Alcohol screening in general health: good news for treatment: specialty addiction professionals should link into SBI initiatives.

Alcohol consumption is part of our social fabric, viewed by many as a rite of passage. Alcoholic beverages are aggressively promoted at the same time that celebrity rehab is glamorized by the media. Drinking in moderation is even touted by scientific researchers as beneficial to one's health. Two drinks per day for men and one drink for women, research findings show, might reduce the risk of cardiovascular disease and other illnesses. (1)

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Yet alcoholism and other drug dependence constitutes the nation's number one health problem. (2) Every year, alcoholism contributes to countless deaths and disabilities. One-quarter of all emergencyroom admissions, one-third of all suicides, and more than half of all homicides and incidents of domestic violence are alcohol-related. The costs associated with heavy drinking are estimated to exceed $185 billion, according to an article by Hugh Myrick, MD, of the Medical University of South Carolina, posted on Medscape in 2006.

Despite the enormity of the problem and our capability to identify and treat alcohol use disorders, studies of primary care practices indicate that patients with alcohol dependence received the recommended quality of care, including assessment and referral to treatment, only about 10% of the time. (3) Clearly, increased training and awareness of alcoholism as a chronic, treatable disease are essential. Physicians, nurses, counselors, and psychologists have a duty to screen their patients for alcohol use disorders and to intervene where indicated. Patients look to their medical and behavioral health practitioners for advice, placing them in a prime position to effect change.

Fortunately for patients and treatment, a sweeping initiative for screening and brief intervention (SBI) efforts, incentives for general health practitioners to screen, and the availability of simple assessment tools are leading general practitioners to take a hands-on approach to the treatment of alcohol use disorders. By addressing alcohol misuse with patients in an empathetic manner, practitioners are playing a larger role in addiction treatment and in the reduction of morbidity and mortality associated with the disease of alcoholism.

Alcohol screening tools

Screening can be performed by asking a single question about heavy drinking days and by utilizing simple screening tools such as the four-question CAGE survey or the 10 question Alcohol Use Disorders Identification Test (AUDIT). These are not diagnostic tools per se, but rather clinical guides to help identify problems with alcohol requiring further assessment and possible treatment.

A written self-reporting instrument, the AUDIT has been found in research to be highly sensitive in defining levels of alcohol use. It includes questions such as, "Have you or someone else been injured because of your drinking?" (i.e., accidents, domestic disputes), and "How often during the last year have you failed to do what was normally expected of you because of drinking?" (i.e., frequent work absences). Asking questions about behaviors associated with drinking can help elicit responses that more accurately define the patient's level of drinking as harmful, heavy, abusive, or dependent. The AUDIT also can be helpful in circumventing denial, a defense mechanism and symptom of the disease that frequently blocks patients from responding accurately to direct questions about how much they drink.

The AUDIT can easily be placed within an informal health questionnaire appropriate for use in professional offices and urgent care settings. To facilitate screenings, patients might be asked to complete the health assessment in advance of their exam. The screening and brief intervention can be accomplished during routine physicals, before prescribing medication, and in urgent care and emergency situations.

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Once a patient has been identified as drinking at risk, the health care practitioner has a 10-to-15 minute window of opportunity to address alcohol use with that patient. It is essential that alcohol consumption be discussed in a supportive and non-confrontational way, using statements such as "I have concerns that you are drinking at risk" and "We need to work on this together."

Here is a summary of steps for conducting a brief intervention as outlined in the National Institute on Alcohol Abuse and Alcoholism's (NIAAA's) updated 2005 edition of Helping Patients Who Drink Too Much: A Clinician's Guide:

* Advise the patient of maximum drinking limits. For healthy men up to age 65, the limit is no more than four drinks per day; for healthy women and healthy men over 65, the limit is no more than three drinks per day and no more than seven drinks per week. Lower levels are recommended for patients who are taking medications; have health conditions associated with or exacerbated by alcohol; and/or are pregnant.

* Relate the medical, psychological, and psychosocial risks and consequences of the patient's drinking.

* Address barriers to postive change such as guilt, shame, and readiness for change.

* Gauge readiness to change drinking habits (pre-contemplative or not ready, contemplative, acceptance and maintenance). Most patients who screen positively for heavy drinking or dependence show some motivation for change (i.e., they can share at least one or two reasons for modifying their behavior).

