Luigi R. Cardella and Luis A. Giuffra
GENERAL PRINCIPLES
Alcohol use disorders (AUDs) are commonly encountered in primary care. Although modest alcohol use has proven cardioprotective benefits, abuse of alcohol can have detrimental physical, mental, emotional, and social effects. Alcohol-related health problems are numerous, including hepatic cirrhosis, pancreatitis, hypertension, cardiomyopathy, numerous cancers, dementia, and gastrointestinal bleeding. Fetal alcohol syndrome is the number one known cause of intellectual disability. Alcohol abuse and dependence have a heavy burden on society as a whole, as alcohol has been cited in half of all homicides and traffic fatalities. Patients of all ages, races, and socioeconomic status can suffer from alcoholism, and physicians should screen patients for alcohol use and abuse in each patient encounter.
Definitions
· Alcohol abuse is defined by the Diagnostic and Statistical Manual (DSM) IV as a maladaptive pattern of use associated with one or more of the following:
o Failure to fulfill work, school, or social obligations
o Recurrent substance use in physically hazardous situations
o Recurrent legal problems related to substance use
o Continued use despite alcohol-related social or interpersonal problems
· Alcohol dependence (DSM IV) is a maladaptive pattern of use associated with three of the following seven behaviors over a 12-month interval:
o Tolerance.
o Evidence of withdrawal.
o Alcohol ingested in larger quantity than intended.
o Significant time spent obtaining or using alcohol.
o Persistent desire to cut back or discontinue alcohol use.
o Alcohol use continues despite physical and psychological distress.
o Social or occupational tasks are harmed.
· Of note, while 50% of patients with alcohol abuse will persistently have alcohol problems, only 10% will actually go on to develop dependence.
· The new DSM V combines alcohol abuse and dependence under alcohol use disorder (AUD). Anyone meeting any 2 of the 11 following criteria over the preceding 12 months may be diagnosed with AUD. The presence of 2 to 3 criteria is mild AUD, 4 to 5 moderate, and ≥6 severe.
o Alcohol is taken in larger amounts or over a longer time than intended
o Persistent desire or unsuccessful attempts to control or reduce alcohol consumption
o A significant time spent in activities to obtain alcohol, use alcohol, or recover from its effects
o Craving, urge, or strong desire to drink
o Recurrent drinking causing failure to fulfill obligations at work, school, or home
o Continued drinking in spite of recurrent or persistent social or interpersonal problems caused or exacerbated by alcohol
o Reducing or giving up important social, occupational, or recreational activities due to drinking
o Recurrent drinking when it is physically hazardous
o Continued drinking in spite of knowing that alcohol is causing or exacerbating a persistent or recurrent physical or psychological problem
o Tolerance
§ Need for increased amounts of alcohol to achieve the same effect
§ Reduced effect with continued use of the same amount of alcohol
o Withdrawal
§ Characteristic withdrawal symptoms
§ Alcohol or another substance used to avoid or relieve withdrawal symptoms
· The National Institute of Alcohol Abuse and Alcoholism defines so-called at-risk drinking as follows:
o Men, >14 drinks per week or >4 drinks per occasion
o Women, >7 drinks per week or >3 drinks per occasion
o Those who habitually drink above these levels are at risk for alcoholism and alcohol-related problems
Epidemiology
· At some point in their lifetime, over 90% of the US population has had an alcoholic drink, and 80% of all high school seniors have had a drink by graduation.
· A recent study showed the lifetime prevalence of alcohol abuse to be 17.8% and the lifetime prevalence of alcohol dependence to be 12.5%.1
· After smoking and obesity, alcoholism is the third leading cause of preventable death in the US.
· Approximately 85,000 deaths a year in the US are attributed to alcohol, and the estimated costs attributed to alcohol are $185 billion yearly.2
· Binge drinking, defined as >5 drinks in a sitting for men and >4 drinks in a sitting for women, is prevalent among teens and college students. It contributes to high levels of risky sexual behavior, drunk driving, and poor academic performance in this patient population.
· It should be noted that patients with AUDs come from all walks of life. Physicians should not refrain from asking patients about alcohol use because they do not fit the stereotype of a typical alcoholic. All patients should be screened for possible alcohol use.
Risk Factors
· Rates of alcohol abuse are higher in young males, single patients, those with lower income, and those from Native American or Caucasian descent. The prevalence of alcoholism is twice as high in men as in women.
· Studies have shown that those who begin drinking at an earlier age are much more likely to develop alcoholism than those who start after age 21.
· Recent evidence has shown that genetic factors can play a role in the development of alcoholism. Identical twins have been found to have a higher concordance of alcohol use than fraternal twins.
Associated Conditions
· AUDs are associated with numerous conditions, including depression, anxiety, and other substance use disorders.
· Patients who present with AUDs should be screened for coexisting substance abuse or psychiatric disorders.
· Data from 1998 show that 30% of smokers are alcoholics and 80% of alcoholics are smokers.3
DIAGNOSIS
· See the “Definitions” section for precise definitions of alcohol abuse/dependence and AUD.
