Physician's Guide to Helping Patients with Alcohol Problems

THE PHYSICIANS' GUIDE TO HELPING PATIENTS WITH ALCOHOL PROBLEMS

U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism

NIH Publication No. 95-3769, Printed l995

Flowchart for Alcohol Screening and Brief Intervention

FOREWARD

This Guide was developed by the National Institute on Alcohol Abuse and Alcoholism (NIAAA) in conjunction with an interdisciplinary working group of alcohol researchers and health professionals. The clinical recommendations in this Guide are based on the findings of more than a decade of research on the health risks associated with alcohol use and on the effectiveness of alcohol screening and intervention methods. NIAAA plans to update this Guide periodically to reflect continuing advances in research.

NIAAA would like to acknowledge the contributions of members of the Working Group on Screening and Brief Intervention, including the following: John Allen, Ph.D.; Peter Anderson, M.D.; Thomas Babor, Ph.D.; Kendall Bryant, Ph.D.; David Buchsbaum, M.D.; Jonathan Chick, M.D.; Frances Cotter, M.A., M.P.H.; Michael Fleming, M.D., M.P.H.; Richard K. Fuller, M.D.; Nick Heather, Ph.D.; Yedy Israel, Ph.D.; Cherry Lowman, Ph.D.; William R. Miller, Ph.D.; Judith Ockene, Ph.D.; and Allen Zweben, D.S.W.

NIAAA also would like to thank other collaborators, including the following: Michael Fleming, M.D., M.P.H., and Frances Cotter, M.A., M.P.H., for their leadership in writing this Guide; the College of Family Physicians of Canada Alcohol Risk Assessment and Intervention (ARAI) Project Steering Committee for sharing their expertise and early drafts of brief intervention materials; and Eve Shapiro and colleagues at CSR, Incorporated, for their expertise in editing and designing this Guide.

Dear Colleagues:

As a primary care physician, you are in an excellent position to identify and manage patients at risk for alcohol-related problems. Alcohol-related problems are common in primary care practice: An estimated 25 percent of adults in the United States either report drinking patterns that put them at risk for developing problems or currently have alcohol-related problems, including alcohol abuse or dependence.* Primary care physicians are the entry point into the health-care system for many individuals. Furthermore, because you are concerned with the overall health of an individual, you generally see patients more frequently than do other health-care professionals.

Primary care physicians are busy. Yet you want to practice good medicine and are willing to take time to address your patients' alcohol problems. This Guide, prepared by the National Institute on Alcohol Abuse and Alcoholism, provides you with a step-by-step approach to identifying and managing these problems and offers practical advise on making alcohol screening, assessment, and brief intervention procedures a routine part of your clinical practice. There are important reasons for doing so. Untreated alcoholism results in a variety of social, economic, and medical consequences. Alcohol use can complicate treatment for medical problems, interfere with prescribed medications, or lead to adverse side effects. Most importantly, left untreated, alcohol abuse and alcoholism often result in severe or fatal outcomes.

Your patients look to you for advice about the risks and benefits associated with drinking. Research, in fact, demonstrates that simply discussing your concerns about alcohol use can be effective in changing many patients' drinking behavior before problems become chronic.

We commend this Guide to your attention and hope that you will make it an integral part of your practice.

Enoch Gordis, M.D.
Director
National Institute on Alcohol Abuse and Alcoholism

________________________________________________________
*Seven percent of the U.S. population -- approximately l4 million adults -- meet the diagnostic criteria for alcohol abuse or dependence

WHAT YOUR PATIENTS SHOULD KNOW ABOUT ALCOHOL USE

Most adults who drink alcohol drink in moderation and are at low risk for developing problems related to their drinking. However, all drinkers, including low-risk drinkers, should be aware of the health risks associated with alcohol consumption. Provide your patients with information and advice about the risks of drinking.

