Etoh Use Syllabus

8/3/2019 Etoh Use Syllabus

1/16intheclinic

in the clinic

Alcohol UseHealth Effects page ITC3-2

Prevention and Screening page ITC3-3

Diagnosis page ITC3-5

Treatment page ITC3-7

Practice Improvement page ITC3-14

CME Questions page ITC3-16

Science WriterJennifer F. Wilson

Section Co-EditorsChristine Laine, MD, MPHDavid R. Goldmann, MDHarold C. Sox, MD

The content ofIn the Clinic is drawn from the clinical information and

education resources of the American College of Physicians (ACP), including

PIER (Physicians Information and Education Resource) and MKSAP (Medical

Knowledge and Self-Assessment Program). Annals of Internal Medicine

editors develop In the Clinic from these primary sources in collaboration with

the ACPs Medical Education and Publishing Division and with the assistance

of science writers and physician writers. Editorial consultants from PIER and

MKSAP provide expert review of the content. Readers who are interested in theseprimary resources for more detail can consult http://pier.acponline.org and other

resources referenced in each issue ofIn the Clinic.

The information contained herein should never be used as a substitute for clinical

judgment.

CME objective: To review the health effects, prevention and screening, diagnosis,

treatment, and practice improvement for alcohol use.

2009 American College of Physicians


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Which health problems havedefinite links to alcohol use?

Excessive drinking is associatedwith acute medical complications,chronic diseases, reproductive prob-lems, nutritional deficiencies,psychological problems, and injuries(3). It is important to note that

alcohol-related morbidity and mor-tality occur at drinking levels belowthose typically associated with alco-hol abuse or dependence (4, 5).

Heavy drinking episodes can lead toacute alcohol poisoning, a medicalemergency that results from highblood alcohol levels that suppressthe central nervous system and maycause loss of consciousness, lowblood pressure and body tempera-ture, coma, respiratory depression,

and death.

Hypertension, stroke, cardiomyopa-thy, cirrhosis, chronic pancreatitis,brain atrophy, osteoporosis, varioustypes of cancer (including liver,mouth, throat, larynx, esophagus,and probably breast and colon),gastroesophageal reflux, esophagitis,peptic ulcers, pancreatitis, seizures,and arrhythmias are among the dis-eases associated with excess alcoholuse. Alcohol also complicates the

management of chronic diseases,such as diabetes mellitus, hepatitisC infection, and HIV infection.

Heavy alcohol users often have poornutrition and are at risk for defi-ciencies in vitamin A, vitamin Bcomplex, vitamin C, folic acid,carnitine, magnesium, selenium,zinc, essential fatty acids, andantioxidants.

2009 American College of Physicians ITC3-2 In the Clinic Annals of Internal Medicine 3 March 2009

The National Institute on Alcohol Abuse and Alcoholism (NIAAA)estimates that the prevalence of alcohol dependence in the UnitedStates is 5%, but up to 3 of every 10 adults drink alcohol at levels

associated with adverse health and social consequences (1). Physicians play animportant role in recognizing alcohol misuse, managing its medical compli-cations, and helping patients change their behavior. Unfortunately, cliniciansprovide recommended alcohol-related screening and intervention for eligiblepatients only about 10% of the time (2).

Health Effects

1. National Institute onAlcohol Abuse andAlcoholism. HelpingPatients Who Drink

Too Much: A Clini-cians Guide. U.S.Department ofHealth and HumanServices, PublicHealth Service,National Institutes ofHealth. NIH Publica-tion No. 07-3769.2007.

2. McGlynn EA, AschSM, Adams J, et al.

The quality of healthcare delivered toadults in the UnitedStates. N Engl J Med.2003;348:2635-45.[PMID: 12826639]

3. Rehm J, Room R, Gra-ham K, et al. The rela-tionship of averagevolume of alcoholconsumption andpatterns of drinkingto burden of disease:an overview. Addic-tion. 2003;98:1209-28.[PMID: 12930209]

4. Fiellin DA, Reid MC,OConnor PG. Outpa-tient management ofpatients with alcoholproblems. Ann InternMed. 2000;133:815-27. [PMID: 11085845]

5. Reid MC, Fiellin DA,OConnor PG. Haz-

ardous and harmfulalcohol consumptionin primary care. ArchIntern Med.1999;159:1681-9.[PMID: 10448769]

6. American PsychiatricAssociation. Diagnos-tic and StatisticalManual of MentalDisorders: DSM IV. 4thed. American Psychi-atric Association. TaskForce on DSM-IV.Washington, DC:American PsychiatricAssociation; 1994.

A pregnant woman who drinksheavily may harm the fetus, withcomplications including miscar-riage, the fetal alcohol syndrome, ormore subtle neurocognitive conse-quences.

In addition to physical complica-

tions, excessive alcohol use causesmental health and social problems(6). Alcohol use is associated withdepression, motor vehicle accidents(7), falls, drowning, burns, firearminjuries, unsafe sex, intimate partner

violence, child maltreatment, homi-cide, and suicide.

Does alcohol use have positivehealth effects?Although heavy drinking increasesthe risk for many health problems,

light-to-moderate alcohol intake(2 drinks per day in men and1 per day in women) has been asso-ciated with positive cardiovascularoutcomes (8). Although some stud-ies suggest that wine has an advan-tage over other types of alcoholicbeverages, other studies suggestthat the type of alcohol is notimportant (9).

The mechanisms behind the favor-able association between light-to-

moderate alcohol intake and car-diovascular outcomes are uncertain.Light-to-moderate alcohol use mayincrease high-density lipoproteincholesterol levels, reduce plasma

viscosity and fibrinogen concentra-tion, increase fibrinolysis, decreaseplatelet aggregation, improveendothelial function, reduce inflam-mation, and promote antioxidanteffects. Alternatively, people who


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7. Ramstedt M. Alcoholand fatal accidents inthe United States-atime series analysisfor 1950-2002. AccidAnal Prev.2008;40:1273-81.[PMID: 18606256]

8. Kloner RA, RezkallaSH. To drink or not todrink? That is thequestion. Circulation.2007;116:1306-17.[PMID: 17846344]

9. Saremi A, Arora R. The

cardiovascular impli-cations of alcoholand red wine. Am J

Ther. 2008;15:265-77[PMID: 18496264]

10. U.S. Preventive Ser-vices Task Force.Screening andbehavioral counsel-ing interventions inprimary care toreduce alcohol mis-use: recommenda-tion statement. AnnIntern Med.2004;140:554-6.[PMID: 15068984]

2009 American College of PhysiciansITC3-3In the ClinicAnnals of Internal Medicine3 March 2009

drink alcohol at this level may behealthier or more socioeconomi-cally advantaged than people withlower or higher alcohol intake.

Although alcohol may have posi-tive health effects, the AmericanHeart Association has strongly

advised that nondrinkers shouldnot start drinking solely to benefittheir heart.

Which groups are at particularly

high risk for adverse health

outcomes from excessive alcohol

intake?

People at especially high risk foralcohol-associated health problemsinclude those with medical

conditions that alcohol can exacer-bate, pregnant women, and peoplerecovering from alcohol depend-ence. Of note, women and the eld-erly are generally more susceptibleto alcohol-related damage to suchorgans as the liver. Of course, peo-ple who intend to drive or engage

in other activities that requirealertness should abstain from alco-hol before these activities.

Many medications interact harm-fully with alcohol (see Box). Theseinteractions may result in increasedrisk for illness, injury, and death.People receiving these medicationsshould exercise caution concerningalcohol use.

Health Effects... Although light-to-moderate alcohol use has been associated withfavorable cardiovascular outcomes, drinking larger amounts (2 drinks per day in

men and 1 per day in women) increases the risk for numerous chronic diseases,

acute medical conditions, reproductive problems, psychological problems, and

injuries. Women who are pregnant endanger the health of their fetus if they drink

alcohol. Alcohol interacts adversely with many medications.