· In this context, screening may be a more appropriate term.
· It should be noted in the definitions of alcohol abuse and dependence that the amount of alcohol consumed is not important. Although the consumption of higher amounts of alcohol may put someone at an elevated risk for an AUD, the amount itself does not diagnose someone as having a disorder.
Clinical Presentation
· As alcoholism can affect patients from all walks of life, physicians must maintain a high index of suspicion and should question patients about alcohol consumption at each encounter.
· Screening should be done with validated tests such as the CAGE or AUDIT (Alcohol Use Disorder Identification Test) questionnaires (see the “Diagnostic Testing” section).
· Physicians should be nonconfrontational and use nonjudgmental language when questioning patients about alcohol use.
· Patients frequently deny alcohol problems for a variety of reasons, including refusing to acknowledge the disease, shame or embarrassment, social stigma of being an alcoholic, and fear of being reported to employers or family members.
· Although physicians should be firm in discussing alcohol abuse with patients, they must also be empathic and should listen to what patients have to say about their disease.
· A mental status examination should be documented even if the patient is suspected to be intoxicated. However, a repeat examination is compulsory when the patient is no longer intoxicated.
· Unless patients are intoxicated at the time of examination, the physical exam is not of great help in diagnosing alcohol disorders.
· Signs of chronic alcohol use include testicular atrophy, gynecomastia, spider angiomata, enlarged spleen, and shrunken or enlarged liver.
Differential Diagnosis
Conditions which may be associated, or confused, with alcohol disorders include depression, anxiety disorder, bipolar disorder, insomnia, and dysthymic disorder.
Diagnostic Testing
· The older CAGE questionnaire is the best-studied screening test for AUDs and is presented in Table 46-1.4
o Patients who answer yes to any of the CAGE questions require further assessment and intervention. Patients who answer yes to two out of the four questions are seven times more likely to have alcohol dependencethan the general population.
o The sensitivity and specificity of two affirmative responses to the CAGE questionnaire is 77% and 79%, respectively; these values decrease for unhealthy alcohol use.5 Critics point out that it fails to identify binge drinkers and it does not distinguish current from past alcohol use. Although it may have its flaws, it remains a reasonable tool to screen patients and is quick, easy to use, and easy to remember.
· Another screening tool is the AUDIT questionnaire (Table 46-2).6–9
o Studies have shown that the AUDIT to be superior to the CAGE questionnaire in patients with active alcohol abuse or dependence.10 It has also been found to have a higher sensitivity in populations with low rates of alcohol use.
o The abbreviated three-item AUDIT-C questionnaire may also be an effective screening tool in primary care settings (Table 46-3).8,11–14
· Perhaps, easiest of all in primary care is single question screening: “How many times in the past year have you had 5 (4 for women) or more drinks containing alcohol?” One or more heavy drinking days constitutes a positive screen.8,15
· Laboratory testing does not have a prominent role in diagnosing AUDs.
o Although tests such as γ-glutamyltransferase (GGT), liver function tests, and mean corpuscular volume can be abnormal in patients with chronic alcohol use, their sensitivity does not approach 50%, and they should not be used as screening laboratories. They can be checked, however, when evaluating patients with chronic alcohol use to help manage patients.
o Blood alcohol levels may be useful in patients who appear to be intoxicated.
o Ethyl glucuronide (EtG) can be detected in various body fluids, tissue, and hair up to 80 hours after the complete elimination of alcohol from the body. This marker has a serum sensitivity of 92% and specificity of 91%.16
TABLE 46-1 CAGE Questionnaire
TABLE 46-2 Alcohol Use Disorders Identification Test
Total score ≥8 indicates hazardous and harmful alcohol use, as well as possible alcohol dependence (≥7 for women and men >65 years).Modified from Babor TF, Higgins-Biddle JC, Saunders JB, et al. AUDIT. The Alcohol Use Disorders Identification Test: Guidelines for Use in Primary Care, 2nd ed. Geneva, Switzerland: World Health Organization Department of Mental Health and Substance Dependence; 2001.
TABLE 46-3 AUDIT-C Questionnaire
Scoring: ≥4 points for men or ≥3 points for women constitutes a positive screen.
TREATMENT
· The first step in treating patients with alcohol abuse and dependence is making the patient aware that they have a disease. This should be done in an empathic and nonjudgmental manner.
· Patients must be willing to change. The physician must listen to the patient and assess their readiness and willingness to change.
· Involving family members and friends is a good strategy to ensure that the patient has a strong support network when they leave the office. This should not be done without approval of the patient.
· Brief interventions have been shown to reduce alcohol consumption.17
· Physicians should remember the Five As when conducting a brief intervention8,18:
o Ask: Ask about alcohol use (see the “Diagnosis” section).
o Advise: Advise patients that their drinking puts them at high risk for alcoholism and alcohol-related problems. The specific effects of high-risk drinking should be explained.
o Assess: Assess the patient’s readiness to change and advise accordingly (see below).
o Assist: Provide specific self-help information.
o Arrange: Arrange follow-up.
