Helping PatientsWho DrinkTooMuch

A CLINICIANS GUIDE

2005Edition

U.S.DEPARTMENTOFHEALTH & HUMANSERVICES NationalInstitutesofHealth NationalInstituteonAlcoholAbuseandAlcoholism

TableofContents
Introduction ...............................................1 Changesinthe2005CliniciansGuide .......................... 2
BeforeYouBegin ............................................ 3
HowtoScreenandConductaBriefIntervention
Step1: AskAboutAlcoholUse ............................... 4
Step2: AssessforAlcoholUseDisorders........................ 5
Step3: AdviseandAssist
ForAtRiskDrinking ................................ 6
ForAlcoholUseDisorders ............................ 7
Step4: AtFollowup:ContinueSupport
ForAtRiskDrinking ................................ 6
ForAlcoholUseDisorders ............................ 7

Appendix
ScreeningSupportMaterials ScreeningInstrument:TheAUDIT ........................... 10
WhatIsaStandardDrink? .................................. 13
AssessmentSupportMaterials AlcoholAbuse ............................................ 14
AlcoholDependence ....................................... 15
BriefInterventionSupportMaterials ApproachtoBriefIntervention............................... 16
U.S.AdultDrinkingPatterns ................................ 17
PrescribingMedicationsforAlcoholDependence ................. 18
ReferralResources ......................................... 21
AlcoholScreeningForms:BaselineandFollowup ................. 22
FrequentlyAskedQuestions .................................. 24
MaterialsfromNIAAA ...................................... 29
Notes ................................................... 30

HELPINGPATIENTSWHO DRINK TOO MUCH

Introduction
Thisguideiswrittenforprimarycareandmentalhealthclinicians.Ithas beenproducedbytheNationalInstituteonAlcoholAbuseandAlcoholism (NIAAA),acomponentoftheNationalInstitutesofHealth,withguidance fromphysicians,nurses,advancedpracticenurses,physicianassistants,and clinicalresearchers.

Howmuchistoomuch?
Drinkingbecomestoomuchwhenitcausesorelevatestheriskforalcohol relatedproblemsorcomplicatesthemanagementofotherhealthproblems. Menwhodrink5ormorestandarddrinksinaday(or15ormoreperweek) andwomenwhodrink4ormoreinaday(or8ormoreperweek)areat increasedriskforalcoholrelatedproblems,accordingtoepidemiologic research.1 Individualresponsestoalcoholvary,however.Drinkingatlowerlevelsmaybe problematicdependingonmanyfactors,suchasage,coexistingconditions, andmedicationuse.Becauseitisnotknownwhetheranyamountofalcoholis safeduringpregnancy,theSurgeonGeneralurgesabstinenceforwomenwho areormaybecomepregnant.2

Whyscreenforheavydrinking?
Atriskdrinkingandalcoholproblemsarecommon. About3in10U.S. adultsdrinkatlevelsthatelevatetheirriskforphysical,mentalhealth,and socialproblems.3 Oftheseheavydrinkers,about1in4currentlyhasalcohol abuseordependence.3 Allheavydrinkershaveagreaterriskofhypertension, gastrointestinalbleeding,sleepdisorders,majordepression,hemorrhagic stroke,cirrhosisoftheliver,andseveralcancers.4 Heavydrinkingoftengoesundetected. Inarecentstudyofprimarycare practices,forexample,patientswithalcoholdependencereceivedthe recommendedqualityofcare,includingassessmentandreferralto treatment,onlyabout10percentofthetime.5 Youareinaprimepositiontomakeadifference. Clinicaltrialshave demonstratedthatbriefinterventionscanpromotesignificant,lasting reductionsindrinkinglevelsinatriskdrinkerswhoarenotalcohol dependent.6 Somedrinkerswhoaredependentwillacceptreferralto addictiontreatmentprograms.Evenforpatientswhodonotaccepta referral,repeatedalcoholfocusedvisitswithahealthprovidercanlead tosignificantimprovement.7,8 Ifyouarenotalreadydoingso,weencourageyoutoincorporatealcohol screening,briefintervention,andtreatmentreferralintoyourpractice. Withthisguide,youhavewhatyouneedtobegin.

CHANGESINTHE 2005CLINICIANSGUIDE

Changesinthe2005 CliniciansGuide
ThisversionprovidesimportantupdatesandrefinementstotheGuide publishedin2003: Broaderaudience:WhereasthepreviousGuide wastargetedtoprimary carepractitionersonly,thiseditioniswrittenforbothprimarycareand mentalhealthclinicians.Mentalhealthpatientsaremorelikelythanthose inthegeneralpopulationtohavesubstanceusedisorders,primarilyalcohol usedisorders.9,10 Oftentheonlycarethesepatientsreceiveismentalhealth care,andheavydrinkingcaninterferewiththeirresponsetotreatment. Routinescreeningforheavydrinkingisimportantforthesepatientsaswell. Simplerscreeningmethod: Thescreeningmethodnowconsistsofasingle questionaboutheavydrinkingdays.Inaddition,forthosewishingto incorporateaselfreportinstrumentintotheirpractices,theAUDITis providedintheappendix.ThepreviousversionoftheGuide recommended usingthequantityfrequencyandCAGEquestions.Ifyouoryourpractice hasadoptedthatmethod,youmaywishtocontinueusingit,oryoumay decidetoswitchtothenewmethod.ThechangesinthisGuide aremeant tosimplifytheprocessandthusincreasethenumberofpractitionersusing it,buttheoldermethodworkedaswelliffullyimplemented. Newassessmentstrategy: Thehowtosectionnowincludesastepfor differentiatingamongpatientswithatriskdrinking,alcoholabuse,and alcoholdependence.Theoutcomeshapestheactionstobetakeninthe briefinterventionandfollowupstepsandgivespractitionersamoreactive roleinpatientmanagement. Guidanceforwhenpatientsrefuseareferral: Somepatientswithalcohol usedisorderswillnotacceptreferraltoaspecialist.ThisGuide provides primarycareandmentalhealthclinicianswithhelpinmanagingthese patientsontheirown. Medicationinformation:Theappendixhasanewsectiononmedications fortreatingalcoholdependence.Threeapprovedmedicationsprovidea potentiallyimportanttoolforhelpingpatientsinprimarycareandgeneral mentalhealthcare.Inaddition,thepocketguidenowcontainsprescribing information. Newformsandfrequentlyaskedquestions(FAQs):Intheappendix youllfindhelpfulpatientprogressnoteforms,includingbothbaselineand followupversions,forphotocopying.NewFAQscoverarangeoftopics includingsettingupanofficebasedscreeningsystem,helpingpatientswho struggletoabstain,andimplementingscreeninginmentalhealthsettings.

HOWTOSCREENANDCONDUCTABRIEFINTERVENTION

BeforeYouBegin
Decideonascreeningmethod
TheGuide providestwomethodsforscreening:asinglequestiontouseduring aclinicalinterview(aboutheavydrinkingdays)andawrittenselfreport instrument(theAUDITseepage11).Thesingleinterviewquestioncanbe usedatanytime,eitherinconjunctionwiththeAUDIToralone.Some practicesmayprefertohavepatientsfillouttheAUDITbeforetheyseethe clinician.Ittakeslessthan5minutestocompleteandcanbecopiedor incorporatedintoahealthhistory.

Thinkaboutclinicalindicationsforscreening
Keyopportunitiesinclude Aspartofaroutineexamination Beforeprescribingamedication thatinteractswithalcohol(seeboxon page25) Intheemergencydepartment orurgentcarecenter Inpatientswho arepregnant ortryingtoconceive arelikelytodrinkheavily,suchassmokers,adolescents,and
youngadults
havehealthproblemsthatmightbealcoholinduced,suchas cardiacarrhythmia dyspepsia liverdisease depressionoranxiety insomnia trauma haveachronicillnessthatisnotrespondingtotreatmentas expected,suchas chronicpain diabetes gastrointestinaldisorders depression heartdisease hypertension

Setupyourpracticetosimplifytheprocess
Decidewhowillconductthescreening(you,otherclinicalpersonnel, thereceptionistwhohandsouttheAUDIT) Usepreformattedprogressnotes(providedonpages22and23) Usecomputerreminders(ifusingelectronicmedicalrecords) Keepcopiesofthepocketguide(provided)andreferralinformationin examinationrooms Monitoryourperformancethroughpracticeaudits

HOWTOSCREENFORHEAVYDRINKING

STEP1 AskAboutAlcoholUse
Prescreen:Doyousometimesdrinkalcoholicbeverages?

