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1 practitioners and physician assistants.advanceweb.com/features/articles/alcohol Abuse.aspx Alcohol Abuse By Neva K.Gulsby, PA-C, and Bonnie A. Dadig, EdD, PA-C Posted on: April 18, 2013 Excessive alcohol use is the third leading lifestyle-related cause of death in the United States, resulting in approximately 80,000 deaths each year. 1 It can present in two forms, heavy drinking and binge drinking. Heavy drinking is defined as an average of more than two drinks per day for men or an average of more than one drink per day for women. 1 Binge drinking is defined as the ingestion of five or more drinks during a single occasion for men or four or more drinks during a single occasion for women. 1 The majority of binge drinkers are not alcohol dependent. 1 Binge drinkers - not alcoholics - contribute to more than half of the deaths that occur due to excessive drinking. 2 Primary care providers have an obligation to screen and counsel patients who abuse alcohol, potentially preventing many premature deaths. 3 The Big Picture Approximately 5% of U.S. adults drink heavily, and 15% engage in binge drinking. 2 Immediate health risks of excessive alcohol use, especially binge drinking, include the following: 1 Unintentional trauma, such as vehicle crashes, drownings, falls, burns and firearm injuries Violence, including partner and child abuse Risky sexual behaviors, potentially resulting in sexually transmitted diseases or pregnancy Alcohol poisoning Among pregnant women, miscarriage and stillbirth. Long-term health risks of excessive alcohol use include these conditions: 1 Liver diseases Gastrointestinal problems Cardiovascular problems Neurologic conditions Psychiatric and social problems Increased risk for certain cancers. What Amount Is Too Much? Drinking becomes excessive when it increases a person's risk for alcohol-related problems or

2 disrupts management of other comorbidities. Usually this amount is four or more standard drinks per day (or more than 14 per week) for men and more than three per day (or more than seven per week) for women. However, smaller amounts of alcohol can cause problems when comorbidities, certain medications or pregnancy are present. 4 The Centers for Disease Control and Prevention recommends moderate drinking of no more than two drinks per day for men and no more than one drink per day for women. 1 Table 1 provides a depiction of standard drink sizes; patients often overestimate these when drinking. Why Screen and Intervene? About one-third of U.S. adults who consume alcohol drink enough to increase their risk of adverse effects such as hypertension, major depression, gastrointestinal bleeding, sleep disorders, hemorrhagic stroke, hepatic cirrhosis and several cancers. 4 About one-quarter of them either abuse or are dependent on alcohol. 4 Many of these adults are not being identified by clinicians and thus only about 10% receive the recommended care. 4 Primary care providers encounter these patients on a regular basis, which provides opportunities to prevent alcohol-related morbidity and mortality through early screening and brief intervention. 5 The National Institute on Alcohol Abuse and Alcoholism (NIAAA) created a clinician's guide to screening for alcohol abuse. This free publication, titled "Helping Patients Who Drink Too Much," is available from the NIAAA at The guide is intended for use in primary care and general mental health settings. It contains evidence-based recommendations that can be applied in busy practices. The website also contains free training programs with continuing education credit, video case scenarios and an animated slide show. 6 The benefits associated with screening for alcohol abuse are numerous and significant. Such interactions provide opportunities to educate patients about risks of excessive alcohol use. Information gathered about the amount and frequency of alcohol use may influence diagnosis of the presenting condition. Alcohol consumption may adversely affect medications or other treatments, so obtaining accurate information about a patient's use can positively influence the course of treatment. Perhaps most importantly, screening provides an opportunity to reduce alcohol-related risks through brief intervention. 7 Brief interventions help identify existing or potential alcohol problems and motivate the patient to change drinking behavior. Brief interventions are not intended to treat patients with alcohol dependence because these patients usually require intensive clinical management by an addiction specialist. However, brief interventions may provide initial treatment for patients who need extended treatment. 7 Brief interventions come in many forms, including motivational interviewing, cognitive behavioral therapy, self-completed action plans,