RECOMMENDATIONS TO PATIENTS FOR LOW-RISK DRINKING

Advise those patients who currently drink to drink in moderation. Moderate drinking is defined as follows:

Men -- no more than two drinks per day
Women -- no more than one drink per day
Over 65 -- no more than one drink per day

Note: A standard drink is l2 grams of pure alcohol, which is equal to one l2-ounce bottle of beer or wine cooler, one 5-ounce glass of wine, or l.5 ounces of distilled spirits.

Advise patients to abstain from alcohol under certain conditions:

when pregnant or considering pregnancy
when taking a medication that interacts with alcohol
if alcohol dependent
if a contraindicated medical condition is present (e.g., ulcer, liver disease)

If a patient is at risk for coronary heart disease, discuss the potential benefits and risks of alcohol use:

Light to moderate drinking is associated with lower rates of coronary heart disease in certain populations (e.g., men over 45, postmenopausal women). Infrequent or nondrinkers are not advised to begin a regimen of light to moderate drinking to reduce the risk of coronary heart disease because vulnerability to alcohol-related problems cannot always be predicted. Similar protective effects can likely be achieved through proper diet and exercise.

Clinical Notes

Women and the elderly have smaller amounts of body water than men; therefore, they achieve a higher blood alcohol concentration than men after drinking the same amount of alcohol

Exposing a fetus to alcohol can cause a broad range of birth defects referred to as fetal alcohol syndrome (FAS) or alcohol-related birth defects (ARBD). Although FAS/ARBD is associated with excessive alcohol consumption during pregnancy, studies also have reported neurobehavioral deficits in infants born to mothers reporting drinking an average of one drink per day during pregnancy.

Studies indicate that heavier episodic drinking (i.e., the consumption of more than four drinks per occasion by men and more than three drinks per occasion by women) impairs cognitive and psychomotor functions and increases the risk of alcohol-related problems, including accidents and injuries.

SCREENING AND BRIEF INTERVENTION PROCEDURES

Recommended screening and brief intervention procedures include four steps:

I...Ask about alcohol use.
II..Assess for alcohol-related problems.
III.Advise appropriate action (i.e., set a drinking goal, abstain, or obtain alcohol treatment).
IV.Monitor patient progress.

STEP I. -- ASK ABOUT ALCOHOL USE

Ask all patients:

Do you drink alcohol, including beer, wine, or distilled spirits?

Ask current drinkers about alcohol consumption:

On average, how many days per week do you drink alcohol?
On a typical day when you drink, how many drinks do you have?
What is the maximum number of drinks you had on any given occasion during the last month?

Ask current drinkers the CAGE questions:

Have you ever felt that you should Cut down on your drinking?
Have people Annoyed you by criticizing your drinking?
Have you ever felt bad or Guilty about your drinking?
Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (Eye opener)?

If there is a positive response to any of these questions:

ASK: Has this occurred during the past year?

A patient may be at risk of alcohol-related problems

IF:

Alcohol consumption is:

Men:
> l4 drinks per week or

> 4 drinks per occasion

Women:
> 7 drinks per week or

> 3 drinks per occasion

OR:

one or more positive responses to the CAGE that have occurred in the past year

When is screening for alcohol problems appropriate?

as part of a routine health examination
before prescribing a medication that interacts with alcohol
in response to presenting problems that may be alcohol-related

STEP II. -- ASSESS FOR ALCOHOL-RELATED PROBLEMS

Patients who screen positive should be assessed to determine the nature and extent of their alcohol-related problems. Use the assessment procedures described below to determine problem severity, as follows: l) at increased risk for developing alcohol-related problems, 2) currently experiencing alcohol-related problems, or 3) may be alcohol dependent.

1. At Increased Risk for Developing Alcohol-Related Problems

Indicators

drinking above recommended low-risk consumption levels or in high-risk situations
personal or family history of alcohol-related problems

Assessment procedures

Ask about typical drinking patterns: How long have you been drinking this amount? How many times in a week (or month) do you have four or more drinks on one occasion? What is the most you have consumed on one occasion during the past year?
Ask about personal and family history: Have you or anyone in your immediate family ever had a drinking problem?