CLINICAL BOTTOM LINE

Prevention and

Screening

drinkers indirectly suggests that

screening and intervention may beparticularly important in youngpeople.

What are effective methods to

screen for unhealthy alcohol use

in clinical settings?

Screening can begin with the sim-ple question, Do you sometimesdrink alcoholic beverages? TheNIAAA recommends that clini-cians next either ask all patients

who drink alcohol about heavydrinking days or have the patientscomplete a formal screening ques-tionnaire.

To estimate a patients level ofalcohol use, clinicians should pur-sue further questioning to deter-mine the average weekly number ofdrinks for all patients who screenpositive.

Should clinicians screen for

unhealthy alcohol use?The NIAAA recommends screen-ing all patients annually to deter-mine their level of alcohol use andto advise patients of the safe levelsof alcohol consumption (see Box)(1). Clinicians should advisepatients who exhibit at-risk drink-ing behavior to decrease their alco-hol consumption to below the rec-ommended safe drinking levels. In2004, on the basis of fair evidence,the U.S. Preventive Services TaskForce (USPSTF) recommendedscreening and behavioral interven-tions to reduce alcohol misuse byadults, including pregnant women,in primary care settings (10). TheUSPSTF found that evidence wasinsufficient regarding screening andbehavioral counseling for adoles-cents. However, the elevated risk foralcohol use disorders in early-onset

Harmful

AlcoholMedication

Interaction Can Occur

With the Following

Medications

Analgesics

Antibiotics

Anticoagulants

Antidepressants Antihistamines

Antiseizure medica-tions

Diabetes medications

-blockers

Sleeping pills

National Institute of Alcohol

Abuse and Alcoholism Safe

Drinking Levels for Adults

Without Contraindications to

Alcohol Use

Men: 14 drinks/week and 4drinks on 1 occasion

Women: 7 drinks/week and 3drinks on 1 occasion

NIAAA recommends 1 drink/dayfor people 65 years old

1 drink is defined as 12 ounces ofbeer, 5 ounces of wine, or 1.5ounces of spirits


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11. Fiellin DA, Reid MC,OConnor PG. Screen-ing for alcohol prob-lems in primary care:a systematic review.Arch Intern Med.2000;160:1977-89.[PMID: 10888972]


Formal screening instruments havebetter sensitivities and specificitiesfor alcohol problems than informaltechniques. Currently, the instru-ments in common use in clinicalsettings include the AUDIT (Alco-hol Use Disorders Identification

Test), the shorter AUDIT-C ques-

tionnaire, the CAGE questionnaire,and the MAST (Michigan AlcoholScreening Test).

AUDIT

The 10-item AUDIT screeninginstrument takes about 5 minutesto complete and asks about quan-tity of alcohol imbibed, frequencyof drinking, binge behavior, andalcohol-related problems. AUDITidentifies not only people with alco-

hol dependence but also at-riskdrinkers (11). When time is limited,the 3-item AUDIT-C questionnairecan be used, which includes itemsabout quantity and frequency ofdrinking (see Box) (12). Cliniciansshould be aware that the operatingcharacteristics of AUDIT instru-ments vary with patient characteris-tics and setting (13).

CAGE questionnaire

The CAGE questionnaire is a

4-item screening test (see Box)(14). It is better at identifying alco-hol dependence than lower levels ofproblem drinking or binge drinkingand performs poorly in the elderly.

Michigan Alcohol Screening Test

The MAST and the shorter MAST(SMAST) questionnaires focus on

alcohol dependence, with items thatassess the consequences of problemdrinking and the participants ownperceptions of their alcohol prob-lems. A geriatric version of MAST(MAST-G) is available and isadvised for use in older patients (15).

During encounters in which atleast 5 minutes are available toaddress alcohol use, the NIAAArecommends the AUDIT question-naire for screening, with use ofAUDIT-C if there is less timeavailable. The U.S. Preventive Ser-

vices Task Force does not recom-mend a single screening tool butacknowledges that the AUDITquestionnaires are the best-studied

tools in primary care settings (10).If there is insufficient time toadminister a formal screening tool,physicians should ask patientsabout heavy drinking days duringthe past year. Patients who reportat least 1 heavy drinking day(5 drinks for men and 4 drinks for

women) are at-risk drinkers andrequire further assessment andcounseling about safe drinkinglevels.

Patient self-report of drinking andits consequences has been found tobe as reliable as collateral reportsfrom family members (16). Evi-dence supports the use of self-report for accurate assessments ofdrinking status (17).

AUDIT-C Questionnaire

How often did you have a drink con-taining alcohol in the past year?

Never (0 points)

Monthly or less (1 point)

2-4 times per month (2 points)

2-3 times per week (3 points)

4 or more times per week(4 points)

How many drinks did you have on atypical day when you were drinkingin the past year?

None or 1-2 (0 points)

3-4 (1 point)

5-6 (2 points)

7-9 (3 points)

10 or more (4 points)

How often did you have 6 or moredrinks on one occasion in the pastyear?

Never (0 points)

Less than monthly (1 point) Monthly (2 points)

Weekly (3 points)

Daily or almost daily (4 points)

Add up points to calculate a score of 1to 12. Positive screen for at-risk drink-ing is >4 points in men and >3 points inwomen. The higher the AUDIT-C score,the more likely it is that the patientsdrinking has adverse health and safetyeffects.

Prevention and Screening... Clinicians should screen all patients annually todetermine their level of alcohol consumption and to advise them on safe drinking

levels (3 drinks per occasion for women) also indicates risky alcohol use. For-

mal screening instruments are more accurate than less formal techniques. AUDIT

is the best-studied instrument in primary care settings.


CAGE Questionnaire1. Have you ever felt you should Cut

down on your drinking?

2. Have people Annoyed you bycriticizing your drinking?

3. Have you ever felt bad or Guiltyabout your drinking?

4. Have you ever had a drink firstthing in the morning to steadyyour nerves or get rid of ahangover (Eye-opener)?

Posttest probability of alcohol depend-ence has been found to be 7%, 46%,72%, 88%, and 98% with CAGE scoresof 0, 1, 2, 3, and 4, respectively.


5/16 2009 American College of PhysiciansITC3-5In the ClinicAnnals of Internal Medicine3 March 2009

12. Bush K, Kivlahan DR,McDonell MB, et al.

The AUDIT alcoholconsumption ques-

tions (AUDIT-C): aneffective briefscreening test forproblem drinking.Ambulatory CareQuality Improve-ment Project(ACQUIP). AlcoholUse Disorders Identi-fication Test. ArchIntern Med.1998;158:1789-95.[PMID: 9738608]

13. Steinbauer JR, Can-tor SB, Holzer CE 3rdet al. Ethnic and sexbias in primary carescreening tests foralcohol use disor-ders. Ann InternMed. 1998;129:353-62. [PMID: 9735062]

14. Buchsbaum DG,Buchanan RG, Cen-tor RM, et al. Screen-ing for alcoholabuse using CAGEscores and likeli-hood ratios. AnnIntern Med.1991;115:774-7.[PMID: 1929025]

15. Morton JL, Jones TV,Manganaro MA. Per-formance of alco-holism screeningquestionnaires inelderly veterans. AmJ Med. 1996;101:153-9. [PMID: 8757354]

16. Babor TF, Steinberg

K, Anton R, et al. Talkis cheap: measuringdrinking outcomesin clinical trials. JStud Alcohol.2000;61:55-63.[PMID: 10627097]

17. Brown J, Kranzler HRDel Boca FK. Self-reports by alcoholand drug abuseinpatients: factorsaffecting reliabilityand validity. Br JAddict.1992;87:1013-24.[PMID: 1322747]

How should clinicians distinguish

between moderate alcohol

consumption, at-risk drinking, and

alcohol abuse and dependence?