* Set goals with the patient for cutting down on drinking in risky situations or for abstinence in alcohol dependence.

* Discuss strategies for cutting down or abstaining from alcohol. Some of these include tracking drinks (counting, measuring), setting goals related to drinking days, being cognizant of drinking triggers such as stressful events, handling urges, and being prepared to say "no."

* Follow-up by general practitioners is paramount to the screening and intervention process and to the self-efficacy and optimization of the patient.

* Referral of patients to specialty treatment as needed is also critical to SBI outcomes and the quality of patient care.

Some at-risk drinkers might be able to cut down or abstain from drinking on their own, but patients with alcohol abuse or dependence (based on screening responses or by utilizing DSM-IV criteria) typically require extended work on the part of the patient and the treatment provider. Addiction specialists are trained to evaluate and address the unique psychosocial and medical needs of patients, such as the risk of withdrawal, seizures and delirium tremens, and complications due to co-occurring disorders. The treatment recommendations for alcohol-dependent individuals might necessitate medically managed inpatient detoxification and rehabilitation followed by intensive outpatient services and mutual self-help support.

Physical findings

Tremor, odor of alcohol on breath, cirrhosis, gastrointestinal disorders, and hypertension are some of the physical findings associated with alcoholism. Although these red flags are sometimes overlooked, such findings have been the most widely used "screening instruments" for the detection of alcoholism, according to Dr. Myrick. Interestingly, verbal assessments have been found by NIAAA studies to be more useful in primary care settings than are biological markers, which identify only about 10 to 30% of heavy drinkers.

Asking about family history of alcoholism is also important and often a key in the early detection of this progressive disease. Many scientific studies, including research conducted among twins and children of alcoholics, have shown that genetic factors influence alcoholism. These findings indicate that children of alcoholics are about four times more likely than the children of non-alcoholic parents to develop alcohol problems. (4)

Collaborating with Physicians

An increase in screening and brief intervention by general practitioners is a call to action for addiction professionals to develop collaborative relationships within their communities. It is in the best interest of patients and addiction professionals to facilitate referrals from general practitioners who are integrating SBI into their busy practices.

Addiction professionals can do this by providing treatment information and walking staff through the specifics of referring a patient for specialized care. The referral process works best when practitioners are familiar with treatment options and admissions. The ability to schedule a referral appointment with patients from the physician's office or an urgent care setting is ideal.

Be sure also that patients have signed appropriate releases. The timely communication with practitioners regarding the coordination of patient care, discharge planning, and aftercare is invaluable to developing mutually beneficial referral relationships and to providing high-quality patient care, Moreover, practitioners also are in an excellent position to assist with follow-up/aftercare for the patients whom they have referred, and to suggest relapse prevention strategies should the need arise.

Heightening awareness of alcoholism as a chronic, treatable disease has always been a core component of AdCare Hospital's mission. Our community services representatives are consistently on the move, offering professional trainings, community education, and outreach about alcoholism and other drug addiction. Individuals and families affected by the disease, and their health care practitioners, are seeking education and information about treatment options. Connecting with general practitioners will maximize SBI efforts and, most importantly, positive treatment outcomes for patients.

References

(1.) Mukamal KJ, Rimm EB. Alcohol's effects on the risk for coronary heart disease. Alcohol Res Health 2001;25:255-61.

(2.) Schneider InstitureInstitute for Health Policy. Substance Abuse: The Nation's Number One Health Problem. Robert Wood Johnson Foundation report, February 2002.

(3.) McGlynn EA, Asch SM, Adams J, et al. The quality of health care delivered to adults in the United States. New Engl J Med 2003;348:2635-45.

(4.) National Institute on Alcohol Abuse and Alcoholism. A Family History of Alcoholism: Are You at Risk? NIH Publication No. 03-5340, printed February 2003.

BY RONALD F. PIKE, MD

Ronald F.Pike, MD, is the Medical Director fo AdCare Hospital, based in Worcester, Massachusetts. He is a past president of the Massachusetts Society of Addiction Medicine and a member of the American Society of Addiction Medicine's (ASAM's) national board. His e-mail address is [e-mail].