NO
Screeningcomplete.

YES
Askthescreeningquestionabout heavydrinkingdays: Howmanytimesinthepastyear haveyouhad... 5ormoredrinksin 4ormoredrinksin aday?(formen) aday?(forwomen)
Onestandarddrinkisequivalentto12ouncesofbeer,5ounces ofwine,or1.5ouncesof80proofspiritsseechartonpage13.

Ifthepatientusedawrittenself report(suchastheAUDIT,p.11), START HERE

Isscreeningpositive?
1ormoreheavydrinkingdaysor AUDITscoreof 8formenor 4forwomen

NO
Advise stayingwithinmaximumdrinkinglimits: Forhealthymenuptoage65 nomorethan4drinksinaday AND nomorethan14 drinksinaweek Forhealthywomen (andhealthy menover age65) nomorethan3 drinksinadayAND nomorethan7 drinksinaweek Recommend lowerlimitsor abstinence as medicallyindicated;forexample,forpatients who takemedications thatinteractwithalcohol haveahealthcondition exacerbatedby alcohol arepregnant (adviseabstinence) Express opennesstotalking aboutalcoholuse andanyconcernsitmayraise Rescreen annually

YES
Yourpatientneedsadditionalevaluation.Fora morecompletepictureofthedrinkingpattern, determinethe weeklyaverage: Onaverage,howmanydays a weekdoyouhaveanalcoholic drink? Onatypicaldrinkingday,how manydrinks doyouhave? Weeklyaverage Record heavydrinkingdaysinthepastyearandthe weeklyaverageinchart(formprovidedonpage22).

GO TO STEP 2

HOWTOASSESSFOR ALCOHOLUSE DISORDERS

STEP2 AssessforAlcoholUseDisorders
Next,determinewhetherthereisamaladaptivepatternofalcoholuse,causingclinicallysignificantimpairmentor distress.Itisimportanttoassesstheseverityandextentofallalcoholrelatedsymptomstoinformyourdecisions aboutmanagement.Seepages14and15forsamplephrasingofthequestions,whichareadaptedfromthe DiagnosticandStatisticalManualofMentalDisorders,4thedition,revised(DSMIV,revised). Determinewhether,inthepast12months,yourpatientsdrinkinghasrepeatedly causedor contributedto rolefailure (interferencewithhome,work,orschoolobligations) risk ofbodilyharm(drinkinganddriving,operatingmachinery,swimming) runins withthelaw(arrestsorotherlegalproblems) relationship trouble(familyorfriends) Ifyestooneormore yourpatienthasalcoholabuse.

Ineithercase,proceedtoassessfordependencesymptoms. Determinewhether,inthepast12months,yourpatienthas showntolerance (neededtodrinkalotmoretogetthesameeffect) shownsignsofwithdrawal (tremors,sweating,nausea,orinsomniawhentryingtoquitor cutdown) notbeenabletosticktodrinkinglimits (repeatedlygoneoverthem) notbeenabletocutdownorstop (repeatedfailedattempts) spentalotoftimedrinking (oranticipatingorrecoveringfromdrinking) spentlesstimeonothermatters (activitiesthathadbeenimportantorpleasurable) keptdrinkingdespiteproblems (recurrentphysicalorpsychologicalproblems) Ifyestothreeormore yourpatienthasalcoholdependence.

Doesthepatientmeetthecriteriaforabuseordependence?

NO
Yourpatientisstill atriskfordeveloping alcoholrelatedproblems

YES
Yourpatienthasan alcoholusedisorder

GO TO STEPS 3&4 forATRISK DRINKING, page6

GO TO STEPS 3&4 forALCOHOLUSE DISORDERS, page7

HOWTOCONDUCTABRIEFINTERVENTION

FOR ATRISKDRINKING(no abuseordependence) STEP3 AdviseandAssist

Stateyourconclusionandrecommendationclearly:
Youaredrinkingmorethanismedicallysafe.Relatetopatientsconcernsandmedicalfindings,ifpresent. (Considerusingthechartonpage17toshowincreasedrisk.) Istronglyrecommendthatyoucutdown(orquit).(Seepage25foradviceconsiderations.)

Gaugereadiness tochangedrinkinghabits:
Areyouwillingtoconsidermakingchangesinyourdrinking?

Isthepatientreadytocommittochangeatthistime?

NO
Donotbediscouragedambivalenceiscommon. Youradvicehaslikelypromptedachangeinyour patientsthinking,apositivechangeinitself.With continuedreinforcement,yourpatientmaydecideto takeaction.Fornow, Restateyourconcern abouthisorherhealth. Encouragereflection: Askpatientstoweighwhat theylikeaboutdrinkingversustheirreasonsfor cuttingdown.Whatarethemajorbarriersto change? Reaffirmyourwillingness tohelp whenhe orsheisready.

YES
Helpsetagoal: Cutdowntowithinmaximum limits(seeStep1)orabstainforaperiodoftime. Agreeonaplan,including whatspecificstepsthepatientwilltake (e.g.,notgotoabarafterwork,measure alldrinksathome,alternatealcoholicand nonalcoholicbeverages) howdrinkingwillbetracked(diary,kitchen calendar) howthepatientwillmanagehighrisksituations whomightbewillingtohelp,suchasaspouse ornondrinkingfriends Provideeducationalmaterials(seepage29).

STEP4 AtFollowup:ContinueSupport
REMINDER: Documentalcoholuseandreviewgoalsateachvisit(formprovidedonpage23).

Wasthepatientabletomeetandsustainthedrinkinggoal?

NO
Acknowledgethatchangeisdifficult. Supportanypositivechangeandaddress barrierstoreachingthegoal. Renegotiate thegoalandplan;consideratrial ofabstinence. Considerengagingsignificantothers. Reassessthediagnosis ifthepatientisunable toeithercutdownorabstain.(GotoStep2.)

YES
Reinforceandsupportcontinuedadherence torecommendations. Renegotiatedrinkinggoals asindicated(e.g.,if themedicalconditionchangesorifanabstaining patientwishestoresumedrinking). Encouragetoreturn ifunabletomaintain adherence. Rescreen atleastannually.

HOWTOCONDUCTABRIEFINTERVENTION

FOR ALCOHOLUSEDISORDERS(abuseordependence) STEP3 AdviseandAssist

Stateyourconclusionandrecommendationclearly:
IbelievethatyouhaveanalcoholusedisorderandIstronglyrecommendthatyouquitdrinking. Relatetothepatient'sconcernsandmedicalfindingsifpresent. Abstainingisthesafestcourseformostpatientswithalcoholusedisorders. Patientswhohavemilderformsofabuseordependenceandareunwillingtoabstainmaybesuccessfulatcuttingdown. (SeeStep3forAtRiskDrinking.)

Negotiateadrinkinggoal:

Consider referringforadditionalevaluationbyanaddictionspecialist,especiallyifthepatientis dependent.(Seepage21fortipsonfindingtreatmentresources.) Consider recommendingamutualhelpgroup. Forpatientswhohavedependence,consider

theneedformedicallymanagedwithdrawal (detoxification)andtreataccordingly(seepage27). prescribingamedication foralcoholdependenceforpatientswhoendorseabstinenceasagoal(seepage18).

Arrangefollowupappointments.

STEP4 AtFollowup:ContinueSupport
REMINDER: Documentalcoholuseandreviewgoalsateachvisit(formprovidedonpage23).

Wasthepatientabletomeetandsustainthedrinkinggoal?

NO
Acknowledgethatchangeisdifficult. Supporteffortstocutdownorabstain,while makingitclearthatyourrecommendationis toabstain. Relatedrinkingtoproblems (medical, psychological,andsocial)asappropriate. Ifthesemeasuresarenotalreadybeingtaken, consider referringtoanaddictionspecialist or consultingwithone. recommendingamutualhelpgroup. engagingsignificantothers. prescribingamedication foralcohol dependentpatientswhoendorse abstinenceasagoal. Addresscoexisting disordersmedicaland psychiatricasneeded.

YES
Reinforceandsupport continuedadherence torecommendations. Coordinatecare withaspecialistifthepatient hasacceptedreferral. Maintainmedications foralcoholdependence foratleast3monthsandasclinicallyindicated thereafter. Treatcoexistingnicotinedependence for6to 12monthsafterreachingthedrinkinggoal. Addresscoexisting disordersmedicaland psychiatricasneeded.