It is important to distinguishbetween moderate alcohol con-

sumption, at-risk drinking, andalcohol abuse and dependencebecause the severity of the alcoholproblem determines the likelihoodthat the patient will respond to var-ious interventions. Table 1 lists cat-egories and definitions of patternsof alcohol use.

NIAAA criteria, or similar criteria,serve as the gold standard for at-risk drinking, and the AmericanPsychiatric Associations (APA)Diagnostic and Statistical Manualof Mental Disorders (DSM)-IV cri-teria are the gold standard for alco-hol abuse and dependence. At-riskdrinking is drinking at levels thatcan lead to diverse physical, psycho-logical, and social consequences,

whereas alcohol use disorders (thatis, abuse and dependence) are char-acterized by continued drinkingdespite adverse consequences. The

World Health Organization(WHO) uses the terms hazardous

drinking for at-risk drinkers andthe term harmful drinking toidentify persons in whom alcohol iscausing physical or psychologicalharm but who have not met criteriafor alcohol dependence. Both theAPA and WHO use similar criteriato define alcohol dependence.

Patient assessment relies on ele-ments of the history and physicalexamination in conjunction withformal screening instruments todetect alcohol problems and otherproblems that can present in a sim-ilar manner or coexist with alcoholproblems. In particular, cliniciansshould look for psychiatric disor-ders, other substance use disorders,a family history of substance use,

Table 1. Categories and Definitions of Alcohol Use Patterns

Alcohol Pattern Characteristics

At-risk drinking* Men 14 drinks per week or >4 drinks per occasion

Women 7 drinks per week or >3 drinks per occasionMen and women 65 years, 1 drink per day

Hazardous drinking At risk for adverse consequences from alcohol

Harmful drinking Alcohol is causing physical or psychological harm

DSM-IV alcohol abuse 1 of the following events in a year:

Recurrent use resulting in failure to fulfill major role obligations

Recurrent use in hazardous situations

Recurrent alcohol-related legal problems (for example, driving under the influence)

Continued use despite social or interpersonal problems caused or exacerbated byalcohol

DSM-IV alcohol 3 of the following events in a year:dependence Tolerance

Increased amounts to achieve effect; diminished effect from same amount

Withdrawal

Great deal of time spent obtaining alcohol, using it, or recovering from its effects

Important activities given up or reduced because of alcohol

Drinking more or longer then intended

Persistent desire or unsuccessful efforts to cut down or control alcohol use

Use continued despite knowledge of having a physical or psychological problemcaused or exacerbated by alcohol

* As defined by the National Institute on Alcohol Abuse and Alcoholism.

As defined by the World Health Organization.

As defined by the American Psychiatric Association.

Diagnosis


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18. Staines GL, MaguraS, Foote J, et al. Poly-substance useamong alcoholics. JAddict Dis.2001;20:53-69.[PMID: 11760926]

19. Booth BM, Yates WR,Petty F, et al. Patientfactors predictingearly alcohol-relatedreadmissions foralcoholics: role ofalcoholism severityand psychiatric co-morbidity. J StudAlcohol. 1991;52:37-43. [PMID: 1994121]

20. Patten CA, Martin JE,Owen N. Can psychi-

atric and chemicaldependency treat-ment units besmoke free? J SubstAbuse Treat.1996;13:107-18.[PMID: 8880668]

21. Lapham SC, Smith E,Cde Baca J, et al.Prevalence of psy-chiatric disordersamong persons con-victed of drivingwhile impaired. ArchGen Psychiatry.2001;58:943-9.[PMID: 11576032]

specific in the absence of liverdisease, but has a sensitivity of onlyabout 60%. Several novel alcoholbiomarkers are the subject of clini-cal investigations.

Although current laboratory tests donot accurately identify alcohol use,

testing can identify medical compli-cations related to alcohol use, such aspancreatitis or cirrhosis.

Which other psychologicalconditions should clinicians bealert for in patients withunhealthy alcohol use?Patients with unhealthy alcohol usemay also have other substance usedisorders. Treatment of thesepatients involves addressing allexisting substance use disorders.

Comorbid substance use disorderscan alter the response to varioustreatment interventions. Thesepatients benefit from additionaltreatment services and treatmentfrom a clinician with a specializa-tion in addiction medicine (18, 19).Persons with alcohol problems fre-quently also use tobacco. As manyas 80% of people with alcoholdependence smoke, compared withabout 30% in the general popula-tion (20).

Psychiatric disorders also occur fre-quently among persons with alco-hol problems. About one half of

women and 33% of men with ahistory of alcohol use disordershave at least 1 other psychiatric dis-order (21). Untreated alcoholdependence can intensify depressivestates and increase the likelihood ofsuicide and other self-destructivebehavior. Mood disorders can exac-erbate the negative affect encoun-

tered during attempts to abstainfrom alcohol. Alcohol abuse mayalso develop when patients usealcohol to self-treat an underlyingmood disorder.

A study that compared 318 patients withmajor depression and no alcohol use disor-der with 187 patients with both majordepression and alcohol use disordershowed that patients with both disorders

and alcohol-associated medicalconditions.

What is the role of history andphysical examination in the

evaluation of patients withunhealthy alcohol use?

When patients screen positive for

at-risk or problem drinking, theyshould undergo assessment for evi-dence of the physical effects ofexcess alcohol, as well as for alco-hol-related social problems thatreflect the DSM criteria for alcoholuse disorders (see Box).

Physical examination is often nor-mal in problem drinkers, but canreveal complications from heavydrinking. Clinicians should lookfor hypertension and adverse effects

on cardiovascular and gastro-intestinal function and liver disease(see Box).

When should clinicians uselaboratory testing to evaluate

patients with unhealthy alcoholuse?

Laboratory tests, such as -glutamyltransferase, aspartate aminotrans-ferase, alanine aminotransferase, andmean corpuscular volume alone donot accurately detect alcohol prob-

lems (11). Percentage of carbohy-drate deficient transferrin is the onlylaboratory marker approved by theU.S. Food and Drug Administration(FDA) to detect chronic heavydrinking. This marker is highly

History of the Following Events

May Indicate Excessive Alcohol

Use

Driving while intoxicated

Missed work

Failed relationships

Arguments about alcohol

Injuries

Alcohol-associated medicalconditions

Physical Examination Findings That

May Indicate Excessive Alcohol Use

Hypertension

Jaundice

Spider angiomata

Cardiomyopathy

Atrial fibrillation

Gynecomastia

Hepatosplenomegaly

Ascites

Testicular atrophy

Palmar erythema, plethoric facies

Peripheral neuropathy

Cognitive abnormalities


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goal of treatment is abstinence.

Among alcohol-dependent individ-uals with otherwise good health,social support, and motivation, thelikelihood of recovery is good.Approximately 50% to 60% remainabstinent at the end of 1 year oftreatment, and a majority of thosestay sober permanently. Those withpoor social support, poor motiva-tion, or psychiatric disorders are athigher risk for relapse. For patients

who do relapse, success is measured

by longer periods of abstinence andreduced use of alcohol.

What should clinicians do if they

identify patients with at-risk orhazardous drinking?

Effective treatment of alcohol prob-lems can occur in the primary caresetting, but many persons whoabuse alcohol never receive treat-ment. One study found that only24% of those with alcohol depend-ence were ever treated (23). Briefinterventions are effective forpatients with at-risk drinking butare less effective for patients with

alcohol abuse and dependence.For patients who misuse alcoholbut are not alcohol dependent, thegoal of treatment is to decreasetheir alcohol consumption to belowthe NIAAA-recommended safedrinking levels. If patients cannotmoderate alcohol intake, theyshould abstain from alcohol.

