When Patients Drink

Posted on Apr 26, 2011 in Patient Care | 2 comments

Do You Know Which Patients Are Likely to Misuse Alcohol?

 

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If your practice is similar to that of your peers, every fifth patient you see is likely to misuse alcohol. One promising solution to identify and help these patients is ‘screening and brief intervention,’ which focuses on helping patients identify their alcohol misuse and reduce their drinking.

Why Screen?

Nearly 14 million Americans—1 in every 13 adults—misuse alcohol or meet the criteria for alcoholism, and it is estimated that alcohol use disorders occur in 10% to 20% of patients presenting to primary care offices.[1] Several million more adults engage in risky drinking that could lead to alcohol problems. These patterns include binge drinking and heavy drinking on a regular basis. In addition, 53% of men and women in the United States report that one or more of their close relatives have a drinking problem.[1] The consequences of alcohol misuse are serious and, in many cases, life threatening. Alcohol abuse and alcoholism can worsen existing conditions such as depression or induce new problems such as memory loss, depression, or anxiety.[1] Heavy drinking can increase the risk for cancer of the liver, esophagus, throat, and larynx and is associated with liver cirrhosis, immune system problems, brain damage, and fetal alcohol syndrome.[2] In addition, drinking increases the risk of death from automobile crashes as well as recreational and on-the-job injuries; homicides and suicides are also more likely to be committed by persons who have been drinking. In purely economic terms, alcohol-related problems cost society approximately $185 billion a year.[3]

Screening is also important because many patients are in denial about their drinking. According to a newly released report from the Substance Abuse and Mental Health Services Administration,[4] almost 10% of people who misuse and abuse alcohol don’t believe they need treatment. Screening is one way to intervene before alcohol misuse becomes life threatening, and should be implemented as part of a routine screening that includes brief discussions about other lifestyle issues such as physical activity, smoking, and safety at home.

Overcoming Barriers to Screening

As a primary care provider, you are in a unique position to recognize patients with potential alcohol problems and to intervene early on. However, heavy drinking often goes undetected. In a study of primary care practices, for example, patients with alcohol dependence received the recommended quality of care, including assessment and referral to treatment, only about 10% of the time.[5] This may be due in part to some data suggesting that only one in five (20%) primary care physicians consider themselves “very prepared” to identify alcoholism.[6] This contrasts dramatically with the level of confidence these same physicians expressed when asked how prepared they felt to diagnosis hypertension (83%) and diabetes (82%). Other notable findings from this same study suggest that up to 96% of primary care providers believe that treatment for alcohol abuse is not effective, 41% find it difficult to discuss alcohol abuse with patients, and nearly 58% don’t discuss alcohol abuse with patients because their patients ‘lie’ about it.[6]

The degree to which primary care practitioners tend to overlook alcohol abuse is sizable. In the same survey[6] noted above, 648 primary care physicians were given case records of either a male or female with a history typical of alcohol abuse and asked to provide a diagnosis. The most common diagnoses listed were ulcer and irritable bowel syndrome; only 6.2% of the primary care physicians correctly identified alcohol abuse as one of the five possible diagnoses.

Who Should be Screened?

The U.S. Preventive Services Task Force strongly recommends screening and behavioral counseling interventions to reduce alcohol misuse by adults, including pregnant women, in primary care settings. During new patient encounters and at least annually, patients in general and mental healthcare settings should be screened for at-risk drinking, alcohol use problems and illnesses, and any tobacco use.[7] Based on this recommendation, the National Quality Forum—a voluntary consensus evidence-based standard-setting organization—recommends that patients 10 years of age or older should be screened for alcohol misuse during new patient encounters and then again at least annually.[8]

When compared with adults’ use, adolescents’ use of alcohol is much more likely to be episodic (binge) and heavy, making their use particularly dangerous. As a result, in 2010 the American Academy of Pediatricians recommended that clinicians screen all of their young patients for alcohol use starting in middle school.[9]

In addition to the key opportunities for screening outlined in Table 1, you might also consider screening patients who have health problems that might be alcohol induced, such as cardiac arrhythmias, dyspepsia, liver disease, depression or anxiety, insomnia, or trauma.

