Physicians Guide to Assessing Alcohol Dependence

THE PHYSICIANS’ GUIDE TO HELPING PATIENTS WITH ALCOHOL PROBLEMS

CONTENTS

FOREWORD

LETTER FROM NIAAA DIRECTOR

WHAT YOUR PATIENTS SHOULD KNOW ABOUT
ALCOHOL USE

RECOMMENDATIONS TO
PATIENTS FOR LOW-RISK DRINKING

SCREENING AND BRIEF
INTERVENTION PROCEDURES

Step I. Ask About Alcohol
Use

Step II. Assess for Alcohol-Related
Problems

Step III. Advise Appropriate
Action

Step IV. Monitor Patient
Progress

WHAT TO DO ABOUT PATIENTS WHO ARE NOT
READY TO CHANGE THEIR DRINKING BEHAVIOR

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FOREWORD

This Guide was developed by the National Institute on Alcohol Abuse
and Alcoholism (NIAAA) in conjunction with an interdisciplinary working
group of alcohol researchers and health professionals. The clinical
recommendations in this Guide are based on the findings of more than a
decade of research on the health risks associated with alcohol use and on
the effectiveness of alcohol screening and interven- tion methods. NIAAA
plans to update this Guide periodically to reflect continuing advances in
research.

NIAAA would like to acknowledge the contributions of members of the
Working Group on Screening and Brief Intervention, including the
following: John Allen, Ph.D.; Peter Anderson, M.D.; Thomas Babor, Ph.D.;
Kendall Bryant, Ph.D.; David Buchsbaum, M.D.; Jonathan Chick, M.D.;
Frances Cotter, M.A., M.P.H.; Michael Fleming, M.D., M.P.H.; Richard K.
Fuller, M.D.; Nick Heather, Ph.D.; Yedy Israel, Ph.D.; Cherry Lowman,
Ph.D.; William R. Miller, Ph.D.; Judith Ockene, Ph.D.; and Allen Zweben,
D.S.W.

NIAAA also would like to thank other collaborators, including the
following: Michael Fleming, M.D., M.P.H., and Frances Cotter, M.A.,
M.P.H., for their leadership in writing this Guide; the College of Family
Physicians of Canada Alcohol Risk Assessment and Intervention (ARAI)
Project Steering Committee for sharing their expertise and early drafts
of brief intervention materials; and Eve Shapiro and colleagues at CSR,
Incorporated, for their expertise in editing and designing this
Guide.

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Letter from
NIAAA Director

Dear Colleagues: As a primary care physician, you are in an excellent
position to identify and manage patients at risk for alcohol-related
problems. Alcohol-related problems are common in primary care practice:
An estimated 25 percent of adults in the United States either report
drinking patterns that put them at risk for developing problems or
currently have alcohol-related problems, including alcohol abuse or
dependence.1 Primary care physicians are the entry point into the
health-care system for many individuals. Furthermore, because you are
concerned with the overall health of an individual, you generally see
patients more frequently than do other health-care professionals.

Primary care physicians are busy. Yet you want to practice good
medicine and are willing to take time to address your patients’ alcohol
problems. This Guide, prepared by the National Institute on Alcohol Abuse
and Alcoholism, provides you with a step-by-step approach to identifying
and managing these problems and offers practical advice on making alcohol
screening, assessment, and brief intervention procedures a routine part
of your clinical practice. There are important reasons for doing so.
Untreated alcohol- ism results in a variety of social, economic, and
medical consequences. Alcohol use can complicate treatment for medical
problems, interfere with prescribed medications, or lead to adverse side
effects. Most importantly, left untreated, alcohol abuse and alcoholism
often result in severe or fatal outcomes.

Your patients look to you for advice about the risks and benefits
associated with drinking. Research, in fact, demonstrates that simply
dis- cussing your concerns about alcohol use can be effective in changing
many patients’ drinking behavior before problems become chronic.

We commend this Guide to your attention and hope that you will make it
an integral part of your practice.