For patients with alcohol abuse anddependence, various psychosocial

counseling strategies (such as 12-step facilitation, cognitive behav-ioral therapy, and motivationalenhancement therapy) and drugagents (such as naltrexone, acam-prosate, and disulfiram) are moreeffective than brief interventions(4, 24).

For patients who meet DSM crite-ria for abuse or dependence, the

22. Sher L, Stanley BH,Harkavy-FriedmanJM, et al. Depressedpatients with co-occurring alcoholuse disorders: aunique patient pop-ulation. J Clin Psychi-

atry. 2008;69:907-15.[PMID: 18422397]23. Hasin DS, Stinson FS

Ogburn E, et al.Prevalence, corre-lates, disability, andcomorbidity of DSMIV alcohol abuse anddependence in theUnited States: resultsfrom the NationalEpidemiologic Sur-vey on Alcohol andRelated Conditions.Arch Gen Psychiatry.2007;64:830-42.[PMID: 17606817

Treatment


were younger at their first psychiatrichospitalization, major depressive episode,or suicide attempt. They also reported

more previous episodes of major depression;more suicide attempts; and higher lifetimeaggression, impulsivity, and hostility. (22).

Diagnosis... Patient assessment relies on elements of the history and physicalexamination in conjunction with formal screening questionnaires to detect alcoholproblems. The physical examination may reveal complications from heavy drinkingand the history may reveal alcohol-related social problems. Laboratory tests can

help detect alcohol-related complications. To determine optimal management, it isimportant to distinguish between moderate alcohol consumption (1 and 2drinks per day in women and men age 65 years), at-risk drinking (more than moderate drinking butno other sequelae), and alcohol abuse (alcohol-related social and behavioral prob-lems) and dependence (tolerance, withdrawal, inability to control use).


Brief Interventions to Reduce

Alcohol Consumption in Patients

with At-Risk Drinking

Feedback on clinical assessmentand adverse effects of alcohol

Discussion of the adverse effectsof alcohol consumption

Comparison to national drinkingnorms

Specificy recommended drinking

limits Prescription to cut down on

drinking

Provide patient education mate-rial from the NIAAA

Daily self-monitoring log informa-tion from the NIAAA

Repeated office sessions

NIAAA = National Institute of AlcoholAbuse and Alcoholism.


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24. Fiellin DA, Reid MC,OConnor PG. Newtherapies for alcoholproblems: applica-tion to primary care.Am J Med.2000;108:227-37.[PMID: 10723977]

25. Fleming MF, BarryKL, Manwell LB, et al.Brief physicianadvice for problemalcohol drinkers. Arandomized con-trolled trial in com-munity-based pri-mary care practices.JAMA.1997;277:1039-45.[PMID: 9091691]

26. Saitz R, Palfai TP,Cheng DM, et al.Brief intervention for

medical inpatientswith unhealthy alco-hol use: a random-ized, controlled trial.Ann Intern Med.2007;146:167-76.[PMID: 17283347]

27. Chappel JN. Addic-tion psychiatry andlong-term recoveryin 12-step programs.In: Miller NS, ed. ThePrinciples and Prac-tice of Addictions inPsychiatry. Philadel-phia: WB Saunders;1997:567.


Are behavioral therapies effective

in the treatment of unhealthyalcohol use?

Treatment can begin once the alco-hol-dependent person accepts thatthe problem exists and is motivatedto stop drinking. Research supportsthe use of brief intervention and

psychosocial counseling in somepatients with alcohol problems. Briefinterventions have been shown to beeffective for patients with at-riskdrinking (see Box).They are lesseffective for patients with alcoholabuse and dependence.

In a randomized clinical trial, 723 problemdrinkers in primary care practices received

either brief intervention or usual care. At 12months, the brief intervention groupshowed a decrease in the mean number of

drinks per week (19.1 to 11.5 drinks) com-pared with usual-care participants (18.9 to15.5 drinks, P < 0.05). Similar decreaseswere seen in the incidence of binge and

excessive drinking (25).

A randomized trial assessed the effective-ness of a brief intervention in 341 mostly

alcohol-dependent medical inpatientswho reported drinking risky amounts (>14drinks/week or 5 drinks/occasion formen, >11 drinks/week or4 drinks/occa-

sion for women). The brief intervention, a30-minute session of motivational coun-

seling during the hospital stay, was notassociated with change in drinks per

month in all patients at 12 months or inreceipt of further alcohol treatment at 3months among the 77% of patients who

were alcohol dependent (26).

For those with alcohol abuse anddependence, more-extensive psy-chosocial counseling strategies,such as 12-step facilitation, cogni-tive behavioral therapy, or motiva-tional enhancement therapy,

improve the chances of treatmentsuccess.

The 12-step facilitation programencourages patients who are alco-hol dependent to first accept thatthey have a chronic and progressiveillness; recognize that they havelost the ability to control theirdrinking; and realize that, becausethere is no cure for alcoholism, the

only viable alternative is completeabstinence. They then surrender totreatment by acknowledging thatthe hope for recovery exists andthat fellowship, such as in Alco-holics Anonymous, aids sustainedsobriety.

Participation in a mutual supportgroup, such as Alcoholics Anony-mous, can provide valuable supportfor people recovering from alcoholdependence. Alcoholics Anony-mous is a free, widely available fel-lowship program, with the onlymembership requirement being adesire to stop drinking(www.aa.org). Alcoholics Anony-mous features the 12-step facilita-tion program. The resources pageof the National Clearinghouse forAlcohol and Drug Information

Web site (www.ncadi.samhsa.gov/referrals) lists additional mutualhelp organizations.

A meta-analysis of 74 studies of Alco-holics Anonymous showed that partici-

pation in Alcoholics Anonymous wasmodestly correlated with drinking reduc-tion. Approximately 50% of new entrants

continued participation at 3 months, and41% of those participating for 1 yearremained an additional year. The dura-

tion of sobriety for Alcoholics Anonymousmembers was evenly distributed, withapproximately one third sober less than

1 year, 1 to 5 years, and more than 5 years,respectively (27).

Cognitive behavioral therapy has 2main components: functional analy-sis and skills training. In functionalanalysis, the therapist and thepatient work together to identifythe thoughts, feelings, and circum-stances of the patient before and

after they drink. This process helpsgive the patient insight into whythey drink, identify coping difficul-ties, and determine risks that maylead to a relapse. Skills traininghelps patients unlearn bad habitsand learn new skills for coping withtheir problems.

Motivational enhancement therapyuses motivational principals to


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enhance behavior change. Thera-pists guide patients through stagesof change toward action and main-tenance (in which they take stepsto change and to maintain suchchanges in the long term) (28).

The 3-year results of a trial showed that

participants high in anger fared better inmotivational enhancement therapy thanin cognitive behavioral therapy or 12-stepfacilitation. Conversely, participants lowin anger performed better after treatmentin cognitive behavioral therapy or 12-stepfacilitation than in motivational enhance-ment therapy. Participants whose socialnetworks were more supportive of drinkingderived greater benefit from 12-step facili-tation treatment than from motivationalenhancement therapy (29).

Family and social networks play animportant role in decreasing alcoholconsumption in patients receivingtreatment for alcohol problems andshould be engaged in the treatmentprocess when possible (30).