Screening can vary from only one question to an extensive assessment using a standardized questionnaire. Clinicians under strict time constraints may have time to ask a patient only one or two screening questions about his or her alcohol consumption, starting with a prescreening question about any alcohol use (do you sometimes drink beer, wine, or other alcoholic beverage?). One study[10] has shown that a positive response to the follow-up question “On any single occasion during the past three months, have you had more than five (men) or four (women) drinks containing alcohol?” accurately identifies patients who meet either National Institute on Alcohol Abuse and Alcoholism’s criteria for at-risk drinking or the criteria for alcohol abuse or dependence specified in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition.[11] Another well-validated screening tool is the CAGE questionnaire, a mnemonic for a word in each of its four questions[12]:

• Have you ever felt you should Cut down on your drinking?
• Have people ever Annoyed you by criticizing your drinking?
• Have you ever felt Guilty about drinking?
• Have you ever taken an Eye-opener drink first thing in the morning to steady your nerves or get rid of a hangover?

A single positive response is considered a positive screening test; a score of 2 to 3 indicates a high index of suspicion and a score of 4 is virtually diagnostic for alcoholism.

Another validated screen to assess the severity of a drinking problem is the Alcohol Use Disorders Identification Test (AUDIT). This is a 10-question survey designed to detect heavy drinking and alcohol use disorder and takes about five minutes to complete. Total scores of 8 or more (men up to age 60) and 4 or more (men older than 60, adolescents, and women) are considered positive screens.[13]

Many people don’t know what counts as a standard drink and so they don’t realize how many standard drinks are in the containers in which these drinks are often sold. Table 2[14] can help you confirm patients’ responses to questions requiring them to quantify how many drinks they consumer per day or week. Men who drink more than four standard drinks in a day (or more than 14 per week) and women who drink more than three in a day (or more than seven per week) are at increased risk for alcohol-related problems.[15]

Screening and Interventions Can Make a Difference

Patients may be more receptive, open, and ready to change than you expect. Most patients don’t object to being screened for alcohol use by clinicians and are open to hearing advice afterward.[16] In addition, most primary care patients who screen positive for heavy drinking or alcohol use disorders show some motivational readiness to change, with those who have the most severe symptoms being the most ready.[17]

Evidence continues to demonstrate that brief interventions can promote significant, lasting reductions in drinking levels in at-risk drinkers who are not alcohol dependent.[18] Brief interventions emphasize reduction in use rather than abstinence in order to reduce the risk of negative drinking-related consequences. For example, a patient who drinks four or more drinks per day has a two- to threefold increase in the risk of a fatal traffic accident or the development of chronic diseases such as liver failure, cancer, or ischemic heart disease. If that same patient can reduce his or her alcohol intake to one or two drinks per day, the risk of harm will be reduced. This is the same technique you already use with patients to help them change other harmful behaviors, including smoking, overeating, sedentary lifestyle, or medication adherence issues.[19] Data suggest that for alcohol-dependent patients with an alcohol-related medical illness, repeated brief interventions at approximately monthly intervals for one to two years can lead to significant reductions in or cessation of drinking.[18] Both the American Medical Association and the Centers for Medicare & Medicaid Services coding systems provide reimbursement codes for screening and brief interventions in 15-minute increments.

Some drinkers who are dependent will accept referral to addiction treatment programs. Even for patients who don’t accept a referral, repeated alcohol-focused visits with a healthcare provider can lead to significant improvement.

Over the last 20 years, the role of adjuvant pharmacotherapy in optimizing outcome in rehabilitation programs for alcohol-dependent patients has become increasingly evident.

Three oral medications (naltrexone, acamprosate, and disulfiram) and one injectable medication (extended-release injectable naltrexone) are currently approved for treating alcohol dependence.[20] They have been shown to help patients reduce drinking, avoid relapse to heavy drinking, achieve and maintain abstinence, or gain a combination of these effects. As is true in treating any chronic illness, addressing patient adherence systematically will maximize the effectiveness of these medications. Topiramate, an oral medication used to treat epilepsy and migraine, has recently been shown to be effective in treating alcohol dependence, although it is not approved by the Food and Drug Administration for this indication.[21]

All approved drugs have been shown to be effective adjuncts to the treatment of alcohol dependence. Thus, consider adding medication whenever you are treating someone with active alcohol dependence or someone who has stopped drinking in the past few months but is experiencing problems such as craving or slips. Patients who have previously failed to respond to psychosocial approaches alone are particularly strong candidates.