3 educational leaflets, drinking diaries and home exercises. 4 Brief alcohol-reduction interventions - even as short as 1 hour or less - can reduce the percentage of heavy drinkers and binge drinkers by helping patients identify and alter their drinking behavior. 2 These interventions can reduce weekly alcohol consumption by about 41 grams of alcohol, or three drinks. 2 In a published study, these interventions led to a slight reduction in the amount of emergency department visits and a 47% reduction in injuries. 2 A common barrier to screening and intervention is the belief that patients will not change their drinking behavior. However, research shows that patients' willingness to change often results from conversations with primary care providers and that many heavy drinkers are already aware of their problem. 5 Additionally, most primary care patients who screen positive for heavy alcohol use or alcohol use disorders show a willingness to change. The patients with the most severe symptoms are usually the most ready to change. Many patients do not mind being screened for alcohol use and are receptive to advice afterward. 4 It is reasonable to integrate drinking intervention into daily clinical practice because it is effective and it can be accomplished in a relatively brief time. 2 Patients with alcohol dependence should be referred to an addiction specialist. Patients with at-risk drinking need simple advice, while patients with alcohol abuse require brief counseling. Brief interventions can reduce levels of total alcohol consumption, change harmful drinking patterns, prevent future drinking problems, improve patient health and reduce health care costs. 7

4 Click to view larger graphic. Click to view larger graphic. Click to view larger graphic. One-third of patients with alcohol dependence who complete a rehabilitation program do not respond to treatment. For these patients, primary care providers can use the NIAAA guide to

5 continue treatment with a combination of medication and disease management, which is as effective as specialized alcohol counseling. 3 Screening One screening tool is the Alcohol Use Disorders Identification Test (AUDIT; Table 2). The AUDIT has been internationally tested in primary care settings and has high levels of validity and reliability. 4 This 10-item questionnaire was designed specifically for use in primary care settings and is accurate across cultures, age and gender. Many providers believe screening and intervention require too much time. However, the AUDIT requires less than 5 minutes to complete. It can even be integrated into the medical history interview. Scoring and interpretation of the AUDIT requires less than a minute. Only 5% to 20% of patients in primary care settings require brief intervention. Brief intervention usually lasts between 5 and 15 minutes, including developing a plan for follow-up or referral. 7 A simpler screening option is to simply ask whether the patient drinks heavily on a regular basis or occasionally. This question can be asked during the medical history interview or in conjunction with the AUDIT. This screening question is used because almost all people who abuse alcohol or are alcohol dependent report at least occasionally drinking four to five drinks or more. The risk for alcohol-related problems increases as the number of daily alcoholic drinks and number of drinking days per week increase. 8 Many opportunities exist for alcohol use screening in routine clinical situations: during routine physical examination, before prescribing a medication that interacts with alcohol, and during preconception or antenatal care. Clinicians should also screen patients who are likely to drink heavily (such as smokers, adolescents, young adults), patients with health problems that might be alcohol-induced (cardiac arrhythmia, depression or anxiety, dyspepsia, insomnia, liver disease, trauma) and patients with chronic illness that isn't responding to treatment as expected (such as chronic pain, depression, diabetes, heart disease, gastrointestinal disorders, hypertension). 4 Clinicians should communicate with staff members to decide how screenings will be conducted. This will streamline the screening process and allow time for any necessary brief intervention. How to Screen and Intervene Step 1. Ask. The first step is to ask about alcohol use in a way that includes various types of alcoholic drinks. If the patient drinks alcohol, ask about heavy drinking days. For example, for men younger than 65 ask, "How many times in the past year have you had five or more drinks in a day?" For women or men older than 65, ask the same question but substitute five drinks with four drinks. A report of one or more heavy drinking days is a positive result. If the patient was screened with the AUDIT instead, a positive screening is a score of 8 or more for men and 4 or more for women.

