Studies have demonstrated that screening is sensitive and that patients are willing to give honest information about their drinking to health care practitioners when appropriate methods are used. Several methods have been shown to work, including quantity-frequency interview questions and questionnaires such as the CAGE, the AUDIT, the shorter AUDIT-C, the TWEAK (for pregnant women), and others. In this Guide, the single screening question about heavy drinking days was chosen for its simplicity and because almost all people with alcohol use disorders report drinking 5 or more drinks in a day (for men) or 4 or more (for women) at least occasionally. This Guide also recommends the AUDIT (provided on page 11) as a self-administered screening tool because of its high levels of validity and reliability.
With the single interview question, screening is positive with just one heavy drinking day in the past year. Isn’t that casting a very broad net?
A common reaction to the screening question is, “Everybody’s going to meet this, at least occasionally.” A large national survey by NIAAA, however, showed that nearly three-fourths of U.S. adults never exceed the limits in the screening question. Even if patients report that they only drink heavily on rare occasions, screening provides an opportunity to educate them about safe drinking limits so that heavy drinking doesn’t become more frequent. The risk for alcohol-related problems rises with the number of heavy drinking days, and some problems, such as driving while intoxicated or trauma, can occur with a single occasion.
How effective are brief interventions?
Randomized, controlled clinical trials in a variety of populations and settings have shown that brief interventions can decrease alcohol use significantly among people who drink above the recommended limits but aren’t dependent. In several intervention trials with multiple brief contacts, for example, heavy drinkers cut an average of three to nine drinks per week, for a 13 to 34 percent net reduction in consumption. Even relatively modest reductions in drinking can have important health benefits when spread across a large number of people. Brief intervention trials have also reported significant decreases in blood pressure readings, levels of gamma-glutamyl transferase (GGT), psychosocial problems, hospital days, and hospital readmissions for alcohol-related trauma. Followup periods typically range from 6 to 24 months, although one recent study reported sustained reductions in alcohol use over 48 months. A cost-benefit analysis in this study showed that each dollar invested in brief physician intervention could reap more than fourfold savings in future health care costs. Other research shows that for alcohol-dependent patients with an alcohol-related medical illness, repeated brief interventions at approximately monthly intervals for 1 to 2 years can lead to significant reductions in or cessation of drinking.
What can I do to encourage my patients to give honest and accurate answers to the screening questions?
It’s often best to ask about alcohol consumption at the same time as other health behaviors such as smoking, diet, and exercise. Using an empathic, nonconfrontational approach can help put patients at ease. Some clinicians have found that prefacing the alcohol questions with a nonthreatening opener such as “Do you enjoy a drink now and then?” can encourage reserved patients to talk. Patients may feel that a written or computerized self-report version of the AUDIT is less confrontational as well. To improve the accuracy of estimated drinking quantities, you could ask patients to look at the “What’s a Standard Drink?” chart on page 24. Many people are surprised to learn what counts as a single standard drink, especially for beverages with a higher alcohol content such as malt liquors, fortified wines, and spirits. The chart also lists the number of standard drinks in commonly purchased beverage containers. In some situations, you may consider adding the questions “How often do you buy alcohol?” and “How much do you buy?” to help build an accurate estimate.
How can a clinic- or office-based screening system be implemented?
The best studied method, which is both easy and efficient, is to ask patients to fill out the 10-item AUDIT before seeing the doctor. This form (provided on page 11) can be added to others that patients fill out. The full AUDIT or the 3-item AUDIT-C can also be incorporated into a larger health history form. The AUDIT-C consists of the first three consumption-related items of the AUDIT; a score of 6 or more for men and 4 or more for women indicates a positive screen. Alternatively, the single-item screen in Step 1 of this Guide could be incorporated into a health history form. Screening can also be done in person by a nurse during patient check-in. (See also “Set Up Your Practice to Simplify the Process” on page 3.)
Are there any specific considerations for implementing screening in mental health settings?
Studies have demonstrated a strong relationship between alcohol use disorders and other mental disorders. Heavy drinking can cause psychiatric symptoms such as depression, anxiety, insomnia, cognitive dysfunction, and interpersonal conflict. For patients who have an independent psychiatric disorder, heavy drinking may compromise the treatment response. Thus, it is important that all mental health clinicians conduct routine screening for heavy drinking.
Less is known about the performance of screening methods or brief interventions in mental health settings than in primary care settings. Still, the single-question screener in this Guide is likely to work reasonably well, since almost everyone with an alcohol use disorder reports drinking above the recommended daily limits at least occasionally.
Mental health clinicians may need to conduct a more thorough assessment to determine whether an alcohol use disorder is present and how it might be interacting with other mental or substance use disorders. The recommended limits for drinking may need to be lowered depending on coexisting problems and prescribed medications.
