Case 1: Darryl

 

Picture of Doctor Barbara Turner

 

Hello.  I’m Dr. Barbara Turner.  I am a professor of medicine at the University of Pennsylvania and I will be taking you through this case.

STEP 1: Ask About Alcohol Use.

Darryl is in his 30s and returns to your practice today for a routine annual physical.  He is overweight and has a history of high cholesterol and is taking a lipid-lowering drug.  His blood pressure is slightly elevated. Take a look at how his visit begins. It is a good idea to review the algorithm below before proceeding.

Click here to review the Step 1 algorithm

Click here to play a recording of the interview

Click here to read a text transcript of the interview

 

You’ve learned that Darryl drinks alcohol. Now it’s time to start the screening process. You may want to refer to Step 1 in the Guide for alcohol screening.

Using the Guide (page 4), what would you say to Darryl next?

Click here for A: Beer is less worrisome, but it’s still a problem

Click here for B: How many days a week do you have a drink?

Click here for C: How many times in the past year have you had 4 or more drinks in a day?

Click here for D: How many times in the past year have you had 5 or more drinks in a day?

Now let’s continue with the case to see how Dr. Wilson manages the interview.

Click here to play a recording of the interview

Click here to read a text transcript of the interview

Click here to review the Step 1 algorithm

We learned a lot about Darryl during this simple screening process. We now know that he is drinking too heavily – on 4 days a week, he’s having about 7 drinks per day. His weekly average is about 28 drinks.

The purpose of the screening question is to open up a dialog with the patient about alcohol use and to stimulate the patient to think about his or her drinking. Some physicians may be concerned that the single screening question is too sensitive. That is, that too many non-problem drinkers will occasionally exceed daily limits. In fact, about 70% of U.S. adults report not exceeding those limits within the past year. And recent research supports the validity of using this question to identify heavy drinkers.

Nearly 3 in 10 U.S. adults do drink too heavily at times, and Darryl is one of them. Research shows that men who have more than 4 drinks on any given day, or more than 14 drinks in a typical week, are at greater risk for alcohol-related problems. Darryl clearly exceeds both of these limits.

As an aside, you may have noticed that the screening question is phrased “5 or more drinks,” which patients find easier to answer.

There’s a common misperception that heavy drinking is the norm. You can use the drinking patterns chart on page 25 of the Guide to show a patient that in reality, the majority of adults – 72% – abstain or drink within the recommended limits. Only about 16% occasionally exceed the daily, but not the weekly, limits. And only 10% exceed both the daily and weekly limits.

STEP 2: Assess for Alcohol Use Disorders.

Now let’s get back to Darryl’s case. The next step is to assess for alcohol use disorders. The goal in this step is to determine whether there is a maladaptive pattern of alcohol use, causing clinically significant impairment or distress. The following link presents a checklist of the criteria for alcohol abuse and dependence.

Click here for a checklist of the criteria for alcohol abuse and dependence.

First, just listen to the interaction between Dr. Wilson and Darryl to hear how she assesses whether the patient has an alcohol use disorder.

Click here to play a recording of the interview

Click here to read a text transcript of the interview

Dr. Wilson was able to complete her initial assessment quickly, using a nonjudgmental, matter-of-fact tone.

You may have noticed that Dr. Wilson didn’t go through every criterion in the list. In the Guide, the criteria for each disorder are listed in a likely sequence of symptoms, with questions about more serious symptoms asked later. Thus, if a patient does not endorse the first few less severe symptoms, he or she is unlikely to endorse more serious symptoms.

Although it would be ideal to ask about each symptom individually, in the reality of clinical practice, a brief assessment similar to Darryl’s will give you the information you need to make an initial diagnosis.

Based on what you heard, does Darryl meet the criteria for an alcohol use disorder?

Click here to select "No"

Click here to select "Yes"

 

STEP 3: Advise and Assist.

The next step in the process is to advise and assist the patient. You can refer to Step 3 for At-Risk Drinking (page 6 of the Guide) to review the recommended approach. Darryl’s physician should state her conclusions and recommendations clearly and then gauge his readiness to change. Let’s see how it goes.

Click here to play a recording of the interview

Click here to read a text transcript of the interview

This physician is doing a great job with Darryl. She stated her concerns about Darryl’s at-risk drinking and clearly made her recommendations. She informed him that drinking at his level has been found to increase blood pressure. Then she asked him directly whether he was willing to change his habits. Her next step depends on Darryl’s response.

Do you think that Darryl is ready to commit to change at this time?

Click here to select "No"

Click here to select "Yes"

 

Once you’ve determined that the patient is ready to commit to change, you need to help him or her set a goal, agree on a plan, and then provide educational materials as necessary. Let’s see how this physician handles it.

Click here to play a recording of the interview

Click here to read a text transcript of the interview

STEP 4: At Followup: Continue Support.

Now let’s skip ahead to Darryl’s next visit, 2 months later. The goal during this visit is to determine whether the patient has been able to meet and sustain his drinking goals and then to provide appropriate continued support based on his progress. Let’s listen to their conversation…

Click here to play a recording of the interview

Click here to read a text transcript of the interview

The primary goal at followup is to assess whether the patient has been able to meet and sustain his drinking goals and then provide appropriate continued support.

Based on what you have heard, do you think that Darryl has met and sustained his goals?

Click here to select "No"

Click here to select "Yes"

 

Now watch as the physician wraps up the visit. Because Darryl has not been able to meet his drinking goals, she will continue to provide support. The key points for discussion are:

  • Acknowledge that change is difficult.
  • Support any positive change.
  • Address barriers to change.
  • Renegotiate the goal and plan

Click here to play recording of the interview

Click here to read a text transcript of the interview

Conclusion.

STEP 1 Ask About Alcohol Use

STEP 2 Assess for Alcohol Use Disorders

STEP 3 Advise and Assist

STEP 4 At Followup: Continue Support

This case went very well for both the physician and the patient. Using the guidelines, the physician was able to quickly determine Darryl’s drinking patterns, assess him for alcohol use disorders, and provide clear recommendations and assistance. She then followed up with an assessment of his progress.

This case can serve as a model for helping patients who are at-risk drinkers. It also shows that a patient’s medical conditions – in this case Darryl’s elevated blood pressure – can be linked to at-risk drinking. Darryl’s weight gain may have also been related to his drinking.

Understanding alcohol’s effect on common clinical conditions can help the physician motivate patients to change their drinking patterns.