What are the indications for

hospitalization of a patient withunhealthy alcohol use?Few empirical data exist to guidethe decision to treat a patient as anoutpatient or inpatient for the alco-hol withdrawal syndrome. Clinicalexperience indicates that contraindi-cations for ambulatory detoxificationinclude acute or chronic medical orpsychiatric illness that would requirehospitalization or that would be

Table 2. Drug Treatment for Alcohol Dependence

Agent (Typical Dosage)* Indication Mechanism Side Effects Notes

Benzodiazepines Treatment or prophylaxis Enhance GABA inhibition Oversedation, paradoxic Caution in the presence of(symptom-triggered: for the alcohol of neuronal excitability hyperactivity, depression. respiratory or hepaticchlordiazepoxide, withdrawal syndrome Can be habit-forming. impairment.50100 mg;diazepam, 1020 mg;or lorezapam, 24 mgevery 12 h untilsymptoms subside.Fixed-dose:chlordiazepoxide, 50 mg;diazepam, 10 mg; orlorezapam, 2 mg every6 h on day 1 then onehalf dose every 6 hon days 2 and 3)

Naltrexone (50100 mg/d Prevention of relapse in Opioid antagonist that Nausea, indigestion, Avoid in the presence of opioidoral or 380 mg monthly alcohol-dependent may reduce the subjective headache, fatigue. use and with cirrhosis or hep-injection) patients reward associated with Rarely drug-associated atitis. Use for longer than

drinking hepatitis. Potential for 12 weeks has not been studiedopioid withdrawal if in placebo-controlled trials.narcotic use not excluded.

Acamprosate (666 mg Prevention of relapse in May antagonize Usually well tolerated. Used in Europe but large U.S.3 times daily) alcohol-dependent glutamate-mediated Occasional gastrointestinal multicenter studies have not

patients neuronal hyperexcitability upset , myalgias, rash, shown eff icacy. Reducedand reduce prolonged dizziness, palpitations. dosage with renal insufficiency(but not acute) Has rarely been associated Can be used with naltrexone.withdrawal symptoms with renal impairment.

Disulfiram (250500 mg/d) Prevention of drinking Aldehyde dehydrogenase Drowsiness, rash. Rarely Many drug interactions.

and relapse in alcohol- inhibition results in drug-associated severe Patient must be abstinent atdependent patients acetaldehyde liver toxicity, optic neuritis, least 12 hours beforeaccumulation when peripheral neuropathy. administration. Avoid indrinking and unpleasant patients with hepaticsymptoms (i.e., alcohol impairment or cardiovasculardisulfiram reaction) disease. Treatment may be

needed for months to years.

GABA = -aminobutyric acid.

* Naltrexone, disulfiram, and acamprosate are all U.S. Food and Drug Administration pregnancy category C (animal studies indicate potential fetal risk orhave not been conducted and no or insufficient human studies have been done; drugs in this category should be used with pregnant or lactating womenonly when potential benefits justify potential risk to the fetus or infant). Benzodiazepines are category X (contraindicated in pregnancy) or D (positiveevidence of risk).

28. Connors GJ, Dono-van DM, DiClementeCC. SubstanceAbuse Treatmentand the Stages ofChange. New York:

Guilford Press, 2001.29. Matching alco-

holism treatments toclient heterogeneityProject MATCHthree-year drinkingoutcomes. AlcoholClin Exp Res.1998;22:1300-11.[PMID: 9756046]

30. Longabaugh R.Involvement of sup-port networks intreatment. RecentDev Alcohol.2003;16:133-47.[PMID: 12638635]



complicated by a hyperautonomicstate, pregnancy, history of seizures,severe withdrawal with delirium,inability to follow-up daily, and noreliable contact person. Thesepatients should be hospitalized foralcohol detoxification.

Intoxicated patients should beobserved until intoxication hasresolved or admitted if a responsibleadult is not available.

When should clinicians considerdrug therapy for patients withunhealthy alcohol use?Pharmacotherapy should be consid-ered in all patients who meet thecriteria for alcohol abuse anddependence for whom there are nocontraindications (31). Short-term

pharmacotherapy provides a safewithdrawal from alcohol, and long-term therapies aim to preventrelapse (Table 2).

When is it appropriate to use apharmacologic detoxification inthe treatment of patients withunhealthy alcohol use?

The response of individuals to thesame level of alcohol intake varies,and many confounding variables,such as duration of drinking and

binge drinking patterns, determinewho develops more serious with-drawal. Withdrawal symptoms gen-erally begin 6 to 24 hours after the

intake of alcohol is substantiallyreduced or stopped. Minor

withdrawal may peak at about 36hours, whereas major withdrawalmay peak at 50 hours and last up to5 days (see Box). Delirium tremens,a rare complication characterized byfever, profound confusion, and hal-

lucinations, does not usually occurbefore the second to third day ofabstinence. Treatment of minor

withdrawal consists of supportivecare and possibly medications,

whereas treatment of major with-drawal requires medication andpossibly hospitalization.

Clinicians should identify theseverity of withdrawal and factorsthat may predict the onset of seri-ous complications. The 10-item

Clinical Institute WithdrawalAssessment Scale for Alcohol,Revised can be used to measuresymptom severity and to help pro-

vide guidance in the course of treat-ment (32).

Which medications are indicatedto prevent or treat alcoholwithdrawal?Benzodiazepines

Benzodiazepines are first-line ther-apy for patients who require phar-

macologic prophylaxis or treatmentfor alcohol withdrawal (see Box).Patients with the alcohol with-drawal syndrome who are treated

with benzodiazepines have fewercomplications, including a decreasein the incidence of seizures anddelirium tremens (33).

All benzodiazepines are similarlyefficacious. Short-acting benzodi-

and lorazepam) can be used for

treatment of alcohol-withdrawalseizures and have been shown todecrease the incidence of secondseizure and hospitalization (34).Longer-acting agents (chlor-

halazepam) may be more effective inpreventing seizures, but can pose a

31. Garbutt JC, West SL,Carey TS, et al. Phar-macological treat-ment of alcoholdependence: areview of the evi-dence. JAMA.1999;281:1318-25.[PMID: 10208148]

32. Sullivan JT, Sykora K,Schneiderman J, etal. Assessment ofalcohol withdrawal:the revised clinicalinstitute withdrawalassessment for alco-hol scale (CIWA-Ar).Br J Addict.1989;84:1353-7.[PMID: 2597811]

33. Mayo-Smith MF.Pharmacologicalmanagement ofalcohol withdrawal.A meta-analysis andevidence-basedpractice guideline.American Society ofAddiction MedicineWorking Group on

PharmacologicalManagement ofAlcohol Withdrawal.JAMA. 1997;278:144-51. [PMID: 9214531]

34. DOnofrio G, RathlevNK, Ulrich AS, et al.Lorazepam for theprevention of recur-rent seizures relatedto alcohol. N Engl JMed. 1999;340:915-9. [PMID: 10094637]

Clinical Features of Alcohol

Withdrawal*

Minor symptoms: Diaphoresis,nystagmus, tachycardia, hyper-reflexia, hypertension, nauseaor vomiting, low-grade fever,diarrhea, mild agitation

Hallucinations (auditory, visual,

tactile): May occur whileintoxicated; sensorium other-wise clear unless progressionto delirium tremens

Withdrawal seizures: Grand mal-peak occurrence 12 to 48hours after last drink; clustermay occur over 3 to 6 hours,although last seizure occursmore than 6 hours after firstin 15% of cases

Delirium tremens: Agitated con-fusional state with tremulous-ness, hallucinations, and strik-ing autonomic overactivity;fever in 82% of cases, often

associated with comorbidillness

* Adapted from reference 32.