Appendix
ScreeningSupportMaterials ScreeningInstrument:TheAUDIT ........................... 10
WhatIsaStandardDrink? .................................. 13
AssessmentSupportMaterials AlcoholAbuse ............................................ 14
AlcoholDependence ....................................... 15
BriefInterventionSupportMaterials ApproachtoBriefIntervention............................... 16
U.S.AdultDrinkingPatterns ................................ 17
PrescribingMedicationsforAlcoholDependence ................. 18
ReferralResources ......................................... 21
AlcoholScreeningForms:BaselineandFollowup ................. 22
FrequentlyAskedQuestions .................................. 24
MaterialsfromNIAAA ...................................... 29
Notes ................................................... 30

SCREENING SUPPORT MATERIALS

ScreeningInstrument:TheAlcoholUseDisorders IdentificationTest(AUDIT)
Yourpracticemaychoosetohavepatientsfilloutawrittenscreening instrumentbeforetheyseeaclinician.InthisGuide,theAUDITisprovidedin bothEnglishandSpanishforthispurpose.Ittakesonlyabout5minutesto complete,hasbeentestedinternationallyinprimarycaresettings,andhashigh levelsofvalidityandreliability.11 Youmayphotocopythesepagesorprintthem asindividualpagesfromthePDFdownloadversionoftheGuide at www.niaaa.nih.gov.

ScoringtheAUDIT
Aminimumscore(fornondrinkers)is0andthemaximumpossiblescoreis40. Scoresof8ormoreformen(uptoage60)or4ormoreforwomen, adolescents,andmenovertheageof60areconsideredpositivescreens.12,13,14 Forpatientswhohavescoresnearthecutpoints,cliniciansmaywishto examineindividualresponsestoquestionsandclarifythemduringthe clinicalexamination. Note: TheAUDITssensitivityandspecificityfordetectingheavydrinkingand alcoholusedisordersvariesacrossdifferentpopulations.Loweringthecut pointsincreasessensitivity(theproportionoftruepositivecases)while increasingthenumberoffalsepositives.Thus,itmaybeeasiesttousea cutpointof4forallpatients,recognizingthatmorefalsepositivesmaybe identifiedamongadultmen.

Continuingwithscreeningandassessment
AftertheAUDITiscompleted,continuewithStep1,page4.

10

SCREENING SUPPORT MATERIALS

PATIENT:Becausealcoholusecanaffectyourhealthandcaninterferewithcertainmedicationsandtreatments,it isimportantthatweasksomequestionsaboutyouruseofalcohol.Youranswerswillremainconfidentialsoplease behonest. PlaceanXinoneboxthatbestdescribesyouranswertoeachquestion. Questions 1. Howoftendoyouhaveadrink containingalcohol? 2. Howmanydrinkscontaining alcoholdoyouhaveonatypical daywhenyouaredrinking? 3. Howoftendoyouhavefiveor moredrinksononeoccasion? 4. Howoftenduringthelastyear haveyoufound thatyouwerenot abletostopdrinkingonceyou hadstarted? 5. Howoftenduringthelastyear haveyoufailedtodowhatwas normallyexpectedofyoubecause ofdrinking? 6. Howoftenduringthelastyear haveyouneededafirstdrinkin themorningtogetyourselfgoing afteraheavydrinkingsession? 7. Howoftenduringthelastyear haveyouhadafeelingofguiltor remorseafterdrinking? 8. Howoftenduringthelastyear haveyoubeenunabletoremem berwhathappenedthenight beforebecauseofyourdrinking? 9. Haveyouorsomeoneelsebeen injuredbecauseofyourdrinking? 10. Hasarelative,friend,doctor,or otherhealthcareworkerbeen concernedaboutyourdrinkingor suggestedyoucutdown? 0 Never 1or2 1 2 3 4 4ormore timesaweek 10ormore

Monthly 2to4 2to3 orless timesamonth timesaweek 3or4 5or6 7to9

Never Never

Lessthan monthly Lessthan monthly

Monthly Monthly

Weekly Weekly

Dailyor almostdaily Dailyor almostdaily

Never

Lessthan monthly

Monthly

Weekly

Dailyor almostdaily

Never

Lessthan monthly

Monthly

Weekly

Dailyor almostdaily

Never

Lessthan monthly Lessthan monthly

Monthly

Weekly

Dailyor almostdaily Dailyor almostdaily

Never

Monthly

Weekly

No No

Yes,butnotin thelastyear Yes,butnotin thelastyear

Yes,during thelastyear Yes,during thelastyear

Total
Note: Thisquestionnaire(theAUDIT)isreprintedwithpermissionfromtheWorldHealthOrganization.ToreflectstandarddrinksizesintheUnited States,thenumberofdrinksinquestion3waschangedfrom6to5.AfreeAUDITmanualwithguidelinesforuseinprimarycareisavailableonline atwww.who.org.

11

SCREENING SUPPORT MATERIALS

PACIENTE:Debidoaqueelusodelalcoholpuedeafectarsusaludeinterferirconciertosmedicamentosy tratamientos,esimportantequelehagamosalgunaspreguntassobresuusodelalcohol.Susrespuestassern confidenciales,asqueseahonestoporfavor. MarqueunaXenelcuadroquemejordescribasurespuestaacadapregunta. Preguntas 1. Conqufrecuenciaconsume algunabebidaalcohlica? 2. Cuantasconsumicionesdebebidas alcohlicassuelerealizarenunda deconsumonormal? 3. Conqufrecuenciatoma5oms bebidasalcohlicasenunsoloda? 0 Nunca 1 Unao menos vecesalmes 3o4 2 De2a4 vecesalmes 5o6 3 De2a3 msveces alasemana De7a9 4 4oms vecesa lasemana 10oms

1o2

Nunca

4. Conqufrecuenciaenelcursodel Nunca ltimoaohasidoincapazdeparar debeberunavezhabaempezado? 5. Conqufrecuenciaenelcursodel Nunca ltimoaonopudohacerloquese esperabadeustedporquehaba bebido? 6. Conqufrecuenciaenelcursodel Nunca ltimoaohanecesitadobeberen ayunaspararecuperarsedespusde haberbebidomuchoeldaanterior? 7. Conqufrecuenciaenelcursodel ltimoaohatenidoremor dimientososentimientosdeculpa despusdehaberbebido? 8. Conqufrecuenciaenelcursodel ltimoaonohapodidorecordar loquesucedilanocheanterior porquehabaestadobebiendo? 9. Ustedoalgunaotrapersonaha resultadoheridoporqueustedhaba bebido? 10. Algnfamiliar,amigo,mdicoo profesionalsanitariohamostrado preocupacinporunconsumode bebidasalcohlicasolehasugerido quedejedebeber? Nunca

Menosde Mensualmente Semanalmente Adiarioo unavez casiadiario almes Menosde Mensualmente Semanalmente Adiarioo unavez casiadiario almes Menosde Mensualmente Semanalmente Adiarioo unavez casiadiario almes Menosde Mensualmente Semanalmente Adiarioo unavez casiadiario almes Menosde Mensualmente Semanalmente Adiarioo unavez casiadiario almes Menosde Mensualmente Semanalmente Adiarioo unavez casiadiario almes S,perono enelcursodel ltimoao S,perono enelcursodel ltimoao S,elltimo ao S,elltimo ao

Nunca

No

No

Total
Note: Thisquestionnaire(theAUDIT)isreprintedwithpermissionfromtheWorldHealthOrganizationandtheGeneralitatValencianaConselleriaDe BenestarSocial.ToreflectstandarddrinksizesintheUnitedStates,thenumberofdrinksinquestion3waschangedfrom6to5.AfreeAUDIT manualwithguidelinesforuseinprimarycareisavailableonlineatwww.who.org.

12

SCREENING SUPPORT MATERIALS

WhatIsaStandardDrink?
Astandarddrinkisanydrinkthatcontainsabout14gramsofpurealcohol(about0.6fluidouncesor1.2 tablespoons).Belowarestandarddrinkequivalents.Theseareapproximate,asdifferentbrandsandtypesof beveragesvaryintheiractualalcoholcontent.

12oz.of beeror cooler

89oz.of malt liquor

8.5oz.shownin a12oz.glassthat, iffull,wouldhold about1.5standard drinksofmaltliquor

5oz.of tablewine

34oz.of fortifiedwine
(suchas sherryorport)
3.5oz.shown

23oz.of cordial, liqueur,or aperitif

2.5oz.shown

1.5oz.of brandy
(asinglejigger)

1.5oz.of spirits
(asinglejigger of80proof gin,vodka, whiskey,etc.)
Shownstraightand inahighballglass withicetoshowlevel beforeaddingmixer*

12oz.