RESOURCE OF THE MONTH: Helping Patients Who Drink Too Much. A Clinician’s Guide. National Institute on Alcohol Abuse and Alcoholism, Updated 2005 Edition, new supporting materials.

Jill Shuman, MS, ELS
Published on April 26, 2011

References

1. National Institute on Alcohol Abuse and Alcoholism. Unpublished data from the 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), a nationwide survey of 43,093 U.S. adults aged 18 or older. 2004.
2. Rehm J, Room R, Graham K, et al.  The relationship of average volume of alcohol consumption and patterns of drinking to burden of disease: an overview.  Addiction 2003;98(9):1209-1228
3. Harwood H. Updating Estimates of the Economic Costs of Alcohol Abuse in the United States: Estimates, Update Methods, and Data. Bethesda, MD: U.S. Department of Health and Human Services; National Institute on Alcohol Abuse and Alcoholism; 2000.
4. Data spotlight: Most adults with alcohol problems do not recognize their need for treatment. The National Survey on Drug Use and Health. April 7, 2011. http://oas.samhsa.gov/spotlight/Spotlight034AdultsAlcohol.pdf Accessed April 25, 2011.
5. McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348(26):2635-2645.
6. The National Center on Addiction and Substance Abuse. Missed Opportunity: National survey of primary care physicians and patients on substance abuse. University of Illinois, Chicago; April 2000. http://www.casacolumbia.org/templates/Publications_Reports.aspx#r41
7. U.S. Preventive Services Task Force. Screening and Behavioral Counseling Interventions in Primary Care to Reduce Alcohol Misuse: Recommendation Statement. April 2004. http://www.uspreventiveservicestaskforce.org/3rduspstf/alcohol/alcomisrs.htm. Accessed April 21, 2011.
8. National Quality Forum. National Voluntary Consensus Standards for the Treatment of Substance Use Conditions: Evidence-Based Treatment Practices. NQFCR-19-07. Washington, DC: National Quality Forum; 2007.
9. Committee on Substance Abuse, Kokotailo PK. Alcohol use by youth and adolescents: a pediatric concern. Pediatrics. 2010;125(5):1078-1087.
10. Taj N, Devera-Sales A, Vinson DC. Screening for problem drinking: does a single question work? J Fam Pract. 1998;46(4):328-335.
11. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision. Washington, DC: American Psychiatric Association; 2000.
12. O’Brien CP. The CAGE Questionnaire for detection of alcoholism: a remarkably useful but simple tool. JAMA. 2008;300(17):2054-2056.
13. Reinert DF, Allen JP. The Alcohol Use Disorders Identification Test (AUDIT): a review of recent research. Alcohol Clin Exp Res. 2002;26(2):272-279.
14. National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism. Rethinking Drinking: Alcohol and Your Health. Bethesda, MD: National Institutes of Health; 2010. NIH publication 10-3770.
15. Dawson DA, Grant BF, Li TK. Quantifying the risks associated with exceeding recommended drinking limits. Alcohol Clin Exp Res. 2005; 29(5):902-908
16. Miller PM, Thomas SE, Mallin R. Patient attitudes towards self-report and biomarker alcohol screening by primary care physicians. Alcohol Alcohol. 2006; 41(3):306-310.
17. Williams EC, Kivlahan DR, Saitz R, et al. Readiness to change in primary care patients who screened positive for alcohol misuse. Ann Fam Med. 2006; 4(3):213-220.
18. Fleming MF, Mundt MP, French MT, et al. Brief physician advice for problem drinkers: long-term efficacy and benefit-cost analysis. Alcohol Clin Exp Res. 2002;26(1):36-43.
19. Ries RK, Miller SC, Fiellin DA, Saitz R. Principles of Addiction Medicine, 4th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2009.
20. Mann K. Pharmacotherapy of alcohol dependence: a review of the clinical data. CNS Drugs. 2004;18(8):485-504.
21. Johnson BA, Rosenthal N, Capece JA, et al; Topiramate for Alcoholism Advisory Board and the Topiramate for Alcoholism Study Group. Topiramate for treating alcohol dependence: a randomized controlled trial. JAMA. 2007; 298(14):1641-1651.