Treating alcohol problems in primary care settings
By Phyllis Maguire
PHILADELPHIA—Consider this startling statistic: Studies published in the Annals of Internal Medicine and elsewhere show that 45% of patients in general medical practices are either at-risk for alcohol abuse or are already abusing or dependent on alcohol. Problem drinking takes a staggering toll on patient health, leading to a host of problems including increased risk of cardiovascular disease, stroke and breast cancer.
Primary care physicians must be in the forefront of aggressive screening and treatment of alcohol abuse, said Patrick G. O'Connor, ACP—ASIM Member, professor of medicine at Yale University School of Medicine. His Annual Session presentation, "Treatment of Alcohol Problems," provided recommendations for office-based interventions and new pharmacological treatments.
The first step is to ask all patients about their current or past alcohol use, Dr. O'Connor said. He pointed out that several studies have looked at how accurately patients self-report alcohol use compared to other behaviors, such as adhering to diabetic diets. "Those studies suggest that people are just as reliable reporting on alcohol as they are other kinds of data that we depend on," Dr. O'Connor said.
Physicians should be empathetic and optimistic about the efficacy of treatment.
To gain a broad picture of patient use, physicians should ask a series of questions, such as: What kinds of alcohol do you drink? How often and how much do you drink? Do you ever drink more than that at any one time? If so, when and how much? Standardized questionnaires such as the 10-question Alcohol Use Disorder Identification Test (AUDIT) and the CAGE questionnaire can also help physicians assess patients' alcohol use. (CAGE is an acronym for four questions to ask patients: Have you tried to cut down? Are you annoyed when your drinking is criticized? Do you feel guilty about drinking? And do you ever drink an alcoholic eye-opener in the morning?)
Physicians should also watch for red-flag symptoms of problem drinking, Dr. O'Connor said. They include hypertension, anemia, cardiac arrhythmia, gastrointestinal bleeding, chronic pain, sexual dysfunction in both men and women, accidents or trauma, elevated GGT levels, depression, reported family history of alcohol abuse, dependence on tobacco or other substances and insomnia.
According to Dr. O'Connor, there are five different categories of alcohol use:
- Abstainers or light drinkers.
- Moderate drinkers. Men under age 65 who drink two or fewer drinks a day, and women and seniors who drink one or fewer drinks a day are considered moderate drinkers.
- At-risk drinkers. Men who drink more than 14 drinks a week, or more than four per occasion, are considered at-risk. So are women who drink more than seven drinks a week, or three per occasion. (Drinking four or more drinks per occasion is defined as binge drinking.)
- Alcohol abusers. Abusers meet at least one of these criteria:
- failure to meet obligations at work, home or school;
- recurrent use in hazardous situations, like while driving;
- legal problems related to alcohol use;
- continued use despite alcohol-related social problems.
- Alcohol dependent. Dependent patients meet at least one of these criteria:
- withdrawal symptoms;
- use of larger amounts of alcohol than intended;
- unsuccessful attempts to control use;
- excessive time spent recovering from alcohol use;
- continued use despite alcohol-related physical or psychological problems.
In approaching treatment, physicians need to stage a brief intervention—which may need to be repeated over several office visits—to discuss the patient's problem with alcohol.
Brief interventions employ counseling strategies "that we all use every day, not just for alcohol," Dr. O'Connor said. Using the feedback method, physicians outline how they believe patients' alcohol use may be linked to medical problems. Physicians should tell patients how alcohol affects social and mental health, but remember that patients respond more to medical issues, Dr. O'Connor said.
During interventions, physicians should advise at-risk drinkers to cut down, or to abstain if they are abusing or dependent on alcohol. Physicians should also provide patients with a menu of options, such as self-help groups or rehabilitation facilities. They should be empathetic and optimistic about the efficacy of treatment.
Dr. O'Connor said that for at-risk drinkers, studies have shown the effectiveness of providing review materials, prescribing lower doses of alcohol, and having patients track their alcohol use in a "drinking diary." Patients should return in a month for another 15-minute visit. Patients should then receive at least two calls from a nurse two weeks apart.
For patients with more serious alcohol problems, primary care physicians should plan to see them weekly for two months, then biweekly for another two months. Physicians typically treat withdrawal symptoms with benzodiazepines. They also use beta-blockers, alpha-agonists or anti-epileptics. Benzodiazepines can be administered through a fixed-dose schedule, front-loaded dosing or symptom-triggered dosing. According to Dr. O'Connor, research indicates that symptom-triggered dosing may be the most effective, though it must be closely monitored.
"The majority [of patients with alcohol problems] either stop or cut way down," Dr. O'Connor said. Studies indicate that with outpatient treatment, 46% of alcohol dependent patients relapse (go back to drinking five or more drinks per episode) after one year, while 19% remain abstinent. The remainder curtail their alcohol use. With inpatient treatment, 40% of patients relapse within a year, while 35% maintain abstinence.
He said that anecdotal evidence suggests that self-help groups such as Alcoholics Anonymous (AA) can be very effective. Dr O'Connor suggested that physicians visit an open AA meeting. They should also counsel patients to try different meetings until they find one where they feel comfortable.
Dr. O'Connor also mentioned other medications that primary care physicians can use to treat alcohol-dependent patients. One is disulfiram (Antabuse), which physicians in the audience gave mixed reviews.
Another is naltrexone, an opioid antagonist that helps decrease alcohol cravings. (Its contraindications are opioid dependence and liver disease.) Dr. O'Connor reported that in randomized placebo trials and feasibility studies, naltrexone—in combination with counseling—has been effective for treating patients in a primary care setting.
Another promising treatment for relapse prevention is acamprosate, which has undergone European trials but is only now being studied in the United States.
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