Enoch Gordis, M.D.
Director
National Institute on Alcohol Abuse and Alcoholism

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WHAT YOUR PATIENTS
SHOULD KNOW ABOUT ALCOHOL USE

Most adults who drink alcohol drink in moderation and are at low risk
for developing problems related to their drinking. However, all drinkers,
including low-risk drinkers, should be aware of the health risks
associated with alcohol consumption. Provide your patients with
information and advice about the risks of drinking.

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RECOMMENDATIONS TO PATIENTS FOR
LOW-RISK DRINKING

Advise those patients who currently drink to drink in
moderation.

Moderate drinking is defined as follows:

  • Men–no more than two drinks per day
  • Women–no more than one drink per day
  • Over 65–no more than one drink per day

Note: A standard drink is 12 grams
of pure alcohol, which is equal to one 12-ounce bottle of beer or wine
cooler, one 5-ounce glass of wine, or 1.5 ounces of distilled
spirits.

Advise patients to abstain from alcohol under certain
conditions:

  • when pregnant or considering pregnancy
  • when taking a medication that interacts with alcohol
  • if alcohol dependent
  • if a contraindicated medical condition is present (e.g., ulcer,
    liver disease)

If a patient is at risk for coronary heart disease, discuss
the potential benefits and risks of alcohol use:

  • Light to moderate drinking is associated with lower rates of
    coronary heart disease in certain populations (e.g., men over 45,
    postmenopausal women). Infrequent or nondrinkers are not advised to
    begin a regimen of light to moderate drinking to reduce the risk of
    coronary heart disease because vulnerability to alcohol-related
    problems cannot always be predicted. Similar protective effects can
    likely be achieved through proper diet and exercise.

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Clinical Notes

  • Women and the elderly have smaller amounts of body water than men;
    therefore, they achieve a higher blood alcohol concentration than men
    after drinking the same amount of alcohol.
  • Exposing a fetus to alcohol can cause a broad range of birth
    defects referred to as fetal alcohol syndrome (FAS) or alcohol-related
    birth defects (ARBD). Although FAS/ARBD is associated with excessive
    alcohol consumption during pregnancy, studies also have reported
    neurobehavioral deficits in infants born to mothers reporting drinking
    an average of one drink per day during pregnancy.
  • Studies indicate that heavier episodic drinking (i.e., the
    consumption of more than four drinks per occasion by men and more than
    three drinks per occasion by women) impairs cognitive and psychomotor
    functions and increases the risk of alcohol-related problems, including
    accidents and injuries.

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SCREENING AND BRIEF INTERVENTION
PROCEDURES

Recommended screening and brief intervention procedures include four
steps:

  • Step I. ASK about alcohol use.
  • Step II. ASSESS for alcohol-related problems.
  • Step III. ADVISE appropriate action (i.e., set a
    drinking goal, abstain, or obtain alcohol treatment).
  • Step IV. MONITOR patient progress.

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Ask all patients:

  • Do you drink alcohol, including beer, wine, or distilled
    spirits?

Ask current drinkers about alcohol consumption:

  • On average, how many days per week do you drink alcohol?
  • On a typical day when you drink, how many drinks do you have?
  • What is the maximum number of drinks you had on any given occasion
    during the last month?

Ask current drinkers the CAGE questions:

  • Have you ever felt that you should Cut down on your drinking?
  • Have people Annoyed you by criticizing your drinking?
  • Have you ever felt bad or Guilty about your drinking?
  • Have you ever had a drink first thing in the morning to steady your
    nerves or get rid of a hangover (Eye opener)?

If there is a positive response to any of these questions:

  • ASK: Has this occurred during the past year?

A patient may be at risk for alcohol-related problems IF:

  • alcohol consumption is:
    Men:
    > 14 drinks per week or
    > 4 drinks per occasion
    Women:
    > 7 drinks per week or
    > 3 drinks per occasion

or

  • one or more positive responses to the CAGE that have occurred in
    the past year

When is screening for alcohol problems appropriate?

