guideline for identification and treatment of alcohol abuse/dependence in primary care

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1 guideline for identification and treatment of alcohol abuse/dependence in primary care This guideline is informational in nature and is not intended to be a substitute for professional clinical judgment. 4 Taft Court Rockville, MD This document applies to MD-Individual Practice Association, Inc. (M.D. IPA), Optimum Choice, Inc. (OCI), MAMSI Life and Health Insurance Company (MLH) and Alliance PPO, LLC (Alliance) /05

2 I. Routine Screening and Evaluation The following protocol is comprised of a series of questions that assist the practitioner in determining the presence and severity of alcohol use. If time contstraints or patient resistance is present, the practitioner is urged to ask about alcohol use within the general context of other lifestyle issues (eating, smoking, exercise habit); e.g., tell me about your alcohol use. A routine screening is administered: 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. 1. Ask the following questions: Do you drink alcohol, including beer, wine or distilled spirits? If yes: (frequency) On average, how many days per week do you drink alcohol? (quantity) On a typical day when you drink, how many drinks do you have? One drink is the equivalent of: one 12-oz can of beer or bottle of wine cooler one 5-oz glass of wine one jigger (shot) of hard liquor (1.5 oz) (heaviest use) What is the maximum number of drinks you had on any given occasion during the past month? 2. For patients who answer yes to question 1 above, use the CAGE questionnaire (Appendix A) and supplement it with the AUDIT (Appendix B) if further clarification is necessary. 3. Assess for medical markers such as gastrointestinal problems, elevated liver enzymes, hypertension, falls, burns or history of emergency room visits that are cause for suspicion but not diagnostic of alcohol use disorder. 4. Ask about work, family and social problems related to drinking (a family history of alcohol abuse/dependence inreases risk). 5. Determine the severity of drinking. a. Alcohol Dependent: CAGE questionnaire score of 3 or 4 for the past year, or Compulsion to drink, or Impaired control over drinking, or Relief drinking, withdrawal symptoms or increased tolerance Page 1 of 9 Origin: 10/1/03 Reviewed/Revised Date: 12/1/04, 3/2/05

3 b. Current Problem: CAGE questionnaire score of 1 or 2 for past year, or Alcohol-related medical problems, or Alcohol-related family, legal or employment problems c. At Risk: Alcohol consumption: a. Men: more than 14 drinks per week, or more than four drinks per occasion b. Women: more than seven drinks per week, or more than three drinks per occasion CAGE questionnaire score of one or higher Personal family history of alcohol problems II. Formulate Diagnosis 1. Alcohol Abuse The diagnosis can be formulated if: a. A maladaptive pattern of alcohol abuse leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occuring within a 12-month period: recurrent alcohol use resulting in failure to fulfill major role obligations at work, school or home (e.g., repeated absences or poor work performance related to alcohol use; alcohol related absences, suspension, or expulsions from school; neglect of children or household). recurrent alcohol use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by alcohol use). recurrent alcohol related legal problems (e.g., arrests for alcohol related disorderly conduct). continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the alcohol (e.g., arguments with spouse about consequences or intoxications, physical fights). b. The symptoms have never met the criteria for alcohol dependence. 2. Alcohol Dependence The diagnosis can be formulated if a maladaptive pattern of alcohol abuse occurs leading to clinically significant impairment or distress, which is manifested by one (or more) of the following, occurring within a 12- month period: Tolerance, as defined by either of the following: a need for markedly increased amounts of alcohol to achieve intoxication or desired effect. markedly diminished effect with continued use of the same amount of alcohol. Page 2 of 9 Origin: 10/1/03 Reviewed/Revised Date: 12/1/04, 3/2/05

4 Withdrawl, as manifested by either of the following: the characteristic withdrawal syndrome for alcohol. alcohol or a similar substance is used to relieve or avoid withdrawal symptoms. Alcohol is often taken in larger amounts or over a longer period than was intended. There is a persistent desire or unsuccessful efforts to cut down or control alcohol use. A great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects. Important social, occupational, or recreational activities are given up or reduced because of alcohol use. The alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by alcohol. 3. At Risk No alcohol abuse or dependence diagnosis can be formulated but a patient is at risk according to At Risk definition (see I.5.c.) and CAGE score (Appendix A). Although all patients who drink will not meet diagnostic criteria for abuse or dependence, brief interventions, education and goal setting is clinically indicated to prevent increased use. III. Goals: 1. Total abstinence: For those who are dependent on substances, are pregnant, have comorbid medical conditions, take medications that interact with alcohol or who have a history of repeated attempts to reduce their alcohol consumption. 2. Drinking at low-risk limits (men: no more than two drinks per day; women or older persons: no more than one drink per day): For those who are considered "At Risk" (see I.5.c.) for developing alcohol-related problems or for those who have current alcohol-related problems. IV. Interventions 1. Alcohol Dependence Refer to a specialist physician or facility and request regular feedback from the specialist regarding progress. Contact with a specialist or PCP should occur frequently at the beginning of treatment: at a minimum, at least 1 visit within 2 weeks of identification followed by 2 additional visits within a 30 day period. Page 3 of 9 Origin: 10/1/03 Reviewed/Revised Date: 12/1/04, 3/2/05