Provide Benzodiazepines to

Patients With:

Previous alcohol-relatedseizures or delirium tremens

Substantial withdrawal symp-toms (CIWA-Ar score >12)

More-severe or long-standingalcohol dependence

History of failed or multipledetoxification attempts

Acute or poorly controlledmedical or surgical illnesses

Current pregnancy (if alcoholdependence risks outweighrisks of benzodiazepines)

azepines (oxazepam, alprazolam,

diazepoxide, diazepam, or


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risk for excess sedation in the elderlyand in patients with marked liverdisease. Because onset of action isslower than that of short-actingagents, the long-acting benzodi-azepines generally have decreasedabuse potential.

Patients with a history of seizuresshould receive a prophylactic long-acting benzodiazepine on a fixedschedule, even if asymptomaticduring the acute alcohol with-drawal period. The Box lists addi-tional indications for prophylacticbenzodiazepines. Patients with sub-stantial respiratory impairment orevidence of hepatic decompensa-tion should not receive diazepam.

Benzodiazepines can be prescribedas fixed-dose or symptom-triggeredregimens.The former are appropri-ate for outpatients, whereas the latterare best applied in monitored set-tings. Outpatient detoxification hasbeen shown to have similar long-term efficacy and decreased costcompared with inpatient detoxifica-tion (35). Symptom-triggered dos-ing has been shown to have lowermedication dose and duration ofinpatient treatment than fixed-doseregimens (33).

Other medications

-blockers, clonidine, carba-mazepine, and neuroleptics are notrecommended as monotherapy for

withdrawal, but may be usefuladjuncts in specific patients withalcohol withdrawal (33). -blockersand clonidine can control tachycar-dia and hypertension. Haloperidolcan treat agitation and hallucinosis.

However, -blockers have beenassociated with a greater incidenceof delirium, and neuroleptics havebeen associated with a greater inci-dence of seizures during with-drawal. Detoxification with alcoholis not supported by the scientificliterature.

Which drugs are indicated for theprevention of relapse in drinking?Medications should be consideredfor prevention of relapse of drink-ing following withdrawal. Naltrex-one, disulfiram, and acamprosatehave all been shown to enhancetreatment outcomes in patients

with alcohol abuse and depend-ence, and are FDA-approved forthis indication. Evidence is notavailable to confidently predict

which patients will benefit fromwhich drugs, and optimal resultsseem to occur in combination withbehavioral interventions (Table 2).

Naltrexone

Naltrexone blocks brain -opioidreceptors, diminishes the euphoriaassociated with alcohol use, and

reduces alcohol craving. Naltrexoneis contraindicated in patients whoare currently receiving or with-drawing from any opioid and inpatients with cirrhosis or acutehepatitis due to a rare occurrence ofdrug-associated hepatitis.Headache, fatigue, and nausea arecommon side effects, but do notusually require discontinuation.However, naloxone treatmenteffects are generally modest, andnot all trials have shown benefit.

A meta-analysis concluded that short-term (12 weeks) naltrexone treatment of 50to 100 mg daily reduces relapse of heavydrinking (relative risk, 0.64 [95% CI, 0.51 to0.82]) and any relapse of drinking (relativerisk, 0.87 [CI, 0.76 to 1.0]) (36).

A large, multicenter, randomized trial con-cluded that naltrexone, 100 mg daily, withbrief medical management was moreeffective than placebo with brief medicalmanagement and as effective as an inten-sive combined behavioral intervention in

achieving an absence of heavy drinking(37).

A randomized trial of naltrexone in thetreatment of 627 alcohol-dependent

patients found no significant difference inthe number of days to relapse between

patients in the naltrexone-treated group(mean, 72.3 days) and the placebo group

35. Hayashida M, Alter-man AI, McLellan AT,et al. Comparativeeffectiveness andcosts of inpatientand outpatientdetoxification of

patients with mild-to-moderate alcohowithdrawal syn-drome. N Engl JMed. 1989;320:358-65. [PMID: 2913493]

36. Srisurapanont M,Jarusuraisin N. Opi-oid antagonists foralcohol depend-ence. CochraneDatabase Syst Rev.2005:CD001867.[PMID: 15674887]

37. Anton RF, OMalleySS, Ciraulo DA, et al.Combined pharma-cotherapies andbehavioral interven-tions for alcoholdependence: the

COMBINE study: arandomized con-trolled trial. JAMA.2006;295:2003-17.[PMID: 16670409]

38. Krystal JH, CramerJA, Krol WF, et al. Nal-trexone in the treat-ment of alcoholdependence. N EnglJ Med.2001;345:1734-9.[PMID: 11742047]



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(mean, 62.4 days [CI for the differencebetween groups, 3.0 to 22.8]) at 13 weeks.

Additionally, at 52 weeks, there were nosignificant differences between the naltrex-one and placebo groups in the percentageof days on which drinking occurred andthe number of drinks per drinking day (38).

Disulfiram

Disulfiram inhibits aldehyde dehy-drogenase, causing an accumulationof acetaldehyde and nausea,headache, flushing, sweating, weak-ness, and increased blood pressure

when the patient ingests alcohol.Treatment trials have providedmixed results, but supervised use inmotivated patients has been shownto enhance treatment outcomes andis a reasonable strategy in selectedcases (39).

Among a group of 126 patients who

received disulfiram or placebo along with

alcoholism counseling, the disulfiram

group experienced a 32% enhancement in

total abstinence and a decrease of similar

magnitude in the mean weekly alcohol

consumption at the 6-month follow-up (40).

One-year follow-up of 605 male veteranswho received disulfiram or placebo alongwith alcoholism counseling revealed nodifference in abstinence but fewer drinkingdays, for those patients who drank, in the

disulfiram-treated group (41).

Acamprosate

Acamprosate, which became avail-able in the United States in 2005but has been used for about 20

years in Europe, is thought tomodulate and normalize brainactivity in heavy alcohol users, par-ticularly in the glutamate and -aminobutyric acid neurotransmittersystems. Acamprosate is not hepat-ically metabolized and is an option

for patients with liver disease whoshould not use naltrexone or disul-firam. Acamprosate does not affectthe action or subjective effects ofalcohol but seems to reduce craving.

Experience in Europe suggests that2 g per day (666 mg 3 times daily) issafe and effective for treating alcoholdependence, with 1 meta-analysis

39. Suh JJ, Pettinati HM,Kampman KM, et al.

The status of disulfi-ram: a half of a cen-tury later. J Clin Psy-chopharmacol.2006;26:290-302.[PMID: 16702894]

40. Chick J, Gough K,Falkowski W, et al.Disulfiram treatmentof alcoholism. Br JPsychiatry.

1992;161:84-9.[PMID: 1638335]

41. Fuller RK, BrancheyL, Brightwell DR, etal. Disulfiram treat-ment of alcoholism.A Veterans Adminis-tration cooperativestudy. JAMA.1986;256:1449-55.[PMID: 3528541]

42. Bouza C, Angeles M,Magro A, et al. Effi-cacy and safety ofnaltrexone andacamprosate in thetreatment of alcoholdependence: a sys-tematic review.Addiction.2004;99:811-28.

[PMID: 15200577]43. Mason BJ, Goodman

AM, Chabac S, et al.Effect of oral acam-prosate on absti-nence in patientswith alcoholdependence in adouble-blind,placebo-controlledtrial: the role ofpatient motivation. JPsychiatr Res.2006;40:383-93.[PMID: 16546214]


estimating a relative increase inabstinence of 1.88 (CI, 1.57 to2.25) relative to placebo (42).Dosage should be reduced inpatients with renal insufficiency, butthe drug is generally well tolerated.However, U.S. trials have shownless favorable effectiveness than tri-

als in other countries. Identifyingacamprosates optimal use willrequire additional research (37, 43).

Other drugs that may help preventrelapse

There are a number of other med-ications that may improve treat-ment outcomes for alcohol depend-ence. Perhaps the best-studied istopiramate, which has been thesubject of several trials including amultisite trial in the United States

(44). These studies suggest that adose of up to 300 mg daily is effec-tive at reducing alcohol use. Otheragents with potential efficacyinclude baclofen (45) andondansetron in early-onset alcoholdependence (46).

