family, she joined AA and was 13 days sober. She had also established a telephone relationship with the social worker at the MS center. She was encouraged to continue sobriety. At last contact Susan had been sober for nearly 13 months and continued to attend weekly AA meetings along with weekly encounters with her therapist.

Summary

There is a dearth of information regarding alcohol abuse and MS. Although some studies show that the incidence of alcohol abuse in people with MS is comparable to the general population, the impact of alcohol on this chronic neurologic disease is unclear. There is literature suggesting a link between alcohol and neurodegeneration, as well as possible links to Alzheimer disease and dementia. The impact of alcohol on the immune system has also been reported. Further research may establish the impact of alcohol use disorders on individuals with MS. At present, comprehensive care provided by clinicians who care for patients with MS should include alcohol-abuse screening.

References

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.

Babor, T. F., Biddle-Higgins, J. C., Saunders, J. B., & Monteiro, M. G. (2001). AUDIT: The alcohols use disorders identification test: Guidelines for use in primary health care. Geneva, Switzerland: World Health Organization.

Bombardier, C., Blake, K., Ehde, D., Gibbons, L., Moore, D., & Kraft, G. (2004). Alcohol and drug abuse among persons with multiple sclerosis. Multiple Sclerosis, 10, 35-40.

Bombardier, C., Boag-Whitley, T., Cunniffe, M., Ehde, D., Gibbons, L., Kraft, G., et al. (2001). Substance abuse among persons with multiple sclerosis [Abstract]. International Journal of Multiple Sclerosis Care, 3(2), 40.

Bush, K., Kivlahan, D., McDonell, M., Fihn, S., & Bradley, K. (1998). The AUDIT alcohol consumption questions (AUDIT-C): An effective brief screening test for problem drinking. Archives of Internal Medicine, 158, 1789-1795.

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Goldberg, I. J., Mosca, L., Piano, M. R., & Fisher, E. A. (2001). AHA Science Advisory: Wine and your heart: A science advisory for healthcare professionals from the Nutrition Committee, Council on Epidemiology and Prevention and Council on Cardiovascular Nursing of the American Heart Association. Circulation, 103(3), 472-475.

National Institute on Alcohol Abuse and Alcoholism. (2006). FAQs. Retrieved January 2007, from www.niaaa.nih.gov/FAQs/GeneralEnglish.

National Institute on Alcohol Abuse and Alcoholism. (2004, Winter). NIAAA council approves definition of binge drinking. NIAAA Newsletter, No. 3. Retrieved September 13, 2007, from http://pubs. niaaa.nih.gov/publicationsfNewsletter/winter2004/Newsletter Number3.pdf.

National Institute on Alcohol Abuse and Alcoholism. (2000). Alcohol alert. Retrieved August 27, 2007, from http://pubs.niaaa.nih.gov/ publications/aal4.htm.

National Institutes of Health. (2004). Largest ever comorbidity study reports prevalence and co-occurrence of alcohol, drug, mood and anxiety disorders. Retrieved August 27, 2007, from www.niaaa. nih.gov/NewsEvents/NewsReleases/Comorbidity.htm.

National Multiple Sclerosis Society. (2006). Alcohol. Retrieved August 27, 2007, from www.nationalmssociety.org/site! PageServer?pagename=HOM_LIB_sourcebook_alcohol.

Quesnel, S. & Feinstein, A. (2004). Multiple sclerosis and alcohol: A study of problem drinking. Multiple Sclerosis, 10(2), 197-201.

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Questions or comments about this article may be directed to Carrie Lyn Sammarco, DrNP MSCN FNP-C, at clo 12@columbia.edu. She is a staff associate (neurology) in the Multiple Sclerosis Clinical Care and Research Center at the New York Presbyterian Hospital-Weill Cornell, New York, NY.
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