A Clinical Guide to Assessing Alcohol Use and Problems

Andrea DiMartini M.D.

 

University of Pittsburgh Medical Center, Western Psychiatric Institute

Alcohol Medical Scholars Program

 

Note: outline contains detail that would allow someone to give the lecture. In the accompanying slides information is abbreviated as bullet points. Some slides contain animation that should be reviewed prior to lecturing to understand the placement and emphasis being highlighted.

 

I. Introduction

 

A. This Lecture Will Cover (Slide 2)

            1. Why alcohol use disorders are important

2. What physicians need to know to appropriately screen

3. Perceived barriers to screening

4. Effective screening techniques

 

B. Why This Is Important (Slide 3)

1. Alcohol use in the US

a. 2/3 in U.S. consume alcohol

b. > 6 % heavy drinkers – defined as 5 drinks 5 or more times in a month

c. Lifetime prevalence of alcohol abuse/dependence 15-20%

2. Alcohol problems often missed / undetected in general practice

a. Alcohol questions not routinely asked

b. Assessments are often insufficient to identify problems

c. Alcohol related problems missed more than 50% of the time.

C. What Dangers Are There? (note to the lecturer; pick one or two examples from each area – otherwise it will be too much information to make the point)

1. Alcohol use has wide ranging deleterious effects on health (Slide 4)

a. Directly toxic to:

i. Hepatocytes (alcoholic fatty liver, alcoholic cirrhosis)

ii. Gastrointestinal (gastritis, stomach/duodenal ulcers)

                                                ii. Myocardial cells (alcoholic cardiomyopathy)

                                                iii. Pancreas (chronic or acute hemorrhagic pancreatitis)

            iv. Brain (generalized atrophy, cerebellar degeneration, dementia)

                                                v. Bone marrow (suppresses marrow – thrombocytopenia / anemia)

b. Systemic effects on:

i. Cardiovascular (hypertension, stroke)

         ii. Endocrine (hypoglycemia, hypothalamus / pituitary          dysfunction, infertility)

      iii. Immune system (suppresses immune system and predisposes to certain infections)

                                    c. Biochemical / Nutritional effects:

i.  Brain (Wernicke-Korsakoff)

ii.   Metabolic acidosis (lactic acidosis / ketoacidosis)

iii. Anemia (B12, folate, iron deficiencies)

d. Associated with higher rates of most cancers:

i. Gastric /Esophagus

ii. Pancreatic

iii. Liver (hepatocelluar carcinoma)

iv. Breast

2. Why should physicians care? (Slide 5)

a. Treatment issues for general medicine

i. May underlie other medical problems / disorders (e.g. hypertension, sleep disorders, affective disorders, etc.)

b. Can affect compliance with medical directives

i. Missing appointments

ii. Missing / not taking medications

iii. Not following up with testing

c. Can interfere/interact with prescribed medications

i.      Can interfere with absorption

ii.     Diminish the efficacy of some medications

iii.   Accentuate sedating effects of some medications

d. Alcohol is the third leading cause of preventable death (behind obesity and smoking)

e. Reduction/cessation of alcohol can prevent morbidity/mortality

f. Reduction/cessation of drinking can reduce health care utilization

3. Behaviors are changeable

a. Patient education can change alcohol habits

b. Alcohol use disorders are treatable

 

II. What Physicians Need To Know About The Use Of Alcohol

 

A. Alcohol Use Patterns: How Much Is Too Much? (Slide 6)

                       1. Often asked question

2. Answer is based on multiple factors

3. Depends on risk factors (note to lecturer, some factors are inherent -the first set            of animation and some may develop during a persons lifetime –second set)

a. Gender (females tend to have less body water, more body fat)

b. Genetics (differential risk for level of intoxication, diseases, alcohol dependence)

c. Body weight (smaller size achieves higher blood levels)

d. Metabolism (less activity of alcohol dehydrogenase results in slower metabolism, higher levels and longer duration of sustained alcohol levels)

e. Medical illness (e.g. liver disease, diabetes, hepatitis C, etc.)

f. Pregnancy (risk for fetal alcohol syndrome, spontaneous abortion, low birth baby, developmental delays, etc)

g. Prior alcohol use disorder (risk for relapse/recurrence)

B. Alcohol Related Health Problems: Relationship Of Alcohol Consumption To Disease (Slides 7)

1. If no risk factors 1-2 drinks a day can have limited specific health benefits (the “J” curve). A standard drink is defined as 10-12 grams of ethanol. This is approximately the amount of ethanol in a 12 ounce beer, a 4 to 6 ounce glass of wine, or 1 to1.5 ounces of hard liquor.

a. Coronary (ischemic) heart disease (HDL, clotting)

b. Ischemic stroke (clotting)

c. May act through changes in lipids (increased HDL) and inhibition of blood clotting (decreased platelet stickiness)

2. Is a threshold beyond which risks outweigh benefits

3. > Threshold risk for disease increases dramatically

4. Most organs (e.g. liver) alcohol has no health benefits (note to lecturer animated green line comes on with mouse click to show the following points)

