ABSTRACT: Standard tools to identify problem drinkers and a stepwise approach to treatment are now available. Only 10% of at-risk patients receive recommended assessment, counseling, and referral.
CME OBJECTIVE: The reader will be aware of alcohol use assessment tools, appropriate interventions, diagnostic criteria for alcohol dependence and abuse, and indications for referral.
Peter S. Lane, DO, no conflicts of interest; Jill K. Billions, MD, no conflicts of interest
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Alcohol abuse leads to an array of medical problems.
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Alcohol screening and behavioral counseling to reduce alcohol misuse are among the highest-ranking preventive services the US Preventive Services Task Force recommends in primary care. Nevertheless, current levels of delivery are the lowest of comparably ranked services (Am J Prev Med. 2008;34[2]:143-152).
About 3 in 10 US adults drink at levels that increase their risk for physical, mental health, and social problems. Health risks increase when drinking exceeds two or three drinks a day. Heavy drinkers have elevated risks of hypertension, gastrointestinal bleeding, sleep disorders, major depression, hemorrhagic stroke, cirrhosis and other liver disorders, and several cancers. The National Institute of Alcohol Abuse and Alcoholism's (NIAAA) clinician's guide "Helping Patients Who Drink Too Much" provides a step-by-step approach to identifying and treating these individuals. Supplementary materials include the Alcohol Use Disorders Identification Test (AUDIT), support materials, and patient education handouts (niaaa.nih.gov/guide).
Identifying and Screening
"Primary care physicians are well positioned to identify problem drinkers," says Peter S. Lane, DO, medical director of the UAB Addiction Recovery Program, one of only two programs in the state that specializes in treating health care professionals with addictions. Evidence shows that screening can accurately identify patients whose consumption patterns or levels place them at risk of increased morbidity and mortality. The NIAAA recommends screening tools such as the four-question CAGE, 10-question AUDIT, or a single interview question: "How many times in the past year have you had five or more drinks in a day (four or more for women)?". An answer of ≥1 day indicates an at-risk drinker. "If a patient indicates that he does not drink, ask why," Lane says. "Also ask about relatives' drinking, because a personal or family history of alcohol-related problems may indicate a genetic makeup that heightens addiction risk."
Red flags that may indicate alcohol problems include frequent absences from work or school, history of trauma or accidental injuries, depression, anxiety, labile hypertension, gastrointestinal symptoms, sexual dysfunction, sleep disorders, and tremor.
Patients who drink moderately may benefit from advice to limit or abstain if medically indicated (eg, pregnancy, medications that interact with alcohol, or a health condition exacerbated by alcohol) or to stay within maximum drinking limits. NIAAA limits for healthy individuals are no more than four drinks per day and 14 per week for men and three drinks per day and seven per week for women. (One drink equals one 12-ounce bottle of beer, one 5-ounce glass of wine, or 1.5 ounces of 80-proof distilled spirits.) Patients who exceed these amounts are heavy drinkers and at-risk for misuse.
Assessment
When a patient has a positive AUDIT or CAGE, the next step is to determine if there is a maladaptive pattern of alcohol use that causes clinically significant impairment or distress. Then it is crucial to make a formal diagnosis using criteria listed in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV), says Lane, who strongly cautions against labeling patients as "dependent" or "abusive" without a diagnosis based on these criteria.
The diagnosis of dependence focuses on symptoms of compulsive use and loss of control. A patient with dependence will meet three of these criteria in a 12-month period: tolerance; withdrawal; drinking larger amounts or for longer periods than intended; repeatedly unable to cut down or abstain; spending a great deal of time acquiring, using, and recovering from the effects of alcohol; abandoning social, job, or recreational activities because of alcohol; and continuing to drink despite psychological or physical consequences.
One or more persistent serious consequences caused or exacerbated by drinking constitute abuse: physically hazardous behavior (eg, drunk driving); relationship problems; role failure at work, school, or home; or legal trouble.
Intervention
Brief interventions lower alcohol consumption for as long as 12 months, although these approaches are effective mostly in men (Cochrane Database Syst Rev. 2007 Apr 18[2]:CD004148). Such interventions may take one to four sessions and include providing feedback on alcohol use and harms, identifying high-risk situations and coping strategies, and increasing motivation and developing a personal plan to reduce drinking. An intervention may take 5 to 15 minutes during a standard consultation.
If the patient is at risk for developing alcohol-related problems but does not meet criteria for abuse or dependence, NIAAA guidelines dictate a brief intervention including the nonjudgmental, clear statement, "You are drinking more than is medically safe," and a recommendation to reduce or quit drinking paired with an offer to help. For individuals ready to change habits, suggestions are to help set a goal, agree on a plan, and provide educational materials.
In follow-up, clinicians should document alcohol use, review goals, reinforce adherence, and continue to rescreen annually. For individuals resistant to change, restate your concern about their health, encourage reflection on barriers to change, and offer to help. If the patient continues at-risk drinking behaviors, acknowledge that change is difficult, address barriers to change, renegotiate reduction goals, and consider reassessment of the diagnosis. Does this patient now fit the criteria for abuse or dependence?
If the patient meets criteria for an alcohol use disorder, then clearly state your conclusion and recommendation that they abstain, referencing medically related findings if present. Assess the patient's readiness and offer to help. Negotiate a drinking goal. "The safest course for most patients with alcohol use disorders is abstinence," UAB addictionologist Jill K. Billions, MD, says. Assess whether the patient is dependent and may need medically managed withdrawal or a referral to an addiction specialist.
At this point also consider recommending a mutual help group, such as Alcoholics Anonymous (AA). "Continued follow-up and support are crucial to success," says Billions. If the patient does not meet and sustain his drinking goals, offer support again, relate drinking to medical, social, or psychological problems as appropriate, and address coexisting medical or psychiatric issues. Revisit earlier steps such as referral to an addiction specialist, support group, or prescription of a medication.
When patients meet and sustain their drinking goals, reinforce adherence, maintaining medications for at least 3 months or as clinically indicated, treat nicotine dependence, and address coexisting medical and psychiatric issues.
Medical Management
Experts have mixed opinions on the efficacy of medications to ameliorate or eliminate alcohol dependence. According to the NIAAA, medications can reduce risk of relapse by 20% to 40%. "Research consistently indicates that naltrexone effectively reduces drinking in a subset of patients," Lane says. "Drugs, however, are not appropriate as long-term treatment. Successful strategies should incorporate counseling and participation in mutual help groups."
"Drug therapy will not ‘cure' alcoholism but can be helpful with harm reduction," Billions says, singling out topiramate, which may reduce drinking and lowers liver enzymes, plasma cholesterol, body mass index, and blood pressure, all of which tend to increase with heavy alcohol use (Arch Int Med. 2008;168[11]:1188-1199).
The recent Combining Medications and Behavioral Interventions (COMBINE) trial indicated that a series of brief support sessions for patients taking medication increased adherence to drug regimens and promoted abstinence (JAMA. 2006;295[17]:2003-2017). The initial session lasted 45 minutes; eight subsequent sessions lasted 20 minutes. Sessions included education and referral to AA. "Typical primary care practices do not have the time or staff for these interventions," Billions says, "and the COMBINE trial did not produce prolonged abstinence. Cognitive therapy and participation in groups such as AA consistently produce long-term abstinence."
For more information contact Dr. Peter Lane or Dr. Jill Billions at 1-800-UAB-MIST or email mist@uabmc.edu