Note: For many conditions, there is a dose-response relationship between alcohol consumption and risk. This applies to cirrhosis of the liver; cancers of the oropharynx, larynx, liver, and breast; hypertension; and stroke.

2. Currently Experiencing Alcohol-Related Problems

one or two positive responses to the CAGE that have occurred in the past year
evidence of alcohol-related medical or behavioral problems

Assessment procedures

Review your patient's medical history for evidence of alcohol-related medical problems, such as:

blackouts
chronic abdominal pain
depression
liver dysfunction
hypertension
sexual dysfunction
trauma
sleep disorders

Note: Chronic heavy use of alcohol (i.e., three or more drinks per day) may be associated with elevations in serum gammaglutamyltransferase (GGT). This can be an indicator of excessive drinking.

Ask about interpersonal or work-related problems: Has your drinking ever caused you problems, such as problems with your family, problems with your work (or school) performance, or accidents/injuries?

3. May Be Alcohol Dependent

Indicators

three or four positive responses to the CAGE that have occurred in the past year
evidence of one or more of the following symptoms:(l)

Compulsion to drink -- preoccupation with drinking

Impaired control -- unable to stop drinking once started

Relief drinking -- drinking to avoid withdrawal symptoms

Withdrawal -- evidence of tremor, nausea, sweats, or mood disturbance

Increased tolerance -- takes more alcohol than before to get "high"

(l)This selective listing of dependence symptoms is offered as an initial assessment procedure and not for the purpose of making a diagnosis. For a diagnostic evaluation, refer your patients to a specialist or use the diagnostic procedures outlined in the "Diagnostic and Statistical Manual of Health Disorders, Fourth Edition (DSM-IV)."

Assessment procedures

Ask the following questions:

- Are there times when you are unable to stop drinking once you have started?

- Does it take more drinks than before to get "high?"

- Do you feel a strong urge to drink?

- Do you change your plans so that you can have a drink?

- Do you ever drink in the morning to relieve the shakes?

STEP III. ADVISE APPROPRIATE ACTION

State your medical concern:

Be specific about your patient's drinking patterns and related health risks.
ASK: How do you feel about your drinking?

Advise to abstain or cut down:

Advise to abstain if:

- evidence of alcohol dependence

- history of repeated failed attempts to cut down

- pregnant or trying to conceive

- contraindicated medical condition or medication

Advise to cut down if:

- drinking above recommended low-risk drinking amounts and no evidence of alcohol dependence

Agree upon a plan of action

ASK: Are you ready to try to cut down or abstain?
Talk with patients who are ready to make a change in their drinking about a specific plan of action.

For patients who are not alcohol dependent:

Recommend low-risk consumption limits for your patient based upon the low-risk drinking recommendations and your patient's health history (see pp. l-2).
Ask your patient to set a specific drinking goal: Are you ready to set a drinking goal? Some patients choose to abstain for a period of time or for good; others prefer to limit the amount they drink. What do you think will work best for you?
Provide patient education materials and tell your patient: It helps to think about your reasons for wanting to cut down and examine what situations trigger unhealthy drinking patterns. These materials will give you some useful tips on how to maintain your drinking goal.

For patients with evidence of alcohol dependence:

Refer for additional diagnostic evaluation or treatment. Procedures for patient referral are as follows:

- Involve your patient in making referral decisions.

- Discuss available alcohol treatment services.

- Schedule a referral appointment while the patient is in the office.

SOME PATIENT COUNSELING TIPS

Use an empathic, nonconfrontational style.
Offer your patient some choices about how to effect change.
Emphasize your patient's responsibility for changing drinking behavior.
Convey confidence in your patient's ability to change drinking behavior.