                                    a. No benefit at low levels (i.e. 1-2 drinks)

                                    b. Risk increases dramatically as amount increases

c. Odds of developing cirrhosis increase exponentially above threshold (specific example using alcoholic liver disease)(Slide 8)

i. < 3 drinks/day higher percentage of cirrhosis (0.15) compared to teetotaler (0.04)

ii. > 3 drinks/day dramatically increasing odds (e.g. 10X greater risk of cirrhosis at 3-6 drinks/day compared to teetotaler whose risk is 0)

           C. Assessment Domains (Slides 9)

1. Alcohol use patterns - often the primary focus in medical interviewing

2. Alcohol related physical problems need to be assessed

3. Alcohol use disorders – need to be assessed based on specific criteria

            4. Assess all 3 areas for integrated treatment plan

           

D. Alcohol Use Disorders: Alcohol Abuse – Diagnostic Criteria (Slide10)

                       1. Clinically significant impairment or distress in 1 or more in a 12-month period

a. Failure to fulfill major obligations (e.g. absences/suspension from work, neglecting household duties)

b. Physically hazardous (e.g. driving while intoxicated)

c. Legal problems (e.g. disorderly conduct, DUIs)

d. Social/interpersonal problems (e.g. arguments with spouse about drinking, physical fights)

2. Approximately 60% continue with abuse; only 10% go on to develop alcohol dependence

 

E. Alcohol Use Disorders: Alcohol Dependence – Diagnostic Criteria (Slide 11)

1. Clinically significant impairment or distress in 3 or more in a 12-month period

a. Tolerance (e.g. increased amount needed for effect, diminished effect)

b. Withdrawal (e.g. autonomic hyperactivity, tremor - see slide 18, use to avoid withdrawal)

c. Larger amounts/longer period than intended

d. Persistent desire/unsuccessful attempts to cut down

e. Excessive time spent with alcohol (e.g. spending all of spare time at bar or recovering from effects)

f. Activities given up due to alcohol (e.g. social, occupational, recreational activities give up to use alcohol instead - not attending son's baseball game, etc.)

g. Continued use despite problems (e.g. knowing of physical disease such as liver disease or psychological problem such as depression caused or worsened by alcohol use)

                        2. Alcohol dependence remains stable over years (unless a patient abstains)

3. Associated with a 10-15 year decrease in lifespan (for above mentioned health reasons), trauma, suicide, etc.

 

III. Perceived Barriers To Screening

 

A.   Which Patient Would You Ask? (Slide 12)

Which of these patients has an alcohol problem? Answer – Everyone!

(Note to the lecturer this slide of faces is from a recovery website and are the faces of                  people in recovery)

 

B. Primary Barriers To Asking (Slide 13)

1. Issues on interviewing

a. Assume your patient would not drink/have a drinking problem

b. Uncomfortable asking

c. Stigma of alcoholism – afraid to offend the patient

d. Don’t know how to ask

                                    e. Afraid to uncover a problem that you won’t know how to handle

                                    f. Forgot to ask -always asking avoids this mistake

2. Think you don’t have the time

a. Afraid that asking alcohol questions will take additional time –however this is like saying you don’t have time to check the blood pressure or ask about medication allergies

b. Afraid to uncover a problem that will require additional time

However:

c. Screening questionnaires can efficient use of time in data gathering

           d. Alcohol use questions can be easily / quickly asked

e. 5 minutes spent advising reduction / cessation can be effective

f. Can refer for further specialist evaluation or counseling

 

IV. Effective Screening Techniques

 

A. Stages Of Evaluation (Slide 14)

1. Screening not assumed to be a comprehensive evaluation

                                    a. Screening is the first step in a process toward further evaluation

                                    b. Primary objective is to detect individuals with alcohol problems

c. Screening should facilitate further assessment or subsequent referral for assessment in those who screen positive

2. Assessment

a. More comprehensive

b. Determines the nature and extent of alcohol problems

                                    c. Determines alcohol use disorders diagnosis

3. Referral for appropriate treatment or intervention as indicated from the assessment     

 

B. Goals Of Screening (Slide 15)

1. Screening not assumed to be a comprehensive evaluation

2. Assess problems from drinking

                                    a. Abuse/dependence diagnoses depend on the pattern of the problems

                                    b. May be easier to engage patient in discussion about problems

3. Assess for consumption patterns

                                    a. May be difficult to get accurate information on quantity/frequency

                                    b. Important in assessing health risks

4. Inform and improve patient treatment plan which may include referral for further assessment

 

C. Methods Of Gathering Data (Slide 16)

1. Physical exam - supplements data from interview, can identify physical problems that can be used to corroborate or augment discussion of reported use

2. Laboratory tests - non-specific, supplements interview/physical exam

3. Interview - primary method to gather information on all domains of alcohol problems

4. Questionnaires - can supplement/inform interview

 

