THE PHYSICIANS' GUIDE TO HELPING PATIENTS WITH ALCOHOL PROBLEMS
FOREWORDThis Guide was developed by the National Institute on Alcohol
Abuse and Alcoholism (NIAAA) in conjunction with an interdisciplinary working
group of alcohol researchers and health professionals. The clinical
recommendations in this Guide are based on the findings of more than a decade of
research on the health risks associated with alcohol use and on the
effectiveness of alcohol screening and intervention methods. NIAAA plans to
update this Guide periodically to reflect continuing advances in research.
NIAAA would like to acknowledge the contributions of members of the Working
Group on Screening and Brief Intervention, including the following: John Allen,
Ph.D.; Peter Anderson, M.D.; Thomas Babor, Ph.D.; Kendall Bryant, Ph.D.; David
Buchsbaum, M.D.; Jonathan Chick, M.D.; Frances Cotter, M.A., M.P.H.; Michael
Fleming, M.D., M.P.H.; Richard K. Fuller, M.D.; Nick Heather, Ph.D.; Yedy
Israel, Ph.D.; Cherry Lowman, Ph.D.; William R. Miller, Ph.D.; Judith Ockene,
Ph.D.; and Allen Zweben, D.S.W.
NIAAA also would like to thank other collaborators, including the following:
Michael Fleming, M.D., M.P.H., and Frances Cotter, M.A., M.P.H., for their
leadership in writing this Guide; the College of Family Physicians of Canada
Alcohol Risk Assessment and Intervention (ARAI) Project Steering Committee for
sharing their expertise and early drafts of brief intervention materials; and
Eve Shapiro and colleagues at CSR, Incorporated, for their expertise in editing
and designing this Guide.
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Contents.
Letter from NIAAA Director
Dear Colleagues: As a primary care physician, you are in an excellent
position to identify and manage patients at risk for alcohol-related problems.
Alcohol-related problems are common in primary care practice: An estimated 25
percent of adults in the United States either report drinking patterns that put
them at risk for developing problems or currently have alcohol-related problems,
including alcohol abuse or dependence.1
Primary care physicians are the entry point into the health-care system for many
individuals. Furthermore, because you are concerned with the overall health of
an individual, you generally see patients more frequently than do other
health-care professionals.
Primary care physicians are busy. Yet you want to practice good medicine and
are willing to take time to address your patients' alcohol problems. This Guide,
prepared by the National Institute on Alcohol Abuse and Alcoholism, provides you
with a step-by-step approach to identifying and managing these problems and
offers practical advice on making alcohol screening, assessment, and brief
intervention procedures a routine part of your clinical practice. There are
important reasons for doing so. Untreated alcoholism results in a variety of
social, economic, and medical consequences. Alcohol use can complicate treatment
for medical problems, interfere with prescribed medications, or lead to adverse
side effects. Most importantly, left untreated, alcohol abuse and alcoholism
often result in severe or fatal outcomes.
Your patients look to you for advice about the risks and benefits associated
with drinking. Research, in fact, demonstrates that simply discussing your
concerns about alcohol use can be effective in changing many patients' drinking
behavior before problems become chronic.
We commend this Guide to your attention and hope that you will make it an
integral part of your practice.
Enoch Gordis, M.D. Director National Institute on Alcohol Abuse and
Alcoholism
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Table of Contents.
WHAT YOUR PATIENTS SHOULD KNOW ABOUT ALCOHOL USE
Most adults who drink alcohol drink in moderation and are at low risk for
developing problems related to their drinking. However, all drinkers, including
low-risk drinkers, should be aware of the health risks associated with alcohol
consumption. Provide your patients with information and advice about the risks
of drinking.
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RECOMMENDATIONS TO PATIENTS FOR LOW-RISK DRINKING
Advise those patients who currently drink to drink in moderation. Moderate drinking is defined as follows:
- Men--no more than two drinks per day
- Women--no more than one drink per day
- Over 65--no more than one drink per day
Note: A standard drink is 12 grams of pure alcohol, which is equal to
one 12-ounce bottle of beer or wine cooler, one 5-ounce glass of wine, or 1.5
ounces of distilled spirits.