  • as part of a routine health examination
  • before prescribing a medication that interacts with alcohol
  • in response to presenting problems that may be alcohol-related

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Patients who screen positive should be
assessed to determine the nature and extent of their alcohol-related
problems. Use the assessment procedures described below to determine
problem severity, as follows: (l) at increased risk for developing
alcohol-related problems, (2) currently experiencing alcohol-related
problems, or (3) may be alcohol dependent.

1. At Increased Risk for Developing Alcohol-Related
Problems

Indicators

  • drinking above recommended low-risk consumption levels or in
    high-risk situations
  • personal or family history of alcohol-related problems

Assessment procedures

  • Ask about typical drinking patterns:
    How long have you been drinking this amount? How many times
    in a week (or month) do you have four or more drinks on one occasion?
    What is the most you have consumed on one occasion during the past
    year?
  • Ask about personal and family history:
    Have you or anyone in your immediate family ever had a drinking
    problem?

Note: For many conditions, there is a
dose-response relationship between alcohol consumption and risk. This
applies to cirrhosis of the liver; cancers of the oropharynx, larynx,
liver, and breast; hypertension; and stroke.

2. Currently Experiencing Alcohol-Related
Problems

Indicators

  • one or two positive responses to the CAGE that have occurred in the
    past year
  • evidence of alcohol-related medical or behavioral problems

Assessment procedures

  • Review your patient’s medical history for evidence of
    alcohol-related medical problems, such as:
    blackouts
    chronic abdominal pain
    depression
    liver dysfunction
    hypertension
    sexual dysfunction
    trauma
    sleep disorders

Note: Chronic heavy use of alcohol (i.e., three
or more drinks per day) may be associated with elevations in serum
gamma-glutamyltransferase (GGT). This can be an indicator of excessive
drinking.

  • Ask about interpersonal or work-related problems:
    Has your drinking ever caused you problems, such as problems with your
    family, problems with your work (or school) performance, or
    accidents/injuries?

3. May Be Alcohol Dependent

Indicators

  • three or four positive responses to the CAGE that have occurred in
    the past year
  • evidence of one or more of the following symptoms: 2
    Compulsion to drink–preoccupation with drinking
    Impaired control–unable to stop drinking once started
    Relief drinking–drinking to avoid withdrawal symptoms
    Withdrawal–evidence of tremor, nausea, sweats, or mood
    disturbance
    Increased tolerance–takes more alcohol than before to get
    “high”

Assessment procedures

  • Ask the following questions:
    — Are there times when you are unable to stop drinking once you have
    started?
    — Does it take more drinks than before to get “high”?
    — Do you feel a strong urge to drink?
    — Do you change your plans so that you can have a drink?
    — Do you ever drink in the morning to relieve the shakes?

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State your medical
concern:

  • Be specific about your patient’s drinking patterns and related
    health risks.
  • ASK: How do you feel about your drinking?

Advise to abstain or cut down:

  • Advise to abstain if:
    — evidence of alcohol dependence
    — history of repeated failed attempts to cut down
    — pregnant or trying to conceive
    — contraindicated medical condition or medication
  • Advise to cut down if:
    — drinking above recommended low-risk drinking amounts and no
    evidence of alcohol dependence

Agree upon a plan of action:

  • ASK: Are you ready to try to cut down or abstain?

Talk with patients who are ready to make a change in their drinking
about a specific plan of action.

For patients who are not alcohol dependent:

  • Recommend low-risk consumption limits for your patient based upon
    the low-risk drinking recommendations and your patient’s health history
    (See Recommendations to patients for low-risk drinking).
  • Ask your patient to set a specific drinking goal:
    Are you ready to set a drinking goal? Some patients choose to abstain
    for a period of time or for good; others prefer to limit the amount
    they drink. What do you think will work best for you?
  • Provide patient education materials and tell your patient:
    It helps to think about your reasons for wanting to cut down and
    examine what situations trigger unhealthy drinking patterns. These
    materials will give you some useful tips on how to maintain your
    drinking goal.