D. Laboratory Tests (Slide 17)

1.     Usually the last piece of data gathered after interview/exam

2.     Tests may aid in identifying health problems, but not necessarily specific

3.     Can sometimes aid in the identification of heavy alcohol use

4.     May be perceived as easier method to gather data

 

E. Commonly Used Specific Tests

1. Liver enzymes- specifically gamma-glutamyltransferase (GGTP) (Slide 18)

a. Increased GGTP related to enzyme induction (initially) or liver cell death (chronic use). May be initially increased before changes in MCV (see below).

b. GGTP can begin to normalize in 1-2 weeks with abstinence

c. Even normal GGTP values (i.e. higher than 35 IU/L) may indicate heavy alcohol use (i.e. > 6 drinks) - normal healthy people do not usually have such values

         d. Non-specific (i.e. poor specificity)- other disease processes may elevate values

e. For the general population average sensitivity of GGTP in detecting heavy alcohol use is 40-60%, specificity is 90% (except for medically ill populations)

f. Increase of GGTP by 20% over baseline was 100% sensitive and 80% specific detecting alcohol relapse after rehabilitation

2. Erythrocyte mean corpuscular volume (MCV) (Slide 19)

a. Alcohol and its metabolic derivative acetaldehyde exert toxic effects on the nuclear maturation of red blood cells

b. Can be associated with coincident folic acid or B12 deficiency which also cause macrocytosis

c. MCV > 98 femtoliters (fL) (or cubic micrometers - mm³ ) reflects macrocytosis

d. MCV > 98 fL has been reported in up to a third of heavy drinkers, but also in 5% normal drinkers

e. Non-specific (i.e. poor specificity)- other disease processes may elevate values (i.e. drug damage, myelodysplasia, nutritional deficiencies).

f. For the general population average sensitivity of MCV in detecting heavy alcohol use is 30-40% and specificity is 90%

                     3. Carbohydrate Deficient Transferrin (CDT) (Slide 20)

                  a. Heavy alcohol use produces a deglycosylated form of transferrin (a liver synthesized protein)

b. Identifies sustained heavy use (6 drinks / day for at least one week)

c. For alcohol use >6 drinks/day CDT sensitivity is 60-80% and specificity is 80-90%

d. With abstinence CDT can normalize in 2-3 weeks

4. Blood Alcohol Levels (BAL) (Slide 21)

a. Acute intake (~ within past 12-18 hours)

b. Depends on amount consumed, timing of intake, and timing of sample

c. Gas chromatography – very specific, gold standard

d. Limit of detection <0.01 g/dl

e. In comparison the legal limit, depending on the state, is 0.08-0.10 g/dl

f. For example, on average ½ of a standard drink can raise the BAL by 0.02 g/dl in an individual.

 

F. Physical Exam (Slide 22)

1. Physical features (heavy alcohol users)

a. Mild elevation in blood pressure (drinking > 3 drinks/day is an important contributor to mild to moderate hypertension)

b. Irregular heart rhythms or tachycardia

c. Abdominal palpation - enlarged liver /spleen (enlarged liver / cirrhosis in only 15-20% of alcohol dependent persons)

d. Extremities - peripheral neuropathy (5-15% of alcoholics), alcoholic myopathy (up to 30% of alcohol misusers – perhaps the most prevalent type of skeletal muscle disorder)

e. Other rarer features

i. Skin - spider angiomata, palmar erythema, Dupytren's contracture

ii. Gynecomastia (men)

iii. Parotid gland swelling

2. Physical disorders associated with alcohol (as described above)

3. Signs/symptoms of withdrawal (Slide 23)

a. A substantial proportion of alcoholics never go into withdrawal. In normal healthy persons clinically observable withdrawal is uncommon. It is more likely to occur in medical / surgical patients.

            i. If withdrawal is present must think of alcohol dependence

ii. However, lack of withdrawal symptoms does not mean absence of alcohol dependence

b. 95% of withdrawals limited to mild or moderate symptoms (listed below)

c. Only 5-10% alcohol dependent individuals ever experience delirium tremens (DTs)

d. Autonomic nervous system hyperactivity (sweating, increased heart rate >100, increased respiratory rate, elevated blood pressure)

e. Tremor

f. Increased reflexes

g. Gastrointestinal symptoms (nausea, anorexia, vomiting)

                                    h. Anxiety, irritability, restlessness, agitation

 

G. Patient / Clinician Rated Questionnaires (Why use them?) (Slide 24)

1.     For efficiency patients can complete these instruments while waiting

2.     Self-administered, easy to score

3.     Doctor can score/review with patient during interview

4.     Questionnaires available that assess patterns / problems of use

 

H. Specific Questionnaires (Slide 25)

1.     These questionnaires can be completed in 10 minutes or less

2.     Scored by physician/clinician 5 minutes or less

3. CAGE (acronym)

i. 4 items Cut down, Annoyed, Guilt, Eye-opener

ii. Self-administered or interview

iii. Less than one minute

iv. “Yes” response on one or more questions may indicate alcohol-related problems

v. One or more positive response - 60-70% sensitivity for identifying alcohol abