Alcohol Use Disorder
Detecting and Managing Alcohol Use Disorders in Primary Care
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In much of the world drinking alcohol-containing beverages is socially normal and legal for adults. One in three U.S. adults has consumed enough alcohol to be legally intoxicated at least once in their lives, and about one in four consume alcohol in amounts or patterns that pose a risk to their own health or the health of those around them. The Centers for Disease Control and Prevention Centers (CDC) estimates that alcohol misuse is the third leading cause of preventable death in the U.S. following tobacco use and obesity. Misuse of alcohol is almost as common as hypertension or hyperlipidemia in our adult patients and we spend a significant portion of our time on screening and early intervention for those conditions. Unlike Type 2 diabetes, hyperlipidemia, and hypertension in which lifestyle modification is crucial to management, alcohol misuse has a social stigma which makes both patients and clinicians less likely to identify it as a problem and to discuss modifying their drinking behavior to help achieve treatment success.  If the Affordable Care Act takes effect as planned in 2014, both detection and management of alcohol and other substance misuse disorders will be required of all the participating health insurance plans and no one can be refused health insurance if the condition has been recognized previously. This may also make employers less likely to reject employees with these disorders and instead, refer them for treatment.
On May 14, 2013, the US Preventive Services Task Force (USPSTF) issued new recommendations that all adults over age 18 not only have routine screening for alcohol misuse in primary care settings, but that those who test positive for risky drinking behavior be given brief behavioral counseling and offered referral for treatment.  This recommendation is based on evidence that programs of screening, brief intervention, and referral to treatment (SBIRT) have been effective in reducing excessive drinking behavior.  The USPSTF did not find the evidence of benefit sufficiently strong for recommending routine screening and intervention in adolescents age 12-17 for alcohol misuse. The USPSTF has no recommendation on screening women who are pregnant or planning for pregnancy, however both the American College of Obstetrics and Gynecology and the American Academy of Pediatrics have developed toolkits for SBIRT specifically directed at preventing fetal alcohol spectrum disorders (FASD) with CDC support including free CME training programs. [6,7]
Federal Substance and Mental Health Administration (SAMHSA) funded the development of tools and training for primary care practices in SBIRT and obtaining reimbursement for the procedures.  The Oregon Health Sciences University SBIRT offers a training program for family medicine residents and useful resources.
A sequential screening process begins with the National Institute of Alcohol Abuse and Alcoholism (NIAAA) single question “How many times in the past year have you had more than X or more drinks (where X=5 for men and 4 for women)?” If the answer is 1 or more, then a more detailed screening of the pattern of alcohol use is administered, eg, Alcohol Use Disorders Identification Test (AUDIT). The NIAAA 1Q takes about one minute to administer and the AUDIT about five minutes. Both of these screens can be done by non-clinical staff and qualify for third party reimbursement. If the AUDIT score suggests risky behavior or dependence, brief intervention to discuss the results of screening with a clinician is indicated either in that office visit or a follow-up visit. AUDIT screening forms in multiple languages are available at the Oregon website mentioned above.
Effective brief Intervention (BI) can be done in as little as five minutes, but most practices schedule a fifteen-minute visit. BI should include: reviewing results of the screening, individualized explanation of the effect of alcohol on health; “motivational interview” of the outcome the patient wants and the behavior changes to get there; and a specific plan of what should be achieved and when. The Oregon website mentioned above has several patient simulations to teach the techniques of BI. There is also an NIAAA-sponsored free CME lesson with patient cases to demonstrate the SBIRT approach.
AUDIT score levels correlate with risky, harmful, and dependent misuse. The NIAAA “Helping Patients Who Drink Too Much: a Clinicians Guide”  provides an algorithmic approach to assessment of alcohol use disorders based on the American Psychiatric Association Diagnostic and Statistical Manual, 4th edition revised (DSM-IV-TR) and correlate it with the diagnostic criteria for the International Classification of Disease (ICD-10). Because the 5th edition DSM-5 was just released in May 2013 and there are changes to the diagnostic criteria, you as the clinician, may not be comfortable labeling an individual with diagnoses which may have significant social and economic consequences to their careers and health insurance. The ICD-10-CM code appropriate for use for those patients is “alcohol use, unspecified” (ICD-1—CM code F10.9). 