For patients with evidence of alcohol dependence:

  • Refer for additional diagnostic evaluation or treatment.
  • Procedures for patient referral are as follows:
    — Involve your patient in making referral decisions.
    — Discuss available alcohol treatment services.
    — Schedule a referral appointment while the patient is in the
    office.

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SOME PATIENT COUNSELING TIPS

  • Use an empathic, nonconfrontational style.
  • Offer your patient some choices about how to effect change.
  • Emphasize your patient’s responsibility for changing drinking
    behavior.
  • Convey confidence in your patient’s ability to change drinking
    behavior.

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Monitor patient progress in the same
way you manage other chronic medical problems, such as hypertension or
diabetes. Recognize that behavior change is an incremental process that
often involves trial and error. Patient management strategies include the
following:

  • Indicate that you (or designated staff) are available to provide
    ongoing assistance and support.
  • Support your patient’s efforts to cut down or abstain at each
    subsequent visit by:
    — reviewing progress to date
    — commending your patient for efforts made
    — reinforcing positive change
    — assessing continued motivation
  • Consider scheduling a separate followup visit or telephone call, as
    appropriate, if the patient needs additional support.
  • Consider referring a selected patient whose counseling needs exceed
    the services provided in a primary care setting.

For patients who have been advised to abstain or have been
referred for alcohol treatment:

  • Ask to receive periodic updates from the treatment specialist on
    your patient’s treatment plan and prognosis.
  • Monitor symptoms of depression and anxiety. Such symptoms may
    occur, but they often decrease or disappear after 2 to 4 weeks of
    abstinence.
  • Monitor GGT levels, when appropriate, as a means of assessing
    alcohol treatment compliance.

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WHAT TO DO ABOUT
PATIENTS WHO ARE NOT READY TO CHANGE THEIR DRINKING BEHAVIOR

Do not be discouraged if patients are not ready to take action
immediately. Decisions to change behavior often involve fluctuating
motivation and feelings of ambivalence. By offering your advice, you have
prompted your patients to think more seriously about their drinking
behavior. In many cases, continued reinforcement is the key to a
patient’s decision to take action. Offer the following guidance to
patients who are not ready to take action:

  • Restate your concern for your patient’s health.
  • Reinforce your willingness to help when the patient is ready.
  • Continue to monitor alcohol use at subsequent office visits.

For patients who may be alcohol dependent, you may want to
consider some additional strategies:

  • Encourage your patient to consult an alcohol specialist.
  • Ask your patient to discuss your recommendation with family members
    and schedule a followup visit that includes family members/significant
    others.
  • Recommend a trial period of abstinence, monitor for withdrawal
    symptoms, and review progress in a followup visit.

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WHERE TO GO FOR ADDITIONAL
INFORMATIO
N

The National Institute on Alcohol Abuse and Alcoholism (NIAAA)
Office of Scientific Affairs
Willco Building
6000 Executive Boulevard, Suite 409
Bethesda, MD 20892-7003
301-443-3860

American Society of Addiction Medicine (ASAM)
4601 North Park Avenue
Suite 101, Upper Arcade
Chevy Chase, MD 20815
301-656-3920

National Council on Alcoholism and Drug Dependence (NCADD)
12 West 21st Street
New York, NY 10010
212-206-6770

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NOTES

1 Seven percent of the U.S. population–approximately 14 million
adults–meet the diagnostic criteria for alcohol abuse or dependence.

Back to Letter.

2 This selective listing of dependence symptoms is offered as an
initial assessment procedure and not for the purpose of making a
diagnosis. For a diagnostic evaluation, refer your patients to a
specialist or use the diagnostic procedures outlined in the Diagnostic
and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV).

Back to Step II, Part 3.

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U.S. Department of Health and Human Services
Public Health Service
National Institutes of Health
National Institute on Alcohol Abuse and Alcoholism

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All material contained in this Guide is in
the public domain and may be reproduced
without permission from NIAAA.
Citation of the source is appreciated.
NIH Publication No. 95-3769
Printed 1995

Prepared: January 1996

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