8.5oz.

5oz.

3.5oz.

2.5oz.

1.5oz.

1.5oz.

Manypeopledonotknowwhatcountsasastandarddrink,andthusareunawareofhowmanystandard drinksareheldinthecontainersinwhichthesedrinksareoftensold.Someexamples: Forbeer,theapproximatenumberofstandarddrinksin 12oz.=1 22oz.=2 16oz.=1.3 40oz.=3.3 Formaltliquor,theapproximatenumberofstandarddrinksin 12oz.=1.5 22oz.=2.5 16oz.=2 40oz.=4.5 Fortablewine,theapproximatenumberofstandarddrinksin astandard750mL(25oz.)bottle=5 For80proofspirits,orhardliquor,theapproximatenumberofstandarddrinksin amixeddrink=1ormore* afifth(25oz.)=17 apint(16oz.)=11 1.75L(59oz.)=39
*Note: Itcanbedifficulttoestimatethenumberofstandarddrinksservedinasinglemixeddrinkmadewith hardliquor.Dependingonfactorssuchasthetypeofspiritsandtherecipe,onemixeddrinkcancontainfrom onetothreeormorestandarddrinks.

13

ASSESSMENTSUPPORTMATERIALS

AlcoholAbuse:
SampleQuestionsforAssessmentBasedonDiagnostic Criteria*
Adiagnosisofalcoholabuse requiresthatthepatientmeetoneormoreofthe followingcriteria,occurringatanytimeinthesame12monthperiod,andnot meetthecriteriaforalcoholdependence. AllquestionsareprefacedbyInthepast12months Failuretofulfillmajorroleobligationsatwork,school,orhome becauseofrecurrentdrinking: Have youhadaperiodwhenyourdrinkingorbeingsickfrom drinkingofteninterferedwithtakingcareofyourhomeor family?Causedjobtroubles?Schoolproblems? Recurrentdrinkinginhazardoussituations: Haveyoumorethanoncedrivenacarorothervehiclewhileyouwere drinking?Orafterhavinghadtoomuchtodrink? Haveyougottenintosituationswhiledrinkingorafterdrinkingthat increasedyourchancesofgettinghurtlikeswimming,usingmachinery, orwalkinginadangerousareaoraroundheavytraffic? Recurrentlegalproblemsrelatedtoalcohol: Have yougottenarrested,beenheldatapolicestation,orhadanyother legalproblemsbecauseofyourdrinking? Continuedusedespiterecurrentinterpersonalorsocialproblems: Haveyoucontinuedtodrinkeventhoughyouknewitwascausingyou troublewithyourfamilyorfriends? Haveyougottenintophysicalfightswhiledrinkingorrightafter drinking?

*AdaptedwithpermissionfromtheDiagnosticandStatisticalManualofMentalDisorders,Fourth
Edition,TextRevision. Copyright2000AmericanPsychiatricAssociation.

14

ASSESSMENTSUPPORTMATERIALS

AlcoholDependence:
SampleQuestionsforAssessmentBasedonDiagnostic Criteria*
Adiagnosisofalcoholdependence requiresthatthepatientmeetthree ormore ofthefollowingcriteria,occurringatanytimeinthesame12monthperiod. AllquestionsareprefacedbyInthepast12months Tolerance: Have youfoundthatyouhavetodrinkmuchmorethanyouoncedidto gettheeffectyouwant?Orthatyourusualnumberofdrinkshasmuchless effectonyouthanitoncedid? Withdrawalsyndromeordrinkingtorelievewithdrawal: Whentheeffectsofalcoholarewearingoff,haveyouhadtrouble sleeping?Foundyourselfshaking?Nervous?Nauseous?Restless?Sweating orwithyourheartbeatingfast?Haveyousensedthingsthatarentreally there?Hadseizures? Haveyoutakenadrinkorusedanydrugormedicine(otherthan overthecounterpainrelievers)tokeepfromhavingbadaftereffectsof drinking?Ortogetoverthem? Impairedcontrol: Have youmorethanoncewantedtostoporcutdownonyour drinking?Ortriedmorethanoncetostoporcutdownbutfound youcouldnt? Drinkingmoreorlongerthanintended: Have youhadtimeswhenyouendedupdrinkingmorethanyoumeantto? Orkeptondrinkingforlongerthanyouintended? Neglectofactivities: Inordertodrink,haveyougivenuporcutdownonactivitiesthatwere importantorinterestingtoyouorgaveyoupleasure? Timespentrelatedtodrinkingorrecovering: Have youhadaperiodwhenyouspentalotoftimedrinking? Orbeingsickorgettingoverthebadaftereffectsofdrinking? Continuedusedespiterecurrentpsychologicalorphysicalproblems: Have youcontinuedtodrinkeventhoughyouknewitwasmakingyoufeel depressedoranxious?Orcausingahealthproblemormakingoneworse? Orafterhavinghadablackout?
*AdaptedwithpermissionfromtheDiagnosticandStatisticalManualofMentalDisorders,Fourth Edition,TextRevision. Copyright2000AmericanPsychiatricAssociation.

15

BRIEF INTERVENTIONSUPPORT MATERIALS

Thissectioncontainsguidanceandmaterialstohelppractitionersconductbrief interventions.Includedarethefollowing: ApproachtoBriefIntervention U.S.AdultDrinkingPatterns PrescribingMedicationsforAlcoholDependence ReferralResources PatientProgressNotes(forphotocopying)

ApproachtoBriefIntervention
Keepinmindthatchanginghealthrelatedbehaviorsisoftenadifficultprocess, withprogressinterruptedbyrelapsetolesshealthybehaviors.Providing reinforcement,support,andthoughtfulreflectionduringanofficevisitcan oftenmakethedifferencebetweenlongtermsuccessandfailure. Generalapproachtobriefinterventionthingstoremember: Useahealtheducationapproach Bematteroffactandnonconfrontational Providepatienteducationmaterials(seepage29) Offerchoicesonhowtomakechanges Emphasizeyourpatientsresponsibilityforchangingdrinkingbehavior Conveyconfidenceinyourpatientsabilitytochangedrinkingbehavior

16

BRIEF INTERVENTIONSUPPORT MATERIALS

U.S.AdultDrinkingPatterns
Nearly3in10U.S.adultsengageinatriskdrinkingpatterns3 andthuswouldbenefitfromadvicetocutdown orareferralforfurtherevaluation.Duringabriefintervention,youcanusethischarttoshowthat(1)mostpeople abstainordrinkwithintherecommendedlimitsand(2)theprevalenceofalcoholusedisordersriseswithheavier drinking.Thoughawisefirststep,cuttingtowithinthelimitsisnotriskfree,sincemotorvehiclecrashesandother problemscanoccuratlowerdrinkinglevels.

WHAT ISYOUR DRINKING PATTERN?

Basedonthefollowinglimitsnumberofdrinks: OnanyDAYNevermorethan4 (men)or3 (women) and InatypicalWEEKNomorethan14 (men)or7 (women)

HOW COMMON ISTHIS PATTERN?

Percentageof U.S.adults aged18 orolder*

HOWCOMMONARE ALCOHOLDISORDERS INDRINKERSWITH THISPATTERN?

Combined prevalence ofalcoholabuse anddependence**

Never exceedthedailyor weeklylimits

(2outof3peopleinthisgroupabstainor drinkfewerthan12drinksayear)

lessthan

1in100 72%

Exceedonly thedaily limit

(Morethan8outof10inthisgroupexceed thedailylimitlessthanonceaweek)

1in5 16%

Exceedboth dailyandweekly limits

(8outof10inthisgroupexceed thedailylimitonceaweekormore)

almost

1in2 10%

* Notincludedinthechart,forsimplicity,arethe2percentofU.S.adultswhoexceedonly theweeklylimits.Thecombinedprevalenceofalcoholuse disordersinthisgroupis8percent. **Seepages14and15forthediagnosticcriteriaforalcoholdisorders.

17

BRIEF INTERVENTIONSUPPORT MATERIALS

PrescribingMedicationsforAlcoholDependence
Threeapprovedmedicationsdisulfiram,naltrexone,andacamprosateare currentlyavailabletotreatalcoholdependence.Theyhavebeenshowntobe helpfultopatientsinreducingdrinking,reducingrelapsetoheavydrinking, achievingandmaintainingabstinence,oracombinationoftheseeffects.