Similarly, a more extended behavioral intervention may be needed to address coexisting alcohol use disorders, either delivered as part of mental health treatment or through referral to an addiction specialist.
When should I recommend abstaining versus cutting down?
Certain conditions warrant advice to abstain as opposed to cutting down. These include when drinkers:
If patients with alcohol use disorders are unwilling to commit to abstinence, they may be willing to cut down on their drinking. This should be encouraged while noting that abstinence, the safest strategy, has a greater chance of long-term success.
For heavy drinkers who don’t have an alcohol use disorder, use professional judgment to determine whether cutting down or abstaining is more appropriate, based on factors such as these:
It may be useful to discuss different options, such as cutting down to recommended limits or abstaining completely for perhaps a month or two, then reconsidering future drinking. If cutting down is the initial strategy but the patient is unable to stay within limits, recommend abstinence.
How do I factor the potential benefits of moderate drinking into my advice to patients who drink rarely or not at all?
Moderate consumption of alcohol (defined by U.S. Dietary Guidelines as up to two drinks a day for men and one for women) has been associated with a reduced risk of coronary heart disease. Achieving a balance between the risks and benefits of alcohol consumption remains difficult, however, because each person has a different susceptibility to diseases potentially caused or prevented by alcohol. The advice you would give to a young person with a family history of alcoholism, for example, would differ from the advice you would give to a middle-aged patient with a family history of premature heart disease. Most experts don’t recommend advising nondrinking patients to begin drinking to reduce their cardiovascular risk. However, if a patient is considering this, discuss safe drinking limits and ways to avoid alcohol-induced harm.
Why are the recommended drinking limits lower for some patients?
The limits are lower for women because they have proportionally less body water than men do and thus achieve higher blood alcohol concentrations after drinking the same amount of alcohol. Older adults also have less lean body mass and greater sensitivity to alcohol’s effects. In addition, there are many clinical situations where abstinence or lower limits are indicated, because of a greater risk of harm associated with drinking. Examples include women who are or may become pregnant, patients taking medications that may interact with alcohol, young people with a family history of alcohol dependence, and patients with physical or psychiatric conditions that are caused by or exacerbated by alcohol.
Some of my patients who drink heavily believe that this is normal. What percentage of people drink at, above, or below moderate levels?
About 7 in 10 adults abstain, drink rarely, or drink within the daily and weekly limits noted in Step 1.3 The rest exceed the daily limits, the weekly limits, or both. The “U.S. Adult Drinking Patterns” chart on page 25 shows the percentage of drinkers in each category, as well as the prevalence of alcohol use disorders in each group. Because heavy drinkers often believe that most people drink as much and as often as they do, providing normative data about U.S. drinking patterns and related risks can provide a helpful reality check. In particular, those who believe that it’s fine to drink moderately during the week and heavily on the weekends need to know that they have a higher chance not only of immediate alcohol-related injuries, but also of developing alcohol use disorders and other alcohol-related medical and psychiatric disorders.
Some of my patients who are pregnant don’t see any harm in having an occasional drink. What’s the latest advice?
Some pregnant women may not be aware of the risks involved with drinking, while others may drink before they realize they’re pregnant. A recent survey estimates that 1 in 10 pregnant women in the United States drinks alcohol. In addition, among sexually active women who aren’t using birth control, more than half drink and 12.4 percent report binge drinking, placing them at particularly high risk for an alcohol-exposed pregnancy.
Each year, an estimated 2,000 to 8,000 infants are born with fetal alcohol syndrome in the United States, and many thousands more are born with some degree of alcohol-related effects. These problems range from mild learning and behavioral problems to growth deficiencies to severe mental and physical impairment. Together, these adverse effects comprise fetal alcohol spectrum disorders.
Because it isn’t known whether any amount of alcohol is safe during pregnancy, the Surgeon General recently reissued an advisory that urges women who are or may become pregnant to abstain from drinking alcohol. The advisory also recommends that pregnant women who have already consumed alcohol stop to minimize further risks and that health care professionals inquire routinely about alcohol consumption by women of childbearing age.
What if a patient reports some symptoms of an alcohol use disorder but not enough to qualify for a diagnosis?
Alcohol use disorders are similar to other medical disorders such as hypertension, diabetes, or depression in having “gray zones” of diagnosis. For example, a patient might report a single arrest for driving while intoxicated and no other symptoms. Since a diagnosis of alcohol abuse requires repetitive problems, that diagnosis couldn’t be made. Similarly, a patient might report one or two symptoms of alcohol dependence, but three are needed to qualify for a diagnosis.
Any symptom of abuse or dependence is a cause for concern and should be addressed, since an alcohol use disorder may be present or developing. These patients may be more successful with abstaining as opposed to cutting down to recommended limits. Closer followup is indicated, as well as reconsidering the diagnosis as more information becomes available.