6 If the screening is negative, advise the patient to stay within recommended maximum drinking limits. It is important to rescreen annually and remain open to discussing patients' concerns about alcohol use. 4 If the screening is positive, the patient is an at-risk drinker. Determine the patient's drinking pattern by calculating a weekly average. Preformatted Progress Notes and templates can be downloaded for free from the NIAAA at Step 2. Assess. For patients who screen positive, assess for a maladaptive pattern of use that causes clinically significant impairment or distress. This information can reveal potential alcohol use disorders (AUDs), such as alcohol abuse or alcohol dependence. The algorithm shown in Table 3 helps the clinician determine whether the patient meets the criteria for alcohol abuse or alcohol dependence. Even if the patient does not appear to have an AUD, a risk for developing alcohol-related problems exists. If the patient meets the criteria for alcohol abuse or alcohol dependence, proceed to step 3. 4 Step 3. Intervene. This step involves brief intervention. First, verbalize the effects of excessive alcohol use. Then, clearly state a recommendation to cut down or abstain from alcohol. Next, answer any outstanding patient concerns. Finally, assess whether the patient is ready to change drinking habits at this time. Do not be discouraged if the patient is not ready to change. Restate your concerns, encourage reflection, and voice your willingness to help. If the patient is ready to commit to change, help him or her set a goal. Then agree on a plan and provide educational materials. Strategies for reducing drinking levels can be found at this link: wn.htm For the patient with an AUD, explain what an AUD is and recommend abstinence from drinking. If the patient has alcohol dependence, discuss referral to an addiction specialist. Other considerations include medically managed withdrawal, medication for alcohol dependence (for those choosing abstinence) and arranging follow-up appointments. Step 4. Follow Up. Continue supporting the patient by scheduling and providing follow-up. Document drinking frequency and quantity, and regularly review goals. Changing behavior can be difficult, and alcohol dependence is a chronic disorder in which relapse is common. Remain optimistic about improvement. The majority of patients with alcohol dependence who work to recover eventually reach partial to full remission of symptoms, often without specialized behavioral treatment. 4 For patients who struggle to abstain or who relapse, consider prescribing a medication for alcohol dependence and follow up with medication management. Treat depression or anxiety disorders when they are present more than 2 to 4 weeks after abstinence is established. Assess and address other possible triggers for struggle or relapse, including stressful events,

7 interpersonal conflict, insomnia, chronic pain, craving or high-temptation situations such as a wedding or convention. If the patient is not attending a mutual help group or is not receiving behavioral therapy, consider recommending these support measures. Encourage patients who relapse by noting that relapse is common and pointing out the value of the recovery that was achieved. Neva Gulsby is a physician assistant employed by Georgia Emergency Medicine Specialists at Athens Regional Medical Center in Athens, Ga. Bonnie A. Dadig is the chairperson of the physician assistant program at Georgia Health Sciences University in Colbert, Ga. and also serves as an associate professor. The authors have completed disclosure statements and report no relationships related to this article. References 1. Centers for Disease Control and Prevention. Alcohol use and health. 2. Cayley WE. Cochrane for clinicians: Putting evidence into practice. Effectiveness of brief alcohol interventions in primary care. Am Fam Physician. 2010;79(5): Willenbring ML, et al. Helping patients who drink too much: An evidence-based guide for primary care physicians. Am Fam Physician. 2009;80(1): U.S. Department of Health and Human Services, National Institute on Alcohol Abuse and Alcoholism. Helping Patients Who Drink Too Much: a Clinician's Guide. Bethesda, MD: National Institute on Alcohol Abuse and Alcoholism; NIH publication no Miller WR, Wilson BE. Making a difference with patients who drink too much. Am Fam Physician. 2009;80(1): U.S. Department of Health & Human Services, National Institute on Alcohol Abuse and Alcoholism. Helping Patients Who Drink Too Much: A Clinician's Guide and Related Professional Support Resources. 7. World Health Organization. Screening and brief intervention for alcohol problems in primary health care. 8. Dawson DA, et al. Quantifying the risks associated with exceeding recommended drinking limits. Alcohol Clin Exp Res. 2005;29(5):

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