WhenshouldIconsiderprescribingmedicationforan alcoholusedisorder?
Allapproveddrugshavebeenshowntobeeffectiveadjunctstothetreatmentof alcoholdependence.Thus,consideraddingmedicationwheneveryouare treatingsomeonewithactivealcoholdependenceorsomeonewhohasstopped drinkinginthepastfewmonthsbutisexperiencingproblemssuchascraving orslips.

Willmedicationsallowmypatientswhoarealcohol dependenttodrinksocially?
Ifsomeonehasdevelopeddependence,thesafestcourseisabstinence,andthat wouldbetheusualclinicalrecommendation.Still,itisbesttodetermine individualizedgoalswitheachpatient.Somepatientsmaynotbewillingto endorseabstinenceasagoal,especiallyatfirst.Ifanalcoholdependentpatient agreestoreducedrinkingsubstantially,itisbesttoengagetheminthatgoal whilecontinuingtonotethatabstinenceremainstheoptimaloutcome. Regardingmedications,disulfiram,ofcourse,wouldbecontraindicatedin patientswhowishtocontinuetodrink,becauseadisulfiramalcoholreaction wouldoccurwithanyalcoholintakeatall.Inarecentstudy,naltrexonehad amodesteffectinreducingtheriskofheavydrinkingindrinkerswithmild tomoderatealcoholdependencewhohadachoiceofcuttingdownor abstaining.15 Atthispoint,lessisknownaboutusingacamprosateforthis purpose.

WhichofthemedicationsshouldIprescribe?
Whichmedicationtousewillbedeterminedbyclinicaljudgmentandpatient preference.Eachworksthroughadifferentmechanismofaction.Somepatients mayrespondbettertoonetypeofmedicationratherthananother. Disulfiram (Antabuse)producesanunpleasantflushingreaction wheneverthepatientdrinksalcohol.Thus,itproducesadisincentiveto drinkingalcoholandprovidessomeexternalcontrolsondrinkingbehavior. Disulfiramhasbeenshowntobemosteffectivewhengiveninamonitored fashion,suchasinaclinicorbyaspouse.16 Ifaspouseorotherfamily memberisthemonitor,instructthepatientandthemonitorthatthe patientshouldbetakingthemedicationandaskingthemonitortosimply observe.Instructthemonitortocallyouifthepatientdoesnotadhereto thisschedulefor2days.Somepatientswillrespondtoselfadministered disulfiram,especiallyiftheyarehighlymotivatedtoabstain.

18

BRIEF INTERVENTIONSUPPORT MATERIALS

Naltrexone (ReVia)blocksopiatereceptorsthatareinvolvedinthe rewardingeffectsofdrinkingalcoholandthecravingforalcoholafter establishingabstinence.Naltrexonesefficacyinreducingrelapsetoheavy drinkinghasbeendemonstratedinmultiplestudies,afindingnow confirmedbymetaanalyses.17,18 Althoughpredictorsoftreatmentresponse havenotbeenclearlydemonstrated,researchsuggeststhatpatientswitha familyhistoryofalcoholdependencemayhaveahigherrateofresponse.19 Severalstudiesalsodemonstratedapositiveinteractionbetweennaltrexone andcognitivebehavioraltherapyforalcoholdependence.20 Acamprosate (Campral)hasbeenusedtotreatalcoholdependencein EuropeformorethanadecadeandwasapprovedintheUnitedStatesfor thisindicationin2004.Althoughitsmodeofactionhasnotbeenclearly established,itmayworkbyreducingsymptomsofprotractedabstinence suchasinsomnia,anxiety,andrestlessness.Acamprosatesefficacyin increasingtheproportionofdependentdrinkerswhomaintainabstinence forseveralweekstomonthshasbeendemonstratedinmultiplestudies,a findingconfirmedbyametaanalysisof17clinicaltrials.21 Inmostpositive studies,patientswerefullywithdrawnfromalcoholforatleastseveraldays toweekspriortoinitiatinguse.22 Seethechartonthenextpageforasummaryofthepropertiesofeach medicationandprescribinginformation.

19

BRIEF INTERVENTIONSUPPORT MATERIALS

MedicationsforTreatingAlcoholDependence
Thechartbelowhighlightssomeofthepropertiesofeachmedication.Itdoesnotprovidecompleteinformation andisnotmeanttobeasubstituteforthepackageinsertsorotherdrugreferencesourcesusedbyclinicians.For patientinformationabouttheseandotherdrugs,theNationalLibraryofMedicineprovidesMedlinePlus (http://medlineplus.gov). Whetherornotamedicationshouldbeprescribedandinwhatamountisamatterbetweenindividualsandtheir healthcareproviders.Theprescribinginformationprovidedhereisnotasubstituteforaprovidersjudgmentinan individualcircumstance,andtheNIHacceptsnoliabilityorresponsibilityforuseoftheinformationwithregard toparticularpatients.

Disulfiram(Antabuse) Action
Inhibitsintermediatemetabolismofalcohol, causingabuildupofacetaldehydeanda reactionofflushing,sweating,nausea,and tachycardiaifapatientdrinksalcohol preparationsormetronidazole;coronaryartery disease;severemyocardialdisease

Naltrexone(ReVia)
Blocksopioidreceptors,resultinginreduced cravingandreducedrewardinresponseto drinking

Acamprosate(Campral)
AffectsglutamateandGABAneurotransmitter systems,butitsalcoholrelatedactionisunclear

Contraindications Concomitantuseofalcoholoralcoholcontaining Currentlyusingopioidsorinacuteopioid

withdrawal;anticipatedneedforopioid analgesics;acutehepatitisorliverfailure

Severerenalimpairment(CrCl 30mL/min)

Precautions

Highimpulsivitylikelytodrinkwhileusingit; psychoses(currentorhistory);diabetesmellitus; epilepsy;hepaticdysfunction;hypothyroidism; renalimpairment;rubbercontactdermatitis Hepatitis;opticneuritis;peripheralneuropathy; psychoticreactions.PregnancyCategoryC.

Otherhepaticdisease;renalimpairment;history Moderaterenalimpairment(doseadjustment ofsuicideattempts.Ifopioidanalgesiais forCrClbetween3050mL/min);depression required,largerdosesmayberequired,and orsuicidality respiratorydepressionmaybedeeperandmore prolonged. Willprecipitateseverewithdrawalifpatientis dependentonopioids;hepatotoxicity (uncommonatusualdoses).Pregnancy CategoryC. Anxiety;depression.Rareeventsincludethe following:suicideattempt,acutekidneyfailure, heartfailure,mesentericarterialocclusion, cardiomyopathy,deepthrombophlebitis,and shock.PregnancyCategoryC.

Seriousadverse reactions

Commonside effects

Metallicaftertaste;dermatitis

Nausea;abdominalpain;constipation;dizziness; Diarrhea;flatulence;nausea;abdominalpain; headache;anxiety;fatigue headache;backpain;infection;flusyndrome; chills;somnolence;decreasedlibido;amnesia; confusion Noclinicallyrelevantinteractionsknown

Examplesofdrug Amitryptyline;anticoagulantssuchaswarfarin; Opioidanalgesics(blocksaction);yohimbine diazepam;isoniazid;metronidazole;phenytoin; (usewithnaltrexoneincreasesnegativedrug interactions

theophylline;warfarin;anynonprescriptiondrug effects) containingalcohol Oraldose: 250mgdaily(range125mgto 500mg)

Usualadult dosage

Oraldose: 666mg(two333mgtablets)three timesdailyor,forpatientswithmoderaterenal Beforeprescribing: Evaluateforpossiblecurrent impairment(CrCl3050mL/min),reduceto Beforeprescribing: (1)warnthatpatientshould opioiduse;consideraurinetoxicologyscreenfor 333mg(onetablet)threetimesdaily nottakedisulfiramforatleast12hoursafter opioids,includingsyntheticopioids.Obtainliver Beforeprescribing: Establishabstinence drinkingandthatadisulfiramalcoholreaction functiontests. canoccurupto2weeksafterthelastdose; Followup: Monitorliverfunctiontests and(2)warnaboutalcoholinthediet(e.g., periodically saucesandvinegars)andinmedicationsand toiletries

Oraldose: 50mgdaily

Followup: Monitorliverfunctiontests periodically Theinformationinthischartwasdrawnprimarilyfromreferences18and23(seepage30).