STEP IV. MONITOR PATIENT PROGRESS

Monitor patient progress in the same way you manage other chronic medical problems, such as hypertension or diabetes. Recognize that behavior change is an incremental process that often involves trial and error. Patient management strategies include the following:

Indicate that you (or your designated staff) are available to provide ongoing assistance and support.
Support your patient's efforts to cut down or abstain at each subsequent visit by:

- reviewing progress to date

- commending your patient for efforts made

- reinforcing positive change

- assessing continued motivation

Consider scheduling a separate followup visit or telephone call, as appropriate, if the patient needs additional support.
Consider referring a selected patient whose counseling needs exceed the services provided in a primary care setting.

For patients who have been advised to abstain or have been referred for alcohol treatment:

Ask to receive periodic updates from the treatment specialist on your patient's treatment plan and prognosis.
Monitor symptoms of depression and anxiety. Such symptoms may occur, but they often decrease or disappear after 2 to 3 weeks of abstinence.
Monitor GGT levels, when appropriate, as a means of assessing alcohol treatment compliance.

WHAT TO DO ABOUT PATIENTS WHO ARE NOT READY TO CHANGE THEIR DRINKING BEHAVIOR

Do not be discouraged if patients are not ready to take action immediately. Decisions to change behavior often involve fluctuating motivation and feelings of ambivalence. By offering your advice, you have prompted your patients to think more seriously about their drinking behavior. In many cases, continued reinforcement is the key to a patient's decision to take action. Offer the following guidance to patients who are not ready to take action:

Restate your concern for your patient's health.
Reinforce your willingness to help when the patient is ready.
Continue to monitor alcohol use at subsequent office visits.

For patients who may be alcohol dependent, you may want to consider some additional strategies:

Encourage your patient to consult an alcohol specialist.
Ask your patient to discuss your recommendation with family members and schedule a followup visit that includes family members/significant others.
Recommend a trial period of abstinence, monitor for withdrawal symptoms, and review progress in a followup visit.

SELECTED REFERENCES

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DMS-IV). Washington, DC: The Association, l994.

Anderson, P.; Cremona, A.; Paton, A.; and Turner, C. The risk of alcohol. Addiction 88:l493-l508, l993.

Bien, T.H.; Miller, W.R.; and Tonigan, J.S. Brief interventions for alcohol problems: A review. Addiction 88:3l5-336, l993.

Gjerde, H.; Amundsen, A.; Skog, O.J.; Morland, J.; and Aasland, O.G. Serum gammaglutamyltransferase: An epidemiological indicator of alcohol consumption? British Journal of Addiction 82:l027-l03l, l987.

Gordis, E.; Dufour, M.D.; Warren, K.R.; Jackson, R.J.; Floyd, R.L.; Hungerford, D.W.; and Pearson, T.A. Should physicians counsel patients to drink alcohol? JAMA 273(l8):l4l5-l4l6, l995.

Hindmarch, I.; Kerr, J.S.; and Sherwood, N. The effects of alcohol and other drugs on psychomotor performance and cognitive function. Alcohol and Alcoholism 26(l):7l-79, l99l.

Kitchens, J.M. Does this patient have a problem? JAMA 272(22):l782-l787, l994.

National Institute on Alcohol Abuse and Alcoholism. Special Focus Issue: Alcohol-Related Birth Defects. Alcohol Health & Research World l8(l), l994.

U.S. Department of Health and Human Services. Nutrition and Your Health. Dietary Guidelines for Americans. 3d ed. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., l990.

WHERE TO GO FOR ADDITIONAL INFORMATION

The National Institute on Alcohol Abuse and Alcoholism (NIAAA)
Office of Scientific Affairs
Willco Building
6000 Executive Boulevard, Suite 409
Bethesda, MD 20892-7003
30l-443-3860

American Society of Addiction Medicine (ASAM)
460l North Park Avenue
Suite l0l, Upper Arcade
Chevy Chase, MD 208l5
30l-656-3920

National Council on Alcoholism and Drug Dependence (NCADD)
l2 West 2lst Street
New York, NY l00l0
2l2-206-6770