Clinician's Guide Tutorial

 

Picture of first screen of the Clinician's Guide Tutorial

 

Clinician’s Guide Tutorial

This tutorial will take you through the four-step process in the NIAAA Clinician’s Guide. When you get to steps 3 and 4, note there are two options – one for at-risk drinking and one for alcohol use disorders.

Step 1: Ask About Alcohol Use.

The first step is to ask about alcohol use. We recommend starting by asking “Do you sometimes drink beer, wine, or other alcoholic beverages?” The question is phrased this way because many patients don’t consider beer or wine to be alcoholic beverages.

If the patient answers “No,” then screening is complete.

If the patient answers “Yes,” the next step is to ask about heavy drinking days in the past year.

The quantities in the screening question come from epidemiological research. A nationwide survey of 43,000 US adults shows an increased risk for alcohol use disorders in men who have 5 or more drinks in a day and in women who have 4 or more drinks in a day. The more drinks in a day, and the more often a person has a heavy drinking day, the more likely it is that he or she will have an alcohol use disorder.

We recommend asking about the past year so you can detect both frequent and infrequent heavy drinkers. This gives you the opportunity to educate the occasional heavy drinkers about limits. In a recent study, this screening question was found to be as sensitive and specific as other screening methods.

A note about delivery -- you can minimize a patient’s defensiveness if you embed this question among ones that you ask about other health habits, such as smoking, diet, and exercise.

When you ask the screening question, it may be useful to show patients the standard drinks chart in the Guide. In the U.S., a “standard drink” contains about .6 fluid ounces (or 14 grams) of absolute ethanol. The Guide shows a set of standard drink equivalents as well as the number of standard drinks in commonly sold containers. Both can help your patients to make accurate estimates.

If patients don’t report any heavy drinking days, then advise them to stay within the maximum drinking limits that we recommend, based on epidemiological research.

The limits are: for healthy men up to age 65, no more than 4 drinks in a day and 14 per week, and for healthy women and men over 65, no more than 3 drinks in a day and 7 per week.

For some patients, it’s important to recommend lower limits or abstinence. This would include women who are--or may become—pregnant and should abstain. It also includes patients who have medical conditions made worse by drinking, or who take medications that interact with alcohol. If you‘d like a patient publication about this, see the document called “Harmful Interactions” on the NIAAA Web site.

If the patient reports one or more heavy drinking days in the past year, then screening is positive. Or, if you choose to use the AUDIT – a written self-report provided in the Guide – then a positive score is 8 or more for men or 4 or more for women.

In either case, the next step is to find out the weekly drinking pattern. Ask first about the average number of drinking days per week, then about the number of drinks on a typical drinking day, and multiply the two responses. In the question about drinks per day, we recommend using the word “typical” because it gives more useful information and doesn’t require patients to calculate an average.

If your patient exceeds the daily or weekly limits—or both—then he or she is at least an at-risk drinker and may have an alcohol use disorder.

To help you with documentation, NIAAA provides progress note templates on the NIAAA Web site.

Step 2: Assess for Alcohol Use Disorders.

An alcohol use disorder is characterized by a maladaptive drinking pattern that causes clinically significant impairment or distress.

In DSM-IV, there are two alcohol use disorders: abuse and dependence. We’ve adapted the criteria for both in two lists that you’ll find in the Guide.

With some patients, you’ll learn whether or not they meet the criteria in the natural course of a conversation. With others, you will need to ask for the information more directly.

For a diagnosis of alcohol abuse, drinking must repeatedly cause or contribute to one or more of the symptoms in the past 12 months.  Criteria for alcohol abuse include:

  • Risk of bodily harm
  • Relationship trouble
  • Role failure
  • Run-ins with the law

Most abuse diagnoses are met through the first criterion on “risk of bodily harm”-- principally through drinking and driving.

Regardless of whether or not the patient has alcohol abuse, the next step is to assess for symptoms of dependence.