JULY2005

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BRIEF INTERVENTIONSUPPORT MATERIALS

ReferralResources
Whenmakingreferrals,involveyourpatientinthedecisionsandschedulea referralappointmentwhileheorsheisinyouroffice.

Findingevaluationandtreatmentoptions
Forpatientswithinsurance,contactabehavioralhealthcasemanageratthe insurancecompanyforareferral. Forpatientswhoareunderinsuredoruninsured,contactyourlocalhealth departmentaboutaddictionservices. Forpatientswhoareemployed,askwhethertheyhaveaccesstoan EmployeeAssistanceProgramwithaddictioncounseling. Tolocatetreatmentoptionsinyourarea: Calllocalhospitalstoseewhichonesofferaddictionservices. CalltheNationalDrugandAlcoholTreatmentReferralRoutingService (1800662HELP)orvisittheSubstanceAbuseFacilityTreatment LocatorWebsiteathttp://findtreatment.samhsa.gov.

Findingsupportgroups
AlcoholicsAnonymous(AA)offersfree,widelyavailablegroupsof volunteersinrecoveryfromalcoholdependence.Volunteersareoften willingtoworkwithprofessionalswhoreferpatients.Forcontact informationforyourregion,visitwww.aa.org. Otherselfhelporganizationsthatoffersecularapproaches,groupsfor womenonly,orsupportforfamilymemberscanbefoundontheNational ClearinghouseforAlcoholandDrugInformationWebsite (www.health.org)underResources.

Localresources
Usethespacebelowforcontactinformationforresourcesinyourarea (treatmentcenters,supportgroupssuchasAA,localgovernmentservices,the closestVeteransAffairsmedicalcenter,shelters,churches).

21

BRIEF INTERVENTIONSUPPORT MATERIALS

Alcoholscreeningformbaseline
AUDIT score(ifdone): Screeningquestion: Heavydrinkingdays inthepastyear ( 5drinksformen/ 4forwomen) Continueifscreenispositive: Averageweeklydrinking DSMIV(revised)symptomcriteria: AbuseRepeatedorpersistentproblemsinanyoftheseareasbecauseofdrinking? no no yesrolefailure yesriskofbodilyharm no yes no no yesruninswiththelaw yesrelationshiptrouble (positive= 8formen; 4forwomen) days(positive= 1) drinksperweek

Is oneormorepositive?

Alcoholabuse

DependenceAnyofthefollowingsymptomsinthepastyear? no no no no yestolerance yeswithdrawal yesnotbeenabletostickto drinkinglimits no no no yes spentalotoftimeon drinkingrelatedactivities yes spentlesstimeon othermatters

yesnotbeenabletocutdown orstopinspiteofattempts Are threeormorepositive? yes no Additionalhistory: Physicalexaminationandlaboratory: Assessment: Negativealcoholscreen Atriskdrinking Plan: Repeatscreeningasneeded Recommendedabstinence Naltrexone50mgdaily Thiamine100mgIM/PO Othermedication/dosage: Followup: Alcoholabuse

yes keptdrinkingdespitepsychological orphysicalproblems Alcoholdependence

Alcoholwithdrawal

Alcoholdependence Patienteducationaboutdrinkinglimits Didthepatientagree? Didthepatientagree? Acamprosate666mg3timesdaily Referral(specify): yes yes no no

Recommendeddrinkingwithinlimits

Disulfiram250mgdaily

Acamprosate333mg3timesdaily(formoderaterenalimpairment)

Additionalplan(withdrawaltreatment,coexistingconditions):

22

BRIEF INTERVENTIONSUPPORT MATERIALS

Alcoholfollowupprogressnote
Heavydrinkingdays inthepastmonth (5drinksformen/4forwomen) Averageweeklydrinking inthepastmonth Workingdiagnosis: Goal: Currentmedications: Other(specify): Intervalhistoryandprogress: Atriskdrinking Drinkingwithinlimits Naltrexone Alcoholabuse Abstinence Acamprosate

days(positive=1) drinksperweek Alcoholdependence

Disulfiram

Physicalexaminationandlaboratory:

Assessment:

Atriskdrinking Alcoholabuse Alcoholdependence

Goalsfullymet Goalspartiallymet Goalsnotmet

Plan: Repeatscreeningasneeded Recommendedabstinence Naltrexone50mgdaily Thiamine100mgIM/PO Othermedication/dosage: Referral(specify): Followup: Additionalplan(withdrawaltreatment,coexistingconditions): Patienteducationaboutdrinkinglimits Didthepatientagree? Didthepatientagree? Acamprosate666mg3timesdaily yes yes no no Recommendeddrinkingwithinlimits

Disulfiram250mgdaily

Acamprosate333mg3timesdaily(formoderaterenalimpairment)

23

FREQUENTLYASKEDQUESTIONS

FrequentlyAskedQuestions
Aboutalcoholscreeningandbrief interventions
Howeffectiveisscreeningforheavydrinking? Studieshavedemonstratedthatscreeningis sensitiveandthatpatientsarewillingtogivehonest informationabouttheirdrinkingtohealth practitionerswhenappropriatemethodsareused.13 Severalmethodshavebeenshowntowork, includingquantityfrequencyinterviewquestions andquestionnairessuchastheCAGE,theAUDIT, theshorterAUDITC,theTWEAK(forpregnant women),andothers.24,25 InthisGuide,thesingle screeningquestionaboutheavydrinkingdayswas chosenforitssimplicityandbecausealmostall peoplewithalcoholusedisordersreportdrinking 5ormoredrinksinaday(formen)or4ormore (forwomen)atleastoccasionally.ThisGuide also recommendstheAUDIT(providedonpage11) asaselfadministeredscreeningtoolbecauseof itshighlevelsofvalidityandreliability.13 Howeffectivearebriefinterventions? Randomized,controlledclinicaltrialsinavariety ofpopulationsandsettingshaveshownthatbrief interventionscandecreasealcoholusesignificantly amongpeoplewhodrinkabovetherecommended limitsbutarenotdependent.Studieshavefound reductionsofupto30percentinconsumption andbingedrinkingover12months,aswellas significantdecreasesinbloodpressurereadings, levelsofgammaglutamyltransferase(GGT), psychosocialproblems,hospitaldays,andhospital readmissionsforalcoholrelatedtrauma.6 Followup periodstypicallyrangefrom6to24months, althoughonerecentstudyreportedsustained reductionsinalcoholuseover48months.6 Acost benefitanalysisinthisstudyshowedthateach dollarinvestedinbriefphysicianinterventioncould reapmorethanfourfoldsavingsinfuturehealth carecosts.Otherresearchshowsthatforalcohol dependentpatientswithanalcoholrelatedmedical illness,repeatedbriefinterventionsatapproximate lymonthlyintervalsfor1to2yearscanleadto significantreductionsinorcessationofdrinking.7,8 WhatcanIdotoencouragemypatientstogive honestandaccurateanswerstothescreening questions? Itisoftenbesttoaskaboutalcoholconsumption atthesametimeasotherhealthbehaviors,such assmoking,diet,andexercise.Usinganempathic, nonconfrontationalapproachcanhelpputpatients atease.Someclinicianshavefoundthatprefacing thealcoholquestionswithanonthreateningopener suchasDoyouenjoyadrinknowandthen?can encouragereservedpatientstotalk.Patientsmay feelthatawrittenorcomputerizedselfreport versionoftheAUDITislessconfrontationalas well.Toimprovetheaccuracyofestimated drinkingquantities,youcouldaskpatientstolook attheWhatIsaStandardDrink?chartonpage 13.Manypeopledonotknowwhatcountsasa singlestandarddrink,especiallyforbeverageswith ahigheralcoholcontentsuchasmaltliquors, fortifiedwines,andspirits. Howcanaclinicorofficebasedscreening systembeimplemented? Thebeststudiedmethod,whichisbotheasyand efficient,istoaskpatientstofilloutthe10item AUDITbeforeseeingthedoctor.Thisform (providedonpage11)canbeaddedtoothersthat patientsfillout.ThefullAUDITorthe3item AUDITCcanalsobeincorporatedintoalarger healthhistoryform.TheAUDITCconsistsof thefirstthreeconsumptionrelateditemsofthe AUDIT;ascoreof6ormoreformenand4or moreforwomen26 indicatesapositivescreen. Alternatively,thesingleitemscreeninStep1of thisGuide couldbeincorporatedintoahealth historyform.Screeningcanalsobedoneinperson byanurseduringpatientcheckin.(Seealso SetUpYourPracticetoSimplifytheProcess onpage3.) Arethereanyspecificconsiderationsforimple mentingscreeninginmentalhealthsettings? Studieshavedemonstratedastrongrelationship betweenalcoholusedisordersandothermental disorders.27 Heavydrinkingcancausepsychiatric

