Case 2: Heather

 

Doctor Louis Baxter

 

Hello – I’m Dr. Louis Baxter. I’m the president elect of the American Society of Addiction Medicine. I will be going through this case with you.

STEP 1: Ask About Alcohol Use.

This patient is named “Heather,” and she is a 21-year-old college student who presents at the student health clinic with a sore wrist. This is her first visit to the clinic and she has no health history on file. Let’s take a look at how her visit begins.

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

The nurse did a nice job with Step 1 of the screening process. Once it became clear that Heather’s injury was associated with drinking, the nurse was able to collect – in a short period of time – a fairly complete picture of Heather’s drinking patterns.

Recall that the limits for women are no more than 3 drinks in a day and no more than 7 drinks per week. Heather has at least 1 heavy drinking day plus 2 or 3 additional drinking days every week, with an average of 22 drinks per week.

Because of Heather’s repeated heavy drinking, she can be easily classified as an “At-Risk Drinker.”

Using the recommended approach, what would you do next?

Click here for A: Assess for at-risk drinking

Click here for B: Assess for alcohol use disorders

Click here for C: Assess readiness to commit to change

Click here for D: Recommend abstinence

STEP 2: Assess for Alcohol Use Disorders.

You can determine whether your patient has alcohol abuse or dependence by answering the questions at the following link.

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

As you view the next video, listen carefully as information relevant to these criteria is obtained.

Click here to play a recording of the interview

Click here to read a text transcript of the interview

As you listened to Dr. Moore conducting her evaluation, you probably noticed that she tailored her questions to Heather’s age group and circumstances. Also, recall that the diagnostic criteria are listed in order of a likely progression of symptoms. Although you may choose to go through all of the symptoms on the list, you can often gather enough information to make an initial determination before you ask them all. The following link reviews the identified symptoms.

Click here to review the identified symptoms

Based on what you’ve heard and observed, does Heather 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 is to advise and assist the patient. Refer to Step 3 for at-risk drinking in the Guide to review the recommended approach. During this step, Dr. Moore will state her conclusions and recommendations for Heather clearly, encourage reflection, discuss barriers to change, gauge readiness to change, provide educational materials, and reaffirm Heather's willingness to change.

Watch as she adapts the tools in the Guide to gauge readiness in a dynamic way, while addressing barriers to change. This is likely the physician’s only opportunity to see Heather, so she needs to use her best judgment to provide Heather with appropriate support. Young people like Heather may not endorse a specific goal, but may be more willing to change than it seems. 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

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

As you see patients like Heather who are unwilling to commit to change, don’t be discouraged. Young people in particular may not be willing to endorse a specific goal, but may be more willing to change than it appears. Your advice may prompt a change in the patient’s thinking, which is a positive impact in itself and may have a major long-term effect. With continued reinforcement from physicians, family, and friends, your patient may think about what you have said and decide to take action at a later time. At the very least, your intervention will have the effect of raising the patient’s awareness of drinking and its consequences.

Dr. Moore and her nurse did a nice job assessing Heather with empathy and a non-judgmental tone. By tailoring their questions to Heather’s age and situation, they were able to ask her about alcohol use, assess her for alcohol use disorders, and provide clear recommendations for change.

Because of the clinic setting, it’s hard to predict whether they will have a chance to provide the recommended follow-up assistance and support. However, Dr. Moore made it clear that Heather could return if she wanted help with her drinking.