Advise patients to abstain from alcohol under certain conditions:
- when pregnant or considering pregnancy
- when taking a medication that interacts with alcohol
- if alcohol dependent
- if a contraindicated medical condition is present (e.g., ulcer, liver
disease)
If a patient is at risk for coronary heart disease, discuss the potential
benefits and risks of alcohol use:
- Light to moderate drinking is associated with lower rates of coronary
heart disease in certain populations (e.g., men over 45, postmenopausal
women). Infrequent or nondrinkers are not advised to begin a regimen of light
to moderate drinking to reduce the risk of coronary heart disease because
vulnerability to alcohol-related problems cannot always be predicted. Similar
protective effects can likely be achieved through proper diet and exercise.
Clinical Notes
- Women and the elderly have smaller amounts of body water than men;
therefore, they achieve a higher blood alcohol concentration than men after
drinking the same amount of alcohol.
- Exposing a fetus to alcohol can cause a broad range of birth defects
referred to as fetal alcohol syndrome (FAS) or alcohol-related birth defects
(ARBD). Although FAS/ARBD is associated with excessive alcohol consumption
during pregnancy, studies also have reported neurobehavioral deficits in
infants born to mothers reporting drinking an average of one drink per day
during pregnancy.
- Studies indicate that heavier episodic drinking (i.e., the consumption of
more than four drinks per occasion by men and more than three drinks per
occasion by women) impairs cognitive and psychomotor functions and increases
the risk of alcohol-related problems, including accidents and injuries.
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Table of Contents.
SCREENING AND BRIEF INTERVENTION PROCEDURES
Recommended screening and brief intervention procedures include four steps:
Step I. ASK about alcohol use.
Step II. ASSESS for alcohol-related problems.
Step III. ADVISE appropriate action (i.e., set a drinking goal,
abstain, or obtain alcohol treatment).
Step IV. MONITOR patient progress. Up to
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Ask all patients:
- Do you drink alcohol, including beer, wine, or distilled spirits?
Ask current drinkers about alcohol consumption:
- On average, how many days per week do you drink alcohol?
- On a typical day when you drink, how many drinks do you have?
- What is the maximum number of drinks you had on any given occasion
during the last month?
Ask current drinkers the CAGE questions:
- Have you ever felt that you should Cut down on your drinking?
- Have people Annoyed you by criticizing your drinking?
- Have you ever felt bad or Guilty about your drinking?
- Have you ever had a drink first thing in the morning to steady your nerves
or get rid of a hangover (Eye opener)?
If there is a positive response to any of these questions:
- ASK: Has this occurred during the past year?
A patient may be at risk for alcohol-related problems IF:
- alcohol consumption is:
Men:
> 14 drinks per week or > 4 drinks per
occasion Women:
> 7 drinks per week or > 3 drinks per occasion
or
- one or more positive responses to the CAGE that have occurred in the past
year
When is screening for alcohol problems appropriate?
- 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
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Patients who screen positive should be assessed to determine the nature and
extent of their alcohol-related problems. Use the assessment procedures
described below to determine problem severity, as follows: (l) at increased risk
for developing alcohol-related problems, (2) currently experiencing
alcohol-related problems, or (3) may be alcohol dependent.
1. At Increased Risk for Developing Alcohol-Related Problems
Indicators
- drinking above recommended low-risk consumption levels or in high-risk
situations
- personal or family history of alcohol-related problems
Assessment procedures
- Ask about typical drinking patterns:
How long have you been drinking
this amount? How many times in a week (or month) do you have four or more
drinks on one occasion? What is the most you have consumed on one occasion
during the past year?
- Ask about personal and family history:
Have you or anyone in your
immediate family ever had a drinking problem?
Note: For many conditions, there is a dose-response relationship
between alcohol consumption and risk. This applies to cirrhosis of the liver;
cancers of the oropharynx, larynx, liver, and breast; hypertension; and
stroke.
