American College of Physicians: Internal Medicine — Doctors for Adults ®

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Empathy, engagement are key to treating alcoholism

Addressing the pros and cons of medications may be the best way to get patients on track for lifestyle changes

From the June ACP Observer, copyright 2005 by the American College of Physicians.

By Janet Colwell

SAN FRANCISCO—A middle-aged woman complaining of nausea and vomiting tells her physician that she often drinks three or four bottles of beer a day, even though she doesn't consider herself a heavy drinker. Probing deeper, the physician finally discovers that those three-to-four daily beer bottles are actually quarts.

Physicians who screen patients for alcohol abuse will recognize the scenario, said Booker T. Bush, MD, in an Annual Session presentation on treating alcohol-related problems. Physicians often have to drill down or ask questions in a new way, he said, before a patient's true story begins to emerge.

"It's not very useful to ask someone 'how much do you drink?,' " said Dr. Bush, an associate professor of medicine at Harvard Medical School who is affiliated with Boston's Beth Israel Deaconess Medical Center. "People don't tend to answer questions directly."


Avoid angry confrontations if patients relapse, says Booker T. Bush, MD.



Dr. Bush said it is important to screen and identify every patient for substance abuse. Following diagnosis, he pointed out, physicians need to assess patients' readiness to change their behavior.

Follow through is just as important, he said. Physicians must guide patients' progress through the stages of recovery and—above all—remain involved throughout treatment.

Questions to ask

With many office visits limited to only 15 minutes, physicians need to follow quick and established screening methods. Dr. Bush recommended using the CAGE method with its four basic questions: Have you ever CUT down on drinking? Does anyone ANNOY you about your drinking? Do you feel GUILTY about alcohol abuse? And do you use alcohol as an EYE-opener?

Physicians should keep in mind that they may have to modify those questions to elicit accurate responses. He noted that the woman in the above example answered "no" to the first three CAGE questions, but then admitted that she "used to" use alcohol as an eye-opener. Dr. Bush said he then discerned that the woman had felt guilty about her drinking and that she and her husband often fought about her alcohol use—and that her original CAGE answers didn't reflect her true situation.

Physicians can also get clues from the physical exam. Some hallmarks of alcohol abuse include elevated blood pressure; anxiety and tremulousness; rosacea, rhinophyma and telangiectasias; obstructive lung disease; and tachycardia and heart failure.

A menu of interventions

When it comes to interventions, Dr. Bush recommended following several stages, starting with educating patients about how alcohol affects their body based on their physical exam and lab test results. Physicians then need to ask patients to weigh the pros and cons of changing their behavior. (See "Tips for treating alcohol abuse.")

If patients choose to move forward with treatment, then it is time to set targets, consider new behaviors and put supports in place, he said. Patients should be given a menu of options to help them change their behavior, said Dr. Bush. Those include 12-step programs, specialist referral, counseling, day or residential treatment, and medications.

Some drugs lessen the effects of alcohol or reduce cravings, while others treat accompanying conditions such as depression. According to Dr. Bush, opiate antagonists are now popular pharmaceutical weapons.

Studies have shown that these drugs can reduce heavy and binge drinking but that patients often have problems with nausea and compliance. Acamprosate is also used to stop heavy drinking, while serotonin-3 receptor antagonists, such as ondansetron—which is still being tested—can be useful in treating early onset alcoholism. Prescribing antidepressants for alcoholism remains controversial, he noted, and may have no positive effects.

Physicians' ongoing support, he added, is vital during all stages of intervention and therapy. "The worst thing you can say is 'great, I'll see you in a year,' " he said. While physicians need to stress the fact that patients can change; "realize that [patients'] ambivalence is normal and that denial is a defense, not a character trait."

Also, avoid angry or confrontational language if a patient relapses, Dr. Bush said. Instead of asking why they started drinking again, instead ask, "how did you feel when everything worked and how can we get back there?"

Keep in mind, said Dr. Bush, that some patients will relapse no matter what the physician does.

The physician's role is to give feedback and clear advice, present alternatives, and show empathy and optimism, said Dr. Bush. But ultimately, "it's the patient's responsibility to change."

The information included herein should never be used as a substitute for clinical judgment and does not represent an official position of ACP.

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Tips for treating alcohol abuse

  • Avoid anger and confrontation.
  • Be an advocate for change.
  • Realize that ambivalence is normal among patients who abuse alcohol.
  • Keep in mind that denial is a defense, not a character trait.

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