24

FREQUENTLYASKEDQUESTIONS

symptomssuchasdepression,anxiety,insomnia, cognitivedysfunction,andinterpersonalconflict. Forpatientswhohaveanindependentpsychiatric disorder,heavydrinkingmaycompromisethe treatmentresponse.Thus,itisimportantthatall mentalhealthcliniciansconductroutinescreening forheavydrinking. Lessisknownabouttheperformanceofscreening methodsorbriefinterventionsinmentalhealth settingsthaninprimarycaresettings.Still,the singlequestionscreenerinthisGuide islikelyto workreasonablywell,sincealmostallpersonswith alcoholusedisordersreportdrinkingabovethe recommendeddailylimitsatleastoccasionally. Mentalhealthcliniciansmayneedtoconducta morethoroughassessmenttodeterminewhetheran alcoholusedisorderispresentandhowitmightbe interactingwithothermentalorsubstanceuse disorders.Therecommendedlimitsfordrinking mayneedtobelowereddependingoncoexisting problemsandprescribedmedications. Similarly,amoreextendedbehavioralintervention maybeneededtoaddresscoexistingalcoholuse disorders,eitherdeliveredaspartofmentalhealth treatmentorthroughreferraltoanaddiction specialist.

areormaybecomepregnant, aretakingacontraindicatedmedication (seebox,below), haveamedicalorpsychiatricdisordercausedor exacerbatedbydrinking,or haveanalcoholusedisorder. Ifpatientswithalcoholusedisordersareunwilling tocommittoabstinence,theymaybewillingto cutdownontheirdrinking.Thisshouldbe encouragedwhilenotingthatabstinence,thesafest strategy,hasagreaterchanceoflongtermsuccess. Forheavydrinkerswhodonothaveanalcoholuse disorder,useprofessionaljudgmenttodetermine whethercuttingdownorabstainingismore appropriate,basedonfactorssuchasthese: afamilyhistoryofalcoholproblems advancedage injuriesrelatedtodrinking symptomssuchassleepdisordersorsexual dysfunction

Itmaybeusefultodiscussdifferentoptions, suchascuttingdowntorecommendedlimitsor abstainingcompletelyforperhaps2months,then reconsideringfuturedrinking.Ifcuttingdownis theinitialstrategybutthepatientisunabletostay withinlimits,recommendabstinence. HowdoIfactorthepotentialbenefitsof moderatedrinkingintomyadvicetopatients whodrinkrarelyornotatall? Moderateconsumptionofalcohol(definedbyU.S. DietaryGuidelinesasuptotwodrinksadayfor menandoneforwomen)hasbeenassociatedwith areducedriskofcoronaryheartdisease.28 Achieving

Aboutdrinkinglevelsandadvice
WhenshouldIrecommendabstainingversus cuttingdown? Certainconditionswarrantadvicetoabstainas opposedtocuttingdown.Theseincludewhen drinkers:

InteractionsBetweenAlcoholand Medications
Alcoholcaninteractnegativelywithmedicationseitherbyinterferingwiththemetabolismofthe medication(generallyintheliver)orbyenhancingtheeffectsofthemedication(particularlyinthe centralnervoussystem).Manyclassesofprescriptionmedicinescaninteractwithalcohol,including antibiotics,antidepressants,antihistamines,barbiturates,benzodiazepines,histamineH2receptoragonists, musclerelaxants,nonopioidpainmedicationsandantiinflammatoryagents,opioids,andwarfarin.In addition,manyoverthecountermedicationsandherbalpreparationscancausenegativesideeffectswhen takenwithalcohol.

25

FREQUENTLYASKEDQUESTIONS

abalancebetweentherisksandbenefitsofalcohol consumptionremainsdifficult,however,because eachpersonhasadifferentsusceptibilitytodiseases potentiallycausedorpreventedbyalcohol.Your advicetoayoungpersonwithafamilyhistoryof alcoholism,forexample,woulddifferfromthe adviceyouwouldgivetoamiddleagedpatient withafamilyhistoryofprematureheartdisease. Mostexpertsdonotrecommendadvising nondrinkingpatientstobegindrinkingtoreduce theircardiovascularrisk.However,ifapatientis consideringthis,discusssafedrinkinglimitsand waystoavoidalcoholinducedharm. Whyaretherecommendeddrinkinglimitslower forsomepatients? Thelimitsarelowerforwomenbecausetheyhave proportionallylessbodywaterthanmendoand thusachievehigherbloodalcoholconcentrations afterdrinkingthesameamountofalcohol.Older adultsalsohavelessleanbodymassandgreater sensitivitytoalcoholseffects.Inaddition,thereare manyclinicalsituationswhereabstinenceorlower limitsareindicated,duetoagreaterriskofharm associatedwithdrinking.Examplesincludewomen whoareormaybecomepregnant,patientstaking medicationsthatmayinteractwithalcohol,young peoplewithafamilyhistoryofalcoholdependence, andpatientswithphysicalorpsychiatricconditions thatarecausedorexacerbatedbyuseofalcohol. Someofmypatientswhodrinkheavilybelieve thatthisisnormal.Whatpercentageofpeople drinkat,above,orbelowmoderatelevels? About7in10adultsabstain,drinkrarely,ordrink withinthedailyandweeklylimitsnotedinStep1.3 Therestexceedthedailylimits,theweeklylimits, orboth.TheDrinkingPatternschartonpage17 showsthepercentageofdrinkersineachcategory, aswellastheprevalenceofalcoholusedisordersin eachgroup.Becauseheavydrinkersoftenbelieve thatmostpeopledrinkasmuchandasoftenas theydo,providingnormative dataaboutU.S. drinkingpatternsandrelatedriskscanprovidea helpfulrealitycheck.Inparticular,thosewho believethatitisfinetodrinkmoderatelyduring theweekandheavilyontheweekendsneedto knowthattheyhaveahigherchancenotonlyof immediatealcoholrelatedinjuries,butalsoof

developingalcoholusedisordersandotheralcohol relatedmedicalandpsychiatricdisorders. Someofmypatientswhoarepregnantdonot seeanyharminhavinganoccasionaldrink. Whatisthelatestadvice? Somepregnantwomenmaynotbeawareofthe risksinvolvedwithdrinking,whileothersmay drinkbeforetheyrealizetheyarepregnant.A recentsurveyestimatesthat1in10pregnant womenintheUnitedStatesdrinksalcohol.29 In addition,amongsexuallyactivewomenwhoare notusingbirthcontrol,morethanhalfdrinkand 12.4percentreportbingedrinking,placingthemat particularlyhighriskforanalcoholexposed pregnancy.29 EachyearintheUnitedStates,anestimated2,000 to8,000infantsarebornwithfetalalcohol syndromeandmanythousandsmorearebornwith somedegreeofalcoholrelatedeffects.30 These problemsrangefrommildlearningandbehavioral problemstogrowthdeficienciestoseveremental andphysicalimpairment.Together,theseadverse effectscompriseFetalAlcoholSpectrumDisorders. Becauseitisnotknownwhat,ifany,amountof alcoholissafeduringpregnancy,theSurgeon Generalrecentlyreissuedanadvisorythaturges womenwhoareormaybecomepregnantto abstainfromdrinkingalcohol.2 Theadvisoryalso recommendsthatpregnantwomenwhohave alreadyconsumedalcoholstoptominimizefurther risks,andthathealthprofessionalsinquireroutinely aboutalcoholconsumptionbywomenof childbearingage.

