Case 4: Ed

 

Doctor Mark Willenbring

 

Hello. I’m Dr. Mark Willenbring. I am an addiction psychiatrist at the National Institutes of Health and I will be taking you through this case.

This case takes place in the hospital, where Monday morning rounds are about to begin. Let’s join the case as the resident briefs the attending physician about Ed Johnson, a 57-year-old patient who was admitted 3 days prior.

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STEP 1: Ask About Alcohol Use.

This patient presents with a situation common in advanced alcohol dependence. Ed’s medically compromised condition is a direct result of his chronic heavy drinking.

Alcohol use contributes to a range of acute and chronic health issues, including trauma, liver disease, cancer, and cardiovascular disease. Chronic Hepatitis C infection is particularly troubling in Ed’s case, as we know that heavy drinking rapidly accelerates liver fibrosis and cirrhosis.

Medical management of chronic alcohol dependence can seem frustrating. It is important to remember that his drinking is a chronic disease, not unlike other chronic illnesses. In this case, Ed will need treatment and support over the course of months to years. The good news is that he is more likely to respond than many physicians think.

Now let’s watch and see how the case progresses.

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STEP 3: Advise and Assist.

Since it’s already clear that Ed is a heavy drinker, Dr. Wong did not have to ask the screening question. However, he did obtain quantity frequency information as part of his assessment.

Click here to review the Step 1 algorithm

This will provide a baseline value that can be used to measure progress over time. He also inferred a diagnosis of dependence based on Ed’s very heavy drinking, his medical complications, and his prior alcohol treatment history.

When Dr. Wong asked Ed whether he was willing to consider abstaining, Ed said he’d rather just cut back. How would you respond? There are three possible answers. Listen to each choice, and then select the best response.

Click here to play a recording of Choice A

Click here to play a recording of Choice B

Click here to play a recording of Choice C

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Which scenario do you think provides the best answer?

Click here for Choice A

Click here for Choice B

Click here for Choice C

During the next step – Advise and Assist – the physician’s role is to help Ed set and work toward achieving an appropriate goal.

The objectives for this step include:

  • State your conclusion and recommendations clearly
  • Negotiate a drinking goal
  • Consider evaluation by an addiction specialist or recommending a mutual help group
  • Arrange followup appointments, including medication management
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

Although the physician wasn’t able to work through all of the recommendations and Ed is far from committed to quitting, his prognosis may be better than you think. Many people stop drinking after a wake-up call like Ed’s. If you engage them through their current medical concerns, and keep talking to them about their drinking over time, many, if not most such patients, will eventually stop drinking.

It’s important to get quantitative information about the patient’s drinking at every visit so you can track progress towards their goal. For a chronic heavy drinker like Ed, this physician may use the number of heavy drinking days in the last week or month. He would work on incremental change in the same way as you would with a noncompliant patient with diabetes. It will take time, but the important thing is to stay engaged not ignore the drinking.

STEP 4: At Followup: Continue Support.

Now let’s return to the case. Ed has just arrived at his follow-up appointment in Dr. Wong’s office one month following his hospital stay. During this step, the physician will document alcohol use, review the patient’s goals, and provide continued support. Some followup suggestions are to acknowledge that change is difficult, support efforts to cut down or abstain, address coexisting disorders, and address barriers to reaching the goal.

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

This physician did a good job talking with Ed about what he has done to reduce his drinking and discussing strategies that can help. Importantly, he asked about and addressed barriers to change. In this case, Ed felt that alcohol helped him to relax and that he’d need to find new activities.

Autonomy is very important to patients like Ed. Dr. Wong emphasized that abstinence is the best recommendation and medical approach, but did it in a non-judgmental way. This allowed Ed to work out his own approach to quitting. Many patients like Ed don’t trust physicians and may get angry if they sense too much pressure. Simply providing support for continued improvement may prove successful in the long run.

It’s important to remember that you can’t successfully treat alcohol dependence in one visit. The process takes place over time and it may take several months or even years with a patient like Ed. Don’t expect things to go perfectly. These patients may have relapses on and off for years, not unlike people who suffer from other chronic illnesses. The important thing is to provide continued support and encouragement.

Recall the four steps in the process – Ask About Alcohol Use, Assess for Alcohol Use Disorders, Advise and Assist, and Followup with Continued Support. By following these guidelines, you will be able to work with even the most difficult cases.