5 2. Current Problem or Alcohol Abuse: Brief intervention Give feedback to include concerns about patient s health and patient responsibility. Provide patient specific advice to include social/occupational/familial/medical consequences of drinking; and promote self efficacy through motivational statements. Negotiate a specific plan for action to include a consumption reduction goal (see Goals ), referral to a specialist or support goups (examples of support groups provided in Appendix C), and/or frequency of follow-up appointments (at least one visit within two weeks of identification followed by two additional visits within a 30-day period). Assist the patient in developing a support network and provide family/support education. Establish follow-up plan to include reassessment of drinking frequency/intensity, lab values (gammaglutamyltransferase) progress related to social/occupational/familial/medical issues, and guilt/shame/depression which may result with abstinence and which may require physchiatric intervention. Consider and explore abuse of drugs other than alcohol and address accordingly. 3. At Risk Drinking: Brief intervention Give feedback to include risk factors (family history) for problem drinking, dangerousness of drinking in high risk situations (driving, operating machinery). Provide education on consequences of drinking and ask patient to keep a diary of when, how much, under what circumstances drinking occurs to identify patterns that may result in problem drinking. Negotiate a specific consumption limit (see Goals ). Establish a follow-up plan to include reassessment through phone calls, office staff, repeat office visits, etc. 3. Timing of interventions: Patients are most likely to make behavior changes when: They perceive they have a problem, or When they believe they can change, or When an adverse event occurs as a result of the problem. Customize support, advice, education and goals to each patient based on your perception of their readiness to respond to your interventions. Page 4 of 9 Origin: 10/1/03 Reviewed/Revised Date: 12/1/04, 3/2/05

6 References American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Text Revision Washington, DC. Babor, T.F., de la Fuente, J.R., Saunders, J., Grant, M. AUDIT: The Alcohol Use Disorders Identification Test: Guidelines for Use in Primary Health Care. Geneva: World Health Organization, Burge, S. K., Schneider, D. F. Alcohol-Related Problems: Recognition and Intervention. American Family Physician, 01/15/1999, Vol. 59, Issue 2, Ewing, J.A. Detecting Alcoholism: The CAGE Questionnaire. Journal of the American Medical Association 252: m Liang B., Blondell R. Brief Intervention for Alcohol Problems in Primary Care. Hospital Physician April; 35(4): Sullivan E., Fleming M. A Guide to Substance Abuse Services for Primary Care Clinicians, Treatment Improvement Protocol (TIP) Series 24. DHHS Publication No. (SMA) Rockville: U.S. Department of Health and Human Services, Public Health Service, Center for Substance Abuse Treatment; U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism. The Physicians Guide to Helping Patients with Alcohol Problems. Washington: GPO, Page 5 of 9 Origin: 10/1/03 Reviewed/Revised Date: 12/1/04, 3/2/05

7 Appendix A CAGE Questionnaire (Eving 1984) 1. Have you ever felt you ought to cut down on your drinking? 2. Have people annoyed you by criticizing your drinking? 3. Have you felt bad or guilty about your drinking? 4. Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (eyeopener)? Item responses on the CAGE questionnaire are scored 0 for no and 1 for yes. Consider conducting a brief intervention with any patient who scores 1 or higher. Page 6 of 9 Origin: 10/1/03 Reviewed/Revised Date: 12/1/04, 3/2/05

8 Appendix B The Alcohol Use Disorder Identification Test (AUDIT) The AUDIT is designed to be used as a brief structured interview or self-report survey that can easily be incorporated into the general health interview, lifestyle questionnaire or medical history. Circle the number that comes closest to the patient s answer. 1. How often do you have a drink containing alcohol? (1) Monthly or less frequently (2) Two to four times a month (3) Two to three times a week (4) Four or more times a week 2. How many drinks containing alcohol do you have on a typical day when you are drinking? (Note: It is assumed that one drink contains 10 g of alcohol.) (0) 1 or 2 (1) 3 or 4 (2) 5 or 6 (3) 7 to 9 (4) 10 or more 3. How often do you have six or more drinks on one occasion? 4. How often during the last year have you found that you were not able to stop drinking once you had started? 5. How often during the last year have you failed to do what was normally expected from you because of drinking? Page 7 of 9 Origin: 10/1/03 Reviewed/Revised Date: 12/1/04, 3/2/05

9 Appendix B, continued 6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? 7. How often during the last year have you had a feeling of guilt or remorse after drinking? 8. How often during the last year have you been unable to remember what happened that night before because you had been drinking? 9. Have you or someone else been injured as a result of your drinking? (0) No (2) Yes, but not in the last year (4) Yes, during the last year 10. Has a relative, friend, or a doctor or other health worker been concerned about your drinking or suggested you cut down? (0) No (2) Yes, but not in the last year (4) Yes, during the last year The minimum score (for non drinkers) is 0 and the maximum possible score is 40. A score of 8 or more indicates likelihood of hazardous or harmful alcohol consumption. Page 8 of 9 Origin: 10/1/03 Reviewed/Revised Date: 12/1/04, 3/2/05

10 Appendix C Examples of Support Groups/Community Services and Other Resources: Al-Anon/Alateen Alcoholics Anonymous (AA) American Council on Alcoholism National Association for Children of Alcoholics National Institute on Alcohol Abuse and Alcoholism National Organization on Fetal Alcohol Syndrome Page 9 of 9 Origin: 10/1/03 Reviewed/Revised Date: 12/1/04, 3/2/05

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