Should I recommend any particular behavioral therapy for patients with alcohol use disorders?
Several types of behavioral therapy are used to treat alcohol use disorders. Cognitive-behavioral therapy, motivational enhancement, and 12-step facilitation (e.g., the Minnesota Model) have all been shown to be effective. A combination of approaches has been shown to be effective as well (see the next question). Getting help in itself appears to be more important than the particular approach used, provided it avoids heavy confrontation and incorporates the basic elements of empathy, motivational support, and an explicit focus on changing drinking behavior. For patients receiving medications for alcohol dependence, brief medical counseling sessions delivered by a nurse or physician have been shown to be effective without additional behavioral treatment by a specialist (see page 17).
As a mental health clinician, how can I learn more about specialized alcohol counseling?
For a recent major clinical trial, NIAAA grantees designed state-of-the-art individual outpatient psychotherapy for alcohol dependence. Called a combined behavioral intervention (CBI), it integrates cognitive-behavioral therapy, motivational enhancement, 12-step approaches, couples therapy, and community reinforcement— all treatments shown in earlier studies to be beneficial. Behavioral specialists deliver CBI in up to 20 sessions of 50 minutes (the median in the trial was 10 sessions). The treatment has four phases: building motivation for change, developing an individual plan for treatment and change, completing individualized skill-training modules, and performing maintenance checkups. Findings from the trial show that this specialized alcohol counseling or the medication naltrexone was effective, when coupled with structured medical management. The CBI strategy and supporting materials are provided in the 328-page Combined Behavioral Intervention Manual from Project COMBINE; to order for a small fee, visit www.niaaa.nih.gov/guide.
How should alcohol withdrawal be managed?
Alcohol withdrawal results when a person who is alcohol dependent suddenly stops drinking. Symptoms usually start within a few hours and consist of tremors, sweating, elevated pulse and blood pressure, nausea, insomnia, and anxiety. Generalized seizures may also occur. A second syndrome, alcohol withdrawal delirium, sometimes follows. Beginning after 1 to 3 days and lasting 2 to 10 days, it consists of an altered sensorium, disorientation, poor short-term memory, altered sleep-wake cycle, and hallucinations. Management typically consists of administering thiamine and benzodiazepines, sometimes together with anticonvulsants, beta adrenergic blockers, or antipsychotics as indicated. Mild withdrawal can be managed successfully in the outpatient setting, but more complicated or severe cases require hospitalization. (Consult references 37 and 38 on page 34 for additional information.)
Are laboratory tests available to screen for or monitor alcohol problems?
For screening purposes in primary care settings, interviews and questionnaires have greater sensitivity and specificity than blood tests for biochemical markers, which identify only about 10 to 30 percent of heavy drinkers. Nevertheless, biochemical markers may be useful when heavy drinking is suspected but the patient denies it. The most sensitive and widely available test for this purpose is the serum gamma-glutamyl transferase (GGT) assay. It isn’t very specific, however, so reasons for GGT elevation other than excessive alcohol use need to be eliminated. If elevated at baseline, GGT and other transaminases may also be helpful in monitoring progress and identifying relapse, and serial values can provide valuable feedback to patients after an intervention. Other blood tests include the mean corpuscular volume (MCV) of red blood cells, which is often elevated in people with alcohol dependence, and the carbohydrate-deficient transferrin (CDT) assay. The CDT assay is about as sensitive as the GGT and has the advantage of not being affected by liver disease.
If I refer a patient for alcohol treatment, what are the chances for recovery?
A review of seven large studies of alcoholism treatment found that about one-third of patients either were abstinent or drank moderately without negative consequences or dependence in the year following treatment. Although the other two-thirds had some periods of heavy drinking, on average they reduced consumption and alcohol-related problems by more than half. These reductions appear to last at least 3 years. This substantial improvement in patients who do not attain complete abstinence or problem-free reduced drinking is often overlooked. These patients may require further treatment, and their chances of benefiting the next time don’t appear to be influenced significantly by having had prior treatments. As is true for other medical disorders, some patients have more severe forms of alcohol dependence that may require long-term management.
What can I do to help patients who struggle to remain abstinent or who relapse?
Changing drinking behavior is a challenge, especially for those who are alcohol dependent. The first 12 months of abstinence are especially difficult, and relapse is most common during this time. If patients do relapse, recognize that they have a chronic disorder that requires continuing care, just like asthma, hypertension, or diabetes. Recurrence of symptoms is common and similar across each of these disorders, perhaps because they require the patient to change health behaviors to maintain gains. The most important principle is to stay engaged with the patient and to maintain optimism about eventual improvement. Most people with alcohol dependence who continue to work at recovery eventually achieve partial to full remission of symptoms, and often do so without specialized behavioral treatment. For patients who struggle to abstain or who relapse:
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