· Although not without critics, the Prochaska transtheoretical model of stages of change is relatively well known to many clinicians, and may serve to provide some very general guidelines regarding how much and what type of effort to invest.19,20 To some extent, the dividing lines between stages are arbitrary, individuals may not progress in a sequential manner between the stages, and the stages may not be mutually exclusive.
o Precontemplation stage: The person is unaware or underaware of the problem and has no intention of changing the behavior. The physician’s role is to advise the patient about the need to reduce alcohol consumption and the hazards of drinking. The counseling can be quite brief, just a minute or two, but should be repeated at every visit.
o Contemplation stage: The patient is aware that a problem exists but is not yet ready to make a full commitment to take action. This stage may last for long periods of time. The physician’s role is to continue stressing the hazards of drinking and the benefits of behavior change. How to choose a goal can also be discussed.
o Preparation stage: The patient intends to take action in the next few months; this may be a brief stage. The physician should increase the intensity and specificity of counseling and help the patient choose a goal and give advice and encouragement. When a patient is really ready to commit to change, this should be the main focus of the office visit.
o Action stage: This is the most visible stage in which the addictive behavior is altered (for 1 day to 6 months). Review specific advice and continue to provide encouragement.
o Maintenance stage: The patient maintains the change and works to prevent relapse. This stage extends beyond 6 months and may last a lifetime. The physician should provide follow-up and continued encouragement.
o Relapse stage: This can also be termed recycle because the patient again moves through the cycle and may achieve long-term success on subsequent cycles. The physician should assist the patient in renewing the process.
· Patients should be encouraged to avoid bars and social gatherings which may strongly encourage the patient to drink, and to seek help when relapse is near. Patients must learn how to cope with stress and anxiety once they abstain from alcohol.
· Constant follow-up is an integral part of treating patients. Unfortunately, <25% of patients will stay abstinent after a year. Given this high relapse rate, physicians and patients may find treatment difficult and frustrating. Nevertheless, continued and consistent interaction with the patient is key to successful recovery.
Medications
· Disulfiram, an inhibitor of the enzyme aldehyde dehydrogenase, has been used to treat patients with AUDs once they become abstinent. Consumption of alcohol results in the accumulation of acetaldehyde and the development of symptoms including tachycardia, dyspnea, flushing, nausea, vomiting, headache, hypotension, and dizziness. Data supporting the use of disulfiram is equivocal.21,22 It may be more effective when compliance is monitored.8
· Naltrexone, an opiate antagonist, has been used in alcoholics to decrease use. Several reviews have generally supported the use of naltrexone.8,23–27 The COMBINE study found better outcomes with the addition of naltrexone to medical management.28
· Acamprosate is a structural analog of γ-amino butyric acid but its mechanism of action is not fully understood. Reviews also support its use.8,23,25,27,29 However, in the COMBINE study, acamprosate was not more effective than placebo.27,28
· Benzodiazepines, β-blockers, clonidine, and anticonvulsants have all been used to treat alcohol withdrawal.
Other Nonpharmacologic Therapies
· Brief interventions are 10 to 15 minutes patient encounters where counseling, feedback, goal setting, and follow-up are discussed. Numerous trials have shown these encounters to be effective in reducing drinking and increasing abstinence.17
· The COMBINE study also demonstrated that cognitive behavior therapy was a helpful addition to medical management.28
· Alcoholics Anonymous and other support groups are effective community resources for patients. Physicians should have information about these resources in their office for patients who are willing to use them.
Lifestyle/Risk Modification
· Patients should be educated that abstinence is the most effective method of preventing relapse. Patients should adjust their lifestyle as much as possible to optimize their chance of remaining abstinent.
· This includes avoiding bars and other social gatherings where the pressure to drink may be significant.
· In addition, patients should be aware of relapse triggers and should have numbers to call if they are in a situation where they may falter.
· Patients with AUDs are prone to poor nutrition and may benefit from vitamin supplementation, especially folic acid.
· Patients with alcohol abuse and dependence should be warned against driving and operating machinery when intoxicated.
SPECIAL CONSIDERATIONS
Patients who are withdrawing from alcohol, have delirium tremens or hallucinations, or have significant psychiatric comorbidity should be considered for inpatient treatment. Detailed discussion of these disorders is beyond the scope of this chapter.
COMPLICATIONS
· Patients who continue to abuse alcohol are predisposed to numerous health conditions. These include cirrhosis, dementia, Wernicke-Korsakoff syndrome, heart disease, malnutrition, pancreatitis, and numerous cancers.
· Women should especially be cautious when pregnant, as even small amounts of alcohol use have been shown to have negative effects on the growing fetus.
REFERRAL
Referrals to a psychiatrist can be helpful in patients with comorbid psychiatric disease such as depression or bipolar disorder.
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