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:

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:


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:


Ask current drinkers about alcohol consumption:


Ask current drinkers the CAGE questions:


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


A patient may be at risk of alcohol-related problems

IF:

Men:
> l4 drinks per week or
> 4 drinks per occasion

Women:
> 7 drinks per week or
> 3 drinks per occasion

OR:


When is screening for alcohol problems appropriate?



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


Assessment procedures


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


Assessment procedures

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


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.


3. May Be Alcohol Dependent

Indicators

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

- 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:

Advise to abstain or cut down:

- evidence of alcohol dependence
- history of repeated failed attempts to cut down
- pregnant or trying to conceive
- contraindicated medical condition or medication
- drinking above recommended low-risk drinking amounts and no evidence of alcohol dependence

Agree upon a plan of action

For patients who are not alcohol dependent:

For patients with evidence of alcohol dependence:

- 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




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:

- reviewing progress to date
- commending your patient for efforts made
- reinforcing positive change
- assessing continued motivation


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

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:


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



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