If the AUDIT screen suggests an alcohol use disorder, the recommendation is for patients to seek resources beyond the practice for further evaluation and possible treatment. It is important to know if a patient is likely to experience physiologic withdrawal if they stop or substantially reduce their alcohol use because they may require admission for detoxification before starting any other treatment.
The Clinician’s Guide also contains a link to a summary of pharmacotherapy for alcohol dependence. In addition, the NIAAA has a manual suggesting a method of managing and documenting treatment with the recommended medications.  Medications are almost always prescribed as an adjunct to a treatment program including group support, substance-abuse counseling, or both. SAMHSA has a national referral resource for treatment including a 24/7 confidential helpline in English and Spanish for substance abuse and mental health at 1-800-662-HELP. 
Charles Sneiderman MD PhD DABFP
Family Physician and Medical Director
Culmore Clinic, Falls Church, VA
Published July 15, 2013
Charles Sneiderman, MD PhD, retired in 2010 after a 31-year career in medical informatics at the Lister Hill National Center for Biomedical Communications, National Library of Medicine, National Institutes of Health. His work included research and development in telemedicine, distance learning, and medical language and image processing. Since leaving federal service, he has developed a computerized clinical decision support system to assist primary healthcare practices in the recognition and management of post-traumatic stress syndromes with support from the NLM Disaster Information Management Research Center. Dr. Sneiderman received a B.S. with high honors from the University of Maryland in 1969, and M.D. and Ph.D. degrees from Duke University in 1975 and completed residency training in family medicine at the Medical University of South Carolina in 1979. He has authored numerous scientific reports, book chapters, and medical educational media. Dr. Sneiderman was a Clinical Assistant Professor of Family Practice at the Uniformed Services University of the Health Sciences and maintains certification by the American Board of Family Medicine. He has practiced family medicine part-time in the Washington, DC area since 1980. He has assisted wounded warriors with adaptive snowsports since 2005.
1. The National Institute on Alcohol Abuse and Alcoholism; Alcohol & Health » Overview of Alcohol Consumption » Drinking Statistics. http://www.niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/drinking-statistics
2. Centers for Disease Control and Prevention. Chronic Diseases and Health Promotion. Chronic diseases are the leading causes of death and disability in the U.S. http://www.cdc.gov/chronicdisease/overview/index.htm#2
3. Denvir PM. When patients portray their conduct as normal and healthy: an interactional challenge for thorough substance use history taking. Soc Sci Med. 2012 Nov 75(9):1650-1659.
4. U.S. Preventive Services Task Force. Screening and behavioral counseling interventions in primary care to reduce alcohol misuse. http://www.uspreventiveservicestaskforce.org/uspstf/uspsdrin.htm
5. Jonas DE, Garbutt JC, Amick HR, et al. Behavioral counseling after screening for alcohol misuse in primary care: a systematic review and meta-analysis for the U.S. Preventive Services Task Force. Ann Intern Med. 2012 Nov 6;157(9):645-654.
6. Drinking and Reproductive Health: A Fetal Alcohol Spectrum Disorders Prevention Tool Kit. Health. http://www.womenandalcohol.org/clinicians.html
7. Fetal Alcohol Spectrum Disorders Program. http://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/fetal-alcohol-spectrum-disorders-toolkit/Pages/default.aspx?
8. Substance Abuse & Mental Health Services Administration. Screening, Brief Intervention, and Referral to Treatment (SBIRT). http://www.samhsa.gov/prevention/SBIRT/index.aspx
9. National Institute on Alcohol Abuse and Alcoholism (NIAAA). Helping patients who drink too much: a clinician’s guide. NIH Publication No. 07–3769; 2007.http://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/clinicians_guide.htm
10. ICD10Data.com. The Free 2013 Medical coding Reference. http://www.icd10data.com/
11. National Institutes of Health National Institute on Alcohol Abuse and Alcoholism Medical Management Treatment Manual: A Clinical Guide for Researchers and Clinicians Providing Pharmacotherapy for Alcohol Dependence (Generic Version; 2010 edition). http://pubs.niaaa.nih.gov/publications/MedicalManual/MMManual.pdf
12. Substance Abuse & Mental Health Services Administration. Find substance abuse and mental health treatment. 24/7 Treatment Referral Line. http://www.samhsa.gov/treatment/