Aboutdiagnosingandhelping patientswithalcoholusedisorders
Whatifapatientreportssomesymptomsofan alcoholusedisorderbutnotenoughtoqualify foradiagnosis? Alcoholusedisordersaresimilartoothermedical disorderssuchashypertension,diabetes,or depressioninhavinggrayzonesofdiagnosis.For example,apatientmightreportasinglearrestfor drivingwhileintoxicatedandnoothersymptoms. Sinceadiagnosisofalcoholabuserequires repetitiveproblems,thatdiagnosiscouldnotbe

26

FREQUENTLYASKEDQUESTIONS

made.Similarly,apatientmightreportoneortwo symptomsofalcoholdependence,butthreeare neededtoqualifyforadiagnosis. Anysymptomsofabuseordependenceareacause forconcernandshouldbeaddressed,asanalcohol usedisordermaybepresentordeveloping.These patientsmaybemoresuccessfulwithabstaining asopposedtocuttingdowntorecommended limits.Closerfollowupisindicated,aswellas reconsideringthediagnosisasmoreinformation becomesavailable. ShouldIrecommendanyparticularbehavioral therapyforpatientswithalcoholusedisorders? Severaltypesofbehavioraltherapyareusedto treatalcoholusedisorders.Thesemaybebased oncognitivebehavioraltechniques,enhancing motivation,the12stepsofAlcoholicsAnonymous (e.g.,theMinnesotaModel),oracombinationof theseandotherpsychosocialapproaches.Allseem tobeequallyeffective,suggestingthatseekinghelp initselfismoreimportantthanwhichparticular approachisused.31 Inadditiontomoreformaltreatmentapproaches, mutualhelpgroupssuchasAlcoholicsAnonymous (AA)appeartobeverybeneficialforpeoplewho stickwiththem.AAiswidelyavailable,free,and requiresnocommitmentotherthanadesiretostop drinking.Ifyouhaveneverattendedameeting, considerdoingsoasanobserverandsupporter.To learnmore,visitwww.aa.org.Otherselfhelp organizationsthatoffersecularapproaches,groups forwomenonly,orsupportforfamilymembers canbefoundontheNationalClearinghousefor AlcoholandDrugInformationWebsite (www.health.org)underResources. Howshouldalcoholwithdrawalbemanaged? Alcoholwithdrawalresultswhenapersonwho isalcoholdependentsuddenlystopsdrinking. Symptomsusuallystartwithinafewhours,and consistoftremor,sweating,elevatedpulseand bloodpressure,nausea,insomnia,andanxiety. Generalizedseizuresmayalsooccur.Asecond syndrome,alcoholwithdrawaldelirium,sometimes follows.Beginningafter1to3daysandlasting 2to10days,itconsistsofanalteredsensorium, disorientation,poorshorttermmemory,altered sleepwakecycle,andhallucinations.Management

typicallyconsistsofadministeringthiamineand benzodiazepines,sometimestogetherwith anticonvulsants,betaadrenergicblockers,or antipsychoticsasindicated.Mildwithdrawalcan bemanagedsuccessfullyintheoutpatientsetting, butmorecomplicatedorseverecasesrequire hospitalization.(Consultreferences32and33on page30foradditionalinformation.) Arelaboratorytestsavailabletoscreenforor monitoralcoholproblems? Forscreeningpurposesinprimarycaresettings, interviewsandquestionnaireshavegreater sensitivityandspecificitythanbloodtestsfor biochemicalmarkers,whichidentifyonlyabout10 to30percentofheavydrinkers.34,35 Nevertheless, biochemicalmarkersmaybeusefulwhenheavy drinkingissuspectedbutthepatientdeniesit.The mostsensitiveandwidelyavailabletestforthis purposeistheserumgammaglutamyltransferase (GGT)assay.However,GGTisnotveryspecific, soreasonsforGGTelevationotherthanexcessive alcoholuseneedtobeeliminated.GGTandother transaminasesmayalsobehelpfulformonitoring progressandidentifyingrelapseifelevatedat baseline,andserialvaluescanprovidevaluable feedbacktopatientsafteranintervention.Other bloodtestsincludethemeancorpuscularvolume (MCV)ofredbloodcells,whichisoftenelevated inalcoholdependentpersons,andthe carbohydratedeficienttransferrin(CDT)assay. TheCDTassayisaboutassensitiveasGGTand hastheadvantagethatitisnotaffectedbyliver disease.36 Itisnot,however,widelyavailableinthe UnitedStates. IfIreferapatientforalcoholtreatment,what arethechancesforrecovery? Areviewofsevenlargestudiesofalcoholism treatmentfoundthataboutonethirdofpatients eitherwereabstinentordrankmoderatelywithout negativeconsequencesordependenceintheyear followingtreatment.37 Althoughtheothertwo thirdshadsomeperiodsofheavydrinking,on averagetheyreducedconsumptionandalcohol relatedproblemsbymorethanhalf.These reductionsappeartolastatleast3years.31 This substantialimprovementinpatientswhodonot attaincompleteabstinenceorproblemfreereduced drinkingisoftenoverlooked.Thesepatientsmay

27

FREQUENTLYASKEDQUESTIONS

requirefurthertreatment,andtheirchancesof benefitingthenexttimedonotappeartobe influencedsignificantlybyhavinghadprior treatments.37 Asistrueforothermedicaldisorders, somepatientshavemoresevereformsofalcohol dependencethatmayrequirelongterm management. WhatcanIdotohelppatientswhostruggleto remainabstinentorwhorelapse? Changingdrinkingbehaviorisachallenge, especiallyforthosewhoarealcoholdependent. Thefirst12monthsofabstinenceareespecially difficult,andrelapseismostcommonduringthis time.Ifpatientsdorelapse,recognizethatthey haveachronicdisorderthatrequirescontinuing care,justlikepatientswhohaveasthma, hypertension,ordiabetes.Recurrenceofsymptoms iscommonandsimilaracrosseachofthese disorders,38 perhapsbecausetheyrequirethepatient tochangehealthbehaviorstomaintaingains.

Forpatientswhostruggletoabstainorwhorelapse: Treatdepressionoranxietydisordersiftheyare presentmorethan2to4weeksafterabstinence isestablished. Assessandaddressotherpossibletriggersfor struggleorrelapse,includingstressfulevents, interpersonalconflict,insomnia,chronicpain, craving,orhightemptationsituationssuchasa weddingorconvention. Ifthepatientisnottakingmedicationfor alcoholdependence,considerprescribingone (seepage18). Ifthepatientisnotattendingamutualhelp grouporisnotreceivingbehavioraltherapy, considerrecommendingthesesupportmeasures. Encouragethosewhohaverelapsedbynoting thatrelapseiscommonandbypointingoutthe valueoftherecoverythatwasachieved. Providefollowupcareandadvisepatientsto contactyouiftheyareconcernedaboutrelapse.

Thesubstantialimprovementinpatientswho donotattaincompleteabstinenceorproblemfree reduceddrinkingisoftenoverlooked.

28

MATERIALSFROMNIAAA

MaterialsfromNIAAA
ThesematerialscanbeorderedfromtheNIAAAPublicationsDistribution Center,P.O.Box10686,Rockville,MD208490686;phone:(301)4433860. TheyarealsoavailableinfulltextonNIAAAsWebsite(www.niaaa.nih.gov). NIAAAcontinuallydevelopsandupdatesmaterialsforpractitionersandpatients; pleasechecktheWebsitefornewofferings.

Forpatients
Alcohol:AWomensHealthIssueDescribestheeffectsofalcoholonwomens healthatdifferentstagesintheirlives.Englishversion:NIHPublication No.054956;Spanishversion:NIHPublicationNo.054956S.Alsoavailable: a12minutevideo,withthesametitle,thatdescribesthehealthconsequencesof heavydrinkinginwomen. Alcohol:WhatYouDontKnowCanHarmYouProvidesinformationon drinkinganddriving,alcoholmedicationinteractions,interpersonalproblems, alcoholrelatedbirthdefects,longtermhealthproblems,andcurrentresearch issues.Englishversion:NIHPublicationNo.024323;Spanishversion: NIHPublicationNo.024323S. Alcoholism:GettingtheFactsDescribesalcoholismandalcoholabuseand offersusefulinformationonwhenandwheretoseekhelp.Englishversion:NIH PublicationNo.054153;Spanishversion:NIHPublicationNo.054153S. DrinkingandYourPregnancyBrieflyconveysthelifelongmedicalandbehavioral problemsassociatedwithfetalalcoholsyndromeandadviseswomennottodrink duringpregnancy.Englishversion:NIHPublicationNo.014101;Spanishver sion:NIHPublicationNo.014102. FrequentlyAskedQuestionsAboutAlcoholismandAlcoholAbuseEnglish version:NIHPublicationNo.014735;Spanishversion:NIHPublication No.024735S.

Forhealthpractitioners
APocketGuideforAlcoholScreeningandBriefInterventionacondensed,portable versionofthispublication. AlcoholAlertsThese4pagebulletinsprovidetimelyinformationonalcohol researchandtreatment. AlcoholResearch&HealthEachissueofthisquarterlypeerreviewedjournal containsreviewarticlesonacentraltopicrelatedtoalcoholresearch.

29

NOTES

Notes
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