The dependence criteria include:

  • Not been able to stick to drinking limits
  • Not been able to cut down or stop
  • Shown tolerance
  • Shown signs of withdrawal
  • Kept drinking despite problems
  • Spent a lot of time drinking
  • Spent less time on other matters

For a diagnosis of dependence, the patient must meet three or more of these seven criteria in the past 12 months.

If the patient does not meet criteria for either diagnosis, then he or she should be classified an “At-Risk Drinker.”

If a patient meets criteria for abuse, dependence, or both, then he or she has an alcohol use disorder. You can estimate the overall severity of the disorder by totaling the number of criteria the patient has met for both abuse and dependence. For example, he or she might meet 2 criteria for abuse and 4 for dependence, for a total of 6 out of 11 possible. The higher the number, the greater the dysfunction and disability. This sense of scale can be helpful when you develop a treatment plan.

From here, we’ll move to Steps 3 and 4. Note that we have two sets of these steps – one for at-risk drinkers and one for patients with alcohol use disorders.

Step 3 for At Risk Drinkers: Advise and Assist

Step 3 for at-risk drinkers is to “Advise and Assist.”  State your conclusion and recommendations clearly. Not doing so is one of the most common mistakes physicians make.  You might say something like “I strongly recommend that you cut down or quit.”  Also, when it’s appropriate, link the patient’s heavy drinking with his or her symptoms and lab results.  When delivered in a nonjudgmental way, this information can enhance your patient’s motivation to change.

Then, gauge the patient’s readiness to change.  You might ask “Are you willing to consider making changes in your drinking?”

If the patient is not ready to change, don’t be discouraged.  Ambivalence is common.  Your advice has likely prompted a change in his or her thinking, which is positive in itself.  If you stay engaged with the patient on this topic, he or she may decide to take action at a later time.

For now, restate your concern about the patient’s health, and do this in a matter-of-fact way. You might also ask about the major barriers to change and how they might be overcome.

Finally, reaffirm your willingness to help when he or she is ready and revisit this issue at the next appointment.

If your patient is willing to change, the next step is to help set a goal to cut down or quit.  Some conditions, like pregnancy, always warrant advice to abstain. Others will depend on your professional judgment as to whether cutting back or quitting is the best advice. For some guidance, see the “Frequently Asked Questions” section of the Guide.

Next, agree on a plan, including how the patient will track his or her drinking and other specific steps to take. It can be helpful to provide blank calendars, standard drink charts, and tips for cutting down or quitting, all available on the NIAAA Web site.

Step 4 for At Risk Drinkers: Advise and Assist.

The final step for “At-Risk Drinkers” is to continue your support at follow up. At each visit, record the quantity and frequency of the patient’s drinking. This way you can track progress over time, and see how it measures up to the drinking goals. Remember the progress notes offered on the NIAAA Web site can facilitate this process.

If the patient was not able to meet and sustain the drinking goal, then acknowledge that change is difficult and support any positive changes that did occur. The patient is no doubt facing some barriers to change; help him or her to identify those barriers and discuss ways to overcome them. Then restate your concern about the health effects of heavy drinking, and renegotiate the drinking goal and plan.

For some patients who haven’t been able to cut down, you may recommend a trial of abstinence. For others you might try recruiting significant others to provide additional support, with the patient’s permission.

Over time, if the patient is unable to either cut down or quit, then reassess the diagnosis. He or she may have alcohol dependence that was not evident earlier on.  If appropriate, consider obtaining a consultation. And if the diagnosis has changed to alcohol dependence, see Steps 3 and 4 for alcohol use disorders.

If the patient was able to meet and sustain the drinking goal, then give positive feedback and reinforce the importance of maintaining that change.  Some patients who initially choose a period of abstinence may now wish to try lower risk drinking. If so, be sure to agree on specific guidelines.  Finally, encourage the patient to return if he or she is unable to stick to the drinking goal, and rescreen the patient at least annually.