2. Currently Experiencing Alcohol-Related Problems
Indicators
- one or two positive responses to the CAGE that have occurred in the past
year
- evidence of alcohol-related medical or behavioral problems
Assessment procedures
- Review your patient's medical history for evidence of alcohol-related
medical problems, such as:
blackouts chronic abdominal pain depression liver
dysfunction hypertension sexual dysfunction trauma sleep
disorders
Note: Chronic heavy use of alcohol (i.e., three or more drinks per
day) may be associated with elevations in serum gamma-glutamyltransferase (GGT).
This can be an indicator of excessive drinking.
- Ask about interpersonal or work-related problems:
Has your drinking
ever caused you problems, such as problems with your family, problems with
your work (or school) performance, or accidents/injuries?
3. May Be Alcohol Dependent
Indicators
- three or four positive responses to the CAGE that have occurred in the
past year
- evidence of one or more of the following symptoms: 2
Compulsion
to drink--preoccupation with drinking Impaired control--unable
to stop drinking once started Relief drinking--drinking to avoid
withdrawal symptoms Withdrawal--evidence of tremor, nausea, sweats,
or mood disturbance Increased tolerance--takes more alcohol than
before to get "high"
Assessment procedures
- Ask the following questions:
-- Are there times when you are unable to
stop drinking once you have started? -- Does it take more drinks than
before to get "high"? -- Do you feel a strong urge to drink? -- Do you
change your plans so that you can have a drink? -- Do you ever drink in
the morning to relieve the shakes?
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Contents.
State your medical concern:
- Be specific about your patient's drinking patterns and related health
risks.
- ASK: How do you feel about your drinking?
Advise to abstain or cut down:
- Advise to abstain if:
-- evidence of alcohol dependence -- history
of repeated failed attempts to cut down -- pregnant or trying to
conceive -- contraindicated medical condition or medication
- Advise to cut down if:
-- drinking above recommended low-risk drinking
amounts and no evidence of alcohol dependence
Agree upon a plan of action:
- ASK: Are you ready to try to cut down or abstain?
Talk with patients who are ready to make a change in their drinking about a
specific plan of action.
For patients who are not alcohol dependent:
- Recommend low-risk consumption limits for your patient based upon the
low-risk drinking recommendations and your patient's health history (See
Recommendations to patients for low-risk drinking).
- Ask your patient to set a specific drinking goal:
Are you ready to set
a drinking goal? Some patients choose to abstain for a period of time or for
good; others prefer to limit the amount they drink. What do you think will
work best for you?
- Provide patient education materials and tell your patient:
It helps to
think about your reasons for wanting to cut down and examine what situations
trigger unhealthy drinking patterns. These materials will give you some useful
tips on how to maintain your drinking goal.
For patients with evidence of alcohol dependence:
- Refer for additional diagnostic evaluation or treatment.
Procedures
for patient referral are as follows: -- Involve your patient in making
referral decisions. -- Discuss available alcohol treatment services.
-- Schedule a referral appointment while the patient is in the
office.
SOME PATIENT COUNSELING TIPS
- Use an empathic, nonconfrontational .
- Offer your patient some choices about how to effect change.
- Emphasize your patient's responsibility for changing drinking behavior.
- Convey confidence in your patient's ability to change drinking behavior.
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Monitor patient progress in the same way you manage other chronic medical
problems, such as hypertension or diabetes. Recognize that behavior change is an
incremental process that often involves trial and error. Patient management
strategies include the following:
- Indicate that you (or designated staff) are available to provide ongoing
assistance and support.
- Support your patient's efforts to cut down or abstain at each subsequent
visit by:
-- reviewing progress to date -- commending your patient for
efforts made -- reinforcing positive change -- assessing continued
motivation
- Consider scheduling a separate followup visit or telephone call, as
appropriate, if the patient needs additional support.
- Consider referring a selected patient whose counseling needs exceed the
services provided in a primary care setting.
For patients who have been advised to abstain or have been referred for
alcohol treatment:
- Ask to receive periodic updates from the treatment specialist on your
patient's treatment plan and prognosis.
- Monitor symptoms of depression and anxiety. Such symptoms may occur, but
they often decrease or disappear after 2 to 4 weeks of abstinence.
- Monitor GGT levels, when appropriate, as a means of assessing alcohol
treatment compliance.
