Helping Patients with Alcohol Problems

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Helping Patients
with Alcohol Problems:
A Health Practitioner's Guide

SCREENING AND BRIEF INTERVENTION PROCEDURES

Recommended screening and brief intervention procedures include four steps:

ASK

ASSESS

ADVISE

MONITOR

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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:
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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STEP II. ASSESS FOR ALCOHOL-RELATED PROBLEMS

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:

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.

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.

Next Section: Patients who are not ready to change their drinking behaviors
Previous Section: What your Patients Should Know/ Recommendations
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