When should clinicians considerantidepressants in the treatmentof patients with unhealthy alcoholuse?

Generally, mixing antidepressantsand alcohol is discouraged becausealcohol acts as a depressant andcould counteract the effects of anti-depressants and lessen their benefit.Mixing the 2 increases the potentialfor drowsiness. Monoamine oxidaseinhibitor antidepressants shouldnever be mixed with alcohol becausethe combination can cause a danger-ous spike in blood pressure.

However, some patients who arerecovering from alcohol dependencemay benefit from antidepressants.A small trial showed that patients

with comorbid psychiatric disor-ders, such as depression, benefitedfrom pharmacotherapy with theantidepressant fluoxetine and coun-seling designed to treat the depres-sion (47). Clinical experience sug-gests that optimal outcomes occur


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44. Topiramate for Alco-holism AdvisoryBoard. Improvementof physical healthand quality of life ofalcohol-dependentindividuals with top-iramate treatment:US multisite ran-domized controlledtrial. Arch InternMed. 2008;168:1188-99. [PMID: 18541827

45. Addolorato G, Leg-gio L, Ferrulli A, et al.Effectiveness andsafety of baclofen fomaintenance of

alcohol abstinencein alcohol-depend-ent patients withliver cirrhosis: ran-domised, double-blind controlledstudy. Lancet.2007;370:1915-22.[PMID: 18068515]

46. Dawes MA, JohnsonBA, Ait-Daoud N, etal. A prospective,open-label trial ofondansetron in ado-lescents with alcohodependence. AddictBehav. 2005;30:1077-85. [PMID: 15925118

47. Cornelius JR, Sal-loum IM, Ehler JG, etal. Fluoxetine in

depressed alco-holics. A double-blind, placebo-con-trolled trial. ArchGen Psychiatry.1997;54:700-5.[PMID: 9283504]

48. Baigent MF. Under-standing alcoholmisuse and comor-bid psychiatric disor-ders. Curr Opin Psy-chiatry.2005;18:223-8.[PMID: 16639144]


after waiting a brief period beforediagnosing depression. Patients

with depression symptoms thatpersist beyond the first week ofabstinence had superior outcomes

with antidepressant treatment (48).Treating the depression helped toreduce the quantity of alcohol

consumed, but the rates of achiev-ing abstinence were low.

What type of follow-up care should

clinicians provide for patients with

unhealthy alcohol use?

Clinicians should monitor alcoholconsumption, compliance with psy-chosocial counseling, and adherence

with pharmacotherapy in appropri-ate patients. Clinicians should alsomonitor the effects of therapy and be

alert for medical complications ofalcohol abuse.

When should clinicians consider

specialty referral for patients with

unhealthy alcohol use?

Consider referral to a psychiatrist oran addiction specialist when acomorbid substance use, psychiatricdiagnosis, or dependence is sus-pected. These comorbid disordersalter the response to various treat-ment interventions and require tar-

geted therapy. Referral for psy-chosocial counseling or to analcohol treatment program may be

warranted. It may also be helpful toconsult with appropriate specialistsfor treating significant complicationsof alcohol-induced disease, such as

cirrhosis or alcohol-associatedcardiomyopathy.

How should clinicians manage

hospitalized patients with

unhealthy alcohol use to avoid

withdrawal?

In general, prophylaxis for alcohol

withdrawal (for example, using afixed-dose regimen vs. carefulobservation and symptom-triggeredtherapy) should be considered inpatients with alcohol use disordershospitalized for medical and surgi-cal conditions. Alcohol abuse andits sequelae are associated with anincreased risk for complications anddeath in a variety of surgical sub-populations, especially in patientsrequiring trauma surgery. Clinicians

should assess symptoms of with-drawal, including tremulousness,exaggerated startle reflex, sleep dis-turbance, and tachycardia.

It is also important to anticipate com-plications among alcohol-abusingpatients undergoing traumasurgery; respiratory tract surgery;cardiac surgery; and major gastro-intestinal tract surgery, includinghepatobiliary procedures and porta-

systemic shunt procedures. Themost common perioperative com-plications of alcohol abuse, exclud-ing withdrawal and delirium,include infection (especially pneu-monia), bleeding problems, andcardiopulmonary insufficiency.

Treatment... Effective treatment of alcohol problems can occur in the primary caresetting. Brief counseling interventions are effective for patients with at-risk drink-ing. For patients with alcohol abuse and dependence, various psychosocialcounseling strategies (12-step facilitation, cognitive behavioral therapy, and moti-

vational enhancement therapy) and pharmacotherapy (naltrexone, acamprosate,and disulfiram) help to achieve independence from alcohol. Benzodiazepines arethe agents of choice for managing and preventing alcohol withdrawal symptoms.When an individual presents for alcohol detoxification, clinicians should follow aprotocol to identify the severity of withdrawal and factors that may predict theonset of serious complications. Consider consultation as needed with a mentalhealth or addiction specialist.




49. Working Group onthe Management ofAlcohol WithdrawalDelirium, PracticeGuidelines Commit-tee, American Soci-ety of AddictionMedicine. Manage-ment of alcoholwithdrawal delirium.An evidence-basedpractice guideline.Arch Intern Med.2004;164:1405-12.[PMID: 15249349]

Practice

Improvement What factors do U.S. stakeholdersuse to evaluate the quality of carefor patients with unhealthyalcohol use?

To date, the Centers for Medicare& Medicaid Services (CMS) and

the Physician Quality ReportingInitiative (PQRI) do not havequality of care measures for thetreatment of patients withunhealthy alcohol use. However,Measure number 132: Patient Co-Development of TreatmentPlan/Plan of Care, seems to be par-ticularly important for patients

with alcohol use disorders. Thismeasure is the percentage ofpatients age 18 years or older iden-tified as having actively participated

in the development of the treat-ment plan or plan of care. Accord-ing to the PQRI, appropriatedocumentation includes signatureof the practitioner and eitherco-signature of the patient or docu-mented verbal agreement obtainedfrom the patient or, when neces-sary, an authorized representative.

What do professionalorganizations recommendregarding the care of patientswith unhealthy alcohol use?

The USPSTF issued recommenda-tions in 2004 regarding screeningand behavioral counseling interven-tions in primary care to reduce alco-hol misuse (10). The USPSTFfound fair evidence to support a rec-ommendation to implement screen-ing and behavioral interventions toreduce unhealthy alcohol use forpregnant and nonpregnant adults inprimary care settings, but foundinsufficient evidence to support arecommendation for adolescents.

Also in 2004, the American Societyof Addiction Medicine published aguideline on the management ofalcohol withdrawal delirium (49).On the basis of the results of 9prospective trials, this guidelineadvocates the use of rapid-actingsedative hypnotics coupled withsupportive medical care in patients

with alcohol withdrawal delirium.

The NIAAA last updated in 2007 aclinicians guide to helping patients

who drink too much (1).This reviewgenerally reflects the care that theNIAAA guide recommends.

inthe

clinic

Tool Kitin the clinic

Alcohol Use

PIER Modules

www.pier.acponline.orgAccess the following PIER Module: Alcohol Use. PIER modules provide evidence-based, updatedinformation on prevention, diagnosis, and treatment in an electronic form designed for rapid accessat the point of care.

Patient Education Resources

www.annals.org/intheclinic/toolkitAccess the patient information material that appears on the following page forduplication and distribution to patients.pubs.niaaa.nih.gov/publications/handout.htmNational Institute on Alcohol Abuse and Alcoholisms information on How to Cut Down on YourDrinking (available in English and Spanish).