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WHAT TO DO ABOUT PATIENTS WHO ARE NOT READY TO CHANGE THEIR DRINKING
BEHAVIOR
Do not be discouraged if patients are not ready to take action immediately.
Decisions to change behavior often involve fluctuating motivation and feelings
of ambivalence. By offering your advice, you have prompted your patients to
think more seriously about their drinking behavior. In many cases, continued
reinforcement is the key to a patient's decision to take action. Offer the
following guidance to patients who are not ready to take action:
- Restate your concern for your patient's health.
- Reinforce your willingness to help when the patient is ready.
- Continue to monitor alcohol use at subsequent office visits.
For patients who may be alcohol dependent, you may want to consider some
additional strategies:
- Encourage your patient to consult an alcohol specialist.
- Ask your patient to discuss your recommendation with family members and
schedule a followup visit that includes family members/significant others.
- Recommend a trial period of abstinence, monitor for withdrawal symptoms,
and review progress in a followup visit.
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SELECTED REFERENCES
American Psychiatric Association. Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition (DSM-IV). Washington, DC: the Association,
1994.
Anderson, P.; Cremona, A.; Paton, A.; and Turner, C. The risk of alcohol.
Addiction 88:1493-1508, 1993.
Bien, T.H.; Miller, W.R.; and Tonigan, J.S. Brief interventions for alcohol
problems: A review. Addiction 88:315-336, 1993.
Gjerde, H.; Amundsen, A.; Skog, O.-J.; Morland, J.; and Aasland, O.G. Serum
gamma-glutamyltransferase: An epidemiological indicator of alcohol consumption?
British Journal of Addiction 82:1027-1031, 1987.
Gordis, E.; Dufour, M.D.; Warren, K.R.; Jackson, R.J.; Floyd, R.L.;
Hungerford, D.W.; and Pearson, T.A. Should physicians counsel patients to drink
alcohol? JAMA 273(18):1415-1416, 1995.
Hindmarch, I.; Kerr, J.S.; and Sherwood, N. The effects of alcohol and other
drugs on psychomotor performance and cognitive function. Alcohol and
Alcoholism 26(1):71-79, 1991.
Kitchens, J.M. Does this patient have a problem? JAMA
272(22):1782-1787, 1994.
National Institute on Alcohol Abuse and Alcoholism. Special Focus Issue:
Alcohol-Related Birth Defects. Alcohol Health & Research World 18(1),
1994.
U.S. Department of Health and Human Services. Nutrition and Your Health:
Dietary Guidelines for Americans. 3d ed. Washington, DC: Supt. of Docs.,
U.S. Govt. Print. Off., 1990.
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WHERE TO GO FOR ADDITIONAL INFORMATION
The National Institute on Alcohol Abuse and Alcoholism (NIAAA) Office of
Scientific Affairs Willco Building 6000 Executive Boulevard, Suite
409 Bethesda, MD 20892-7003 301-443-3860
American Society of Addiction Medicine (ASAM) 4601 North Park
Avenue Suite 101, Upper Arcade Chevy Chase, MD 20815 301-656-3920
National Council on Alcoholism and Drug Dependence (NCADD) 12 West 21st
Street New York, NY 10010 212-206-6770
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NOTES
1 Seven percent of the U.S.
population--approximately 14 million adults--meet the diagnostic criteria for
alcohol abuse or dependence.
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2 This selective listing of dependence symptoms
is offered as an initial assessment procedure and not for the purpose of making
a diagnosis. For a diagnostic evaluation, refer your patients to a specialist or
use the diagnostic procedures outlined in the Diagnostic and Statistical Manual
of Mental Disorders, Fourth Edition (DSM-IV).
Back to
U.S. Department of Health and Human Services Public Health
Service National Institutes of Health National Institute on Alcohol Abuse
and Alcoholism
All material contained in this Guide is in the public domain and
may be reproduced without permission from NIAAA. Citation of the source is
appreciated.
NIH Publication No. 95-3769 Printed 1995
NOTE: Printed copies of the publication Physicians' Guide to Helping
Patients with Alcohol Problems is out-of stock. This publication is only
available online via the NIAAA Web site.
Updated: March 2000
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