Step 3 for Alcohol Use Disorders: Advise and Assist.

We pick up at Step 3 for patients with alcohol use disorders.  Once again, clearly state your conclusion and recommendations. Relate them to the patient’s concerns and medical findings, if present.

For many physicians, presenting this diagnosis can feel uncomfortable. It’s important to use language that is least likely to generate defensiveness on the part of the patient and to avoid stigmatizing terms, such as abuse and alcoholic.

Here’s one example of a clearly stated conclusion and recommendation.  You might say: “There are indications that you have an alcohol use disorder. I strongly recommend that you quit drinking and I’m willing to help.”

It’s important to assess readiness to change in patients with alcohol use disorders, just as it is with at-risk drinkers.

If the patient is not willing to change, then restate your concern, ask him or her to weigh the pros and cons of drinking at their current level, address barriers to change, and reaffirm that you’re available to help when he or she is ready.

If the patient is willing to make a change, then negotiate a drinking goal.  Abstinence is the safest course for most patients with alcohol use disorders. Those with milder forms who are unwilling to abstain may be successful at cutting down, but they are at higher risk for relapse.

If you would like to refer the patient to an addiction specialist, see the Guide for tips on finding treatment resources. In addition, I recommend that most patients try a mutual-help group such as Alcoholics Anonymous, stressing that they may need to attend several different meetings to find one that’s comfortable for them.

For patients who have dependence, consider whether you need to provide treatment for withdrawal.  Refer to standard medical textbooks for information about treating withdrawal.

Next, consider prescribing a medication for the alcohol dependence itself. Research confirms that these medications can reduce the risk of relapse in early recovery by 20% to 40%.  These medications are not prone to abuse, so they don’t pose a conflict with other support strategies that emphasize abstinence.

For the medications to be most effective, it’s important to provide some ongoing monitoring and support, just as you do for patients taking medications for diabetes, asthma, and other chronic illnesses.

In a major clinical trial called the COMBINE Study, physicians and nurses in outpatient settings gave brief behavioral support sessions to patients who took medications for alcohol dependence. The study found that this approach was as effective as specialized alcohol counseling.

To help you start a similar program in your practice, we developed a set of easy-to-use templates that serve as both interview guides and progress notes for brief support sessions. You can find the templates in the Guide or on the NIAAA Web site.

Step 4 for Alcohol Use Disorders: At Followup: Continue Support.

The next step is following up and providing continuing support. At each visit, document the quantity and frequency of your patient’s drinking.  This quantitative indicator can then be used to review progress toward the patient’s goals.

If the patient has not been successful in meeting and sustaining the drinking goal, acknowledge that change is difficult and support any effort to cut down or abstain, while making it clear that abstinence is your recommendation.  Relate drinking to physical, psychological, and social problems as appropriate.

If you haven’t already taken these measures, periodically consider whether to refer the patient to an addiction specialist, recommend a mutual-help group, engage significant others in providing support, or prescribe a medication.

Finally, regardless of the progress on the patient’s drinking goal, address any coexisting medical and psychiatric disorders as needed.

The most important thing 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, often without specialized behavioral treatment.

If the patient was able to meet and sustain the drinking goal, then reinforce and support continued adherence to the treatment plan.

The risk of relapse to alcohol dependence is very high in the first 6 to 12 months after initiating abstinence, and gradually diminishes over several years. If medications have been prescribed, maintain them for at least 3 months.  Although an optimal treatment duration has not been established, it’s reasonable to continue treatment for a year or longer.  After patients discontinue medications, follow them more closely for the first few weeks and reinstate pharmacotherapy if relapse occurs.

Since many heavy drinkers are also heavy smokers, it is important to treat nicotine dependence as well. Some evidence suggests that quitting smoking at the same time as quitting drinking may lead to worse drinking outcomes.  Therefore, it may be best to start treatment for nicotine dependence after the patient reaches the drinking goal.

This concludes Step 4 for patients with alcohol use disorders.