Clinical Guidelines

www.niaaa.nih.gov/Publications/EducationTrainingMaterials/default.htmHelping Patients Who Drink Too Much: A Clinicians Guide. National Institute on Alcohol

Abuse and Alcoholism. Supplemental resources for clinicians and patients are also available on theNIAAA Web site.

Alcohol Screening Questionnaire

pier.acponline.org/physicians/diseases/d282/tables/d282-tables.htmlAccess a copy of the AUDIT-C questionnaire for use in your practice.http://images2.clinicaltools.com/images/pdf/ciwa-ar/pdfAccess a copy of the revised Clinical Institute Withdrawal Assessment for Alcohol, a tool to helpevaluate the severity of alcohol withdrawal.

Community-Based Resources for Treatment of Alcohol Misuse

www.aa.orgAlcoholics Anonymous. Information available in English, Spanish, and French.ncadi.samhsa.gov/referralsThe resources page of the National Clearinghouse for Alcohol and Drug Information Web sitelists mutual help organizations for patients with alcohol problems.


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WHAT YOU SHOULD KNOWABOUT ALCOHOL

In the ClinicAnnals of Internal Medicine

annals.org

Drinking more than the following amounts of alcohol

puts a person at risk for heath and social problems: 1 drink a day for women or anyone older than

65 years

2 drinks a day for men younger than 65 years

5 or more drinks per occasion for men and 4 or moredrinks per occasion for women.

A standard drink is 12 oz. of beer or a wine cooler,5 oz. of wine, 3 to 4 oz. of sherry or port, 2 to 3 oz. ofcordial/liqueur/aperitif, 1.5 oz. of spirits (e.g., a singleshot glass of 80-proof gin, vodka, whiskey), or 8 to 9oz. of malt liquor.

Over time, drinking more than moderate amounts ofalcohol can result in:

Liver disease

Heart disease and high blood pressure

Pancreatic disease

Accidents and injuries

Problems at home, at work, and with relationships

Some people with certain health conditions should notdrink alcohol at all:

Pregnant women

History of liver or pancreatic disease or bleeding inthe brain

Cancer or precancerous changes in the esophagus,

throat, or mouthPeople with a family history of alcoholism are athigher risk for alcoholism and should be particularlycautious about drinking.

Alcohol interacts with many common medications.Ask you doctor about drinking alcohol if you takemedications.

Short self-test:Are you drinking too much?

1. Have you ever felt you should cutdown on yourdrinking?

2. Have people annoyedyou by criticizing yourdrinking?

3. Have you ever felt bad or guiltyabout yourdrinking?

4. Have you ever had a drink first thing in the morn-ing to steady your nerves or get rid of a hangover(eye-opener)?

Two yes answers to the above questions indicates apossible alcohol problem that you should discuss withyour doctor.

P

t i t I f

t i

For More Information

www.niaaa.nih.gov

National Institute on Alcohol Abuse and Alcoholism(Including pamphlets on Aging and Alcohol Abuse,Drinking and Your Pregnancy, A Family History of Alco-holism: Are You at Risk?, Harmful Interactions: MixingAlcohol with Medicines, How to Cut Down on YourDrinking)

www.aa.org

Alcoholics Anonymous. Information on treatment ofalcohol problems available in English, Spanish, andFrench.

www.findtreatment.samhsa.gov

Substance Abuse and Mental Health Services Adminis-tration: Substance Abuse Treatment Facility Locator.


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CME Questions

A 34-year-old woman presents for rou-tine care. On questioning, she reportsdrinking 1 to 2 alcohol-containingbeverages each evening. On weekends,she may drink 2 to 3 each evening. Shehas not had any legal or social problemsrelated to alcohol use; she has nothad any significant withdrawal symp-toms and has been consistent in thispattern of use for several years. OnCAGE questioning, she denies any effortor interest in cutting back and does notfeel guilty about her alcohol use. Shedenies any history of morning alcoholuse, but does note that her husbandintermittently encourages her todecrease her alcohol use.

What is the most appropriate interven-tion at this point?

A. Reassure the patient that there isno evidence of alcohol abuse ordependence

B. Intervene briefly to identifydrinking patterns and to setcommon goals on future use

C. Begin inpatient detoxificationD. Prescribe benzodiazepines for

supporting cessation

E. Prescribe disulfiram

A 35-year-old man is evaluated for a

swollen wrist 2 days after having fallenon the sidewalk on his way home from alocal bar. He indicates that he mayhave had 1 too many that evening. Hehas a stable marriage and has notmissed work or received any citationsfor driving under the influence of alco-hol. This is the first time he has pre-sented with an alcohol-related injury.

Which of the following is the mostappropriate initial step in managing thispatient?

A. Deliver a clear, personalized

messageB. Ask the CAGE questionsC. Assess the average frequency and

quantity of alcohol intake

D. Recommend he attend an

Alcoholics Anonymous meeting

A 48-year-old man with a long historyof alcohol abuse presents for ongoingcare after an inpatient stay for alcoholwithdrawal. This is his third episode ofacute detoxification, with the longestperiod of abstinence being 4 months. Hedenies any current symptoms of depres-sion and states that he is not using anyillicit drugs or prescription medications.His last alcohol intake was 2 weeksbefore his visit to your office, and he isnow enrolled in an alcohol treatmentprogram.

Which of the following pharmacologicagents would be the best adjunct to histreatment?

A. Naltrexone

B. ParoxetineC. DiazepamD. BuspironeE. Disulfiram

A 36-year-old man with a long historyof heavy alcohol use presents within 24hours of his last drink. He states that heneeds help with the withdrawal. Hedenies any other drug use.

On examination, his pulse rate is120/min and blood pressure is 172/96mm Hg. He is moderately tremulous and

is having visual hallucinations.What is the most appropriate manage-ment?

A. Admit the patient and giveclonidine, 1 mg

B. Admit the patient and givediazepam, 20 mg

C. Prescribe outpatientchlordiazepoxide, 50 mg

D. Prescribe outpatient lorazepam,2 mg

E. Prescribe outpatient atenolol,

50 mg

A 48-year-old man is evaluated forweakness and fatigue. He has a historyof hypertension and gout. Medicationsinclude ramipril, hydrochlorothiazide,and colchicine. Social history is signifi-cant for having lost his job 2 years ago,after which he has been drinking beerand wine every day. He does not haveepisodes of delirium tremens but admitsto feeling guilty about his alcoholintake.

Physical examination reveals adisheveled man in no acute distress. Theblood pressure is 135/80 mm Hg, andpulse rate is 78/min. Chvostek sign ispositive on the right. The liver is pal-pated 3 cm below the right costal mar-

gin and is tender on palpation. No spiderangiomata or palmar erythema is noted.His hematocrit is 33%, sodium is133 mEq/L (133 mmol/L), potassium is3.4 meq/L (3.4 mmol/L), blood ureanitrogen is 25 mg/dL (8.93 mmol/L),creatinine is 1.2 mg/dL (106.1 mol/L),alanine aminotransferase is 50 U/L,aspartate aminotransferase is 110 U/L,alkaline phosphatase is 55 U/L, albuminis 3.5 g/dL (35 g/L), and calcium is7.2 mg/dL (1.8 mmol/L).

Which of the following is the mostappropriate next test in the evaluationof this patient?

A. Parathyroid hormoneB. 25-hydroxyvitamin DC. 1,25-hydroxyvitamin D

3

D. Phosphate

E. Magnesium

Questions are largely from the ACPs Medical Knowledge Self-Assessment Program (MKSAP). Go to www.annals.org/intheclinic/

to obtain up to 1.5 CME credits, to view explanations for correct answers, or to purchase the complete MKSAP program.

1.

2.

5.3.

4.

Etoh Use Syllabus

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