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Alcohol Screening in General Health: Good News for Treatment

June 16, 2008
by Ronald F. Pike, MD
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Specialty addiction professionals should link into SBI initiatives

Alcohol consumption is part of our social fabric, viewed by many as a rite of passage. Alcoholic beverages are aggressively promoted at the same time that celebrity rehab is glamorized by the media. Drinking in moderation is even touted by scientific researchers as beneficial to one's health. Two drinks per day for men and one drink for women, research findings show, might reduce the risk of cardiovascular disease and other illnesses.1

Yet alcoholism and other drug dependence constitutes the nation's number one health problem.2 Every year, alcoholism contributes to countless deaths and disabilities. One-quarter of all emergency-room admissions, one-third of all suicides, and more than half of all homicides and incidents of domestic violence are alcohol-related. The costs associated with heavy drinking are estimated to exceed $185 billion, according to an article by Hugh Myrick, MD, of the Medical University of South Carolina, posted on Medscape in 2006.

Despite the enormity of the problem and our capability to identify and treat alcohol use disorders, studies of primary care practices indicate that patients with alcohol dependence received the recommended quality of care, including assessment and referral to treatment, only about 10% of the time.3 Clearly, increased training and awareness of alcoholism as a chronic, treatable disease are essential. Physicians, nurses, counselors, and psychologists have a duty to screen their patients for alcohol use disorders and to intervene where indicated. Patients look to their medical and behavioral health practitioners for advice, placing them in a prime position to effect change.

Fortunately for patients and treatment, a sweeping initiative for screening and brief intervention (SBI) efforts, incentives for general health practitioners to screen, and the availability of simple assessment tools are leading general practitioners to take a hands-on approach to the treatment of alcohol use disorders. By addressing alcohol misuse with patients in an empathetic manner, practitioners are playing a larger role in addiction treatment and in the reduction of morbidity and mortality associated with the disease of alcoholism.

Alcohol screening tools

Screening can be performed by asking a single question about heavy drinking days and by utilizing simple screening tools such as the four-question CAGE survey or the 10 question Alcohol Use Disorders Identification Test (AUDIT). These are not diagnostic tools per se, but rather clinical guides to help identify problems with alcohol requiring further assessment and possible treatment.

A written self-reporting instrument, the AUDIT has been found in research to be highly sensitive in defining levels of alcohol use. It includes questions such as, “Have you or someone else been injured because of your drinking?” (i.e., accidents, domestic disputes), and “How often during the last year have you failed to do what was normally expected of you because of drinking?” (i.e., frequent work absences). Asking questions about behaviors associated with drinking can help elicit responses that more accurately define the patient's level of drinking as harmful, heavy, abusive, or dependent. The AUDIT also can be helpful in circumventing denial, a defense mechanism and symptom of the disease that frequently blocks patients from responding accurately to direct questions about how much they drink.

The AUDIT can easily be placed within an informal health questionnaire appropriate for use in professional offices and urgent care settings. To facilitate screenings, patients might be asked to complete the health assessment in advance of their exam. The screening and brief intervention can be accomplished during routine physicals, before prescribing medication, and in urgent care and emergency situations.

Once a patient has been identified as drinking at risk, the health care practitioner has a 10-to-15 minute window of opportunity to address alcohol use with that patient. It is essential that alcohol consumption be discussed in a supportive and non-confrontational way, using statements such as “I have concerns that you are drinking at risk” and “We need to work on this together.”

Here is a summary of steps for conducting a brief intervention as outlined in the National Institute on Alcohol Abuse and Alcoholism's (NIAAA's) updated 2005 edition of Helping Patients Who Drink Too Much: A Clinician's Guide:

  • Advise the patient of maximum drinking limits. For healthy men up to age 65, the limit is no more than four drinks per day; for healthy women and healthy men over 65, the limit is no more than three drinks per day and no more than seven drinks per week. Lower levels are recommended for patients who are taking medications; have health conditions associated with or exacerbated by alcohol; and/or are pregnant.

  • Relate the medical, psychological, and psychosocial risks and consequences of the patient's drinking.

  • Address barriers to postive change such as guilt, shame, and readiness for change.

  • Gauge readiness to change drinking habits (pre-contemplative or not ready, contemplative, acceptance and maintenance). Most patients who screen positively for heavy drinking or dependence show some motivation for change (i.e., they can share at least one or two reasons for modifying their behavior).

  • Set goals with the patient for cutting down on drinking in risky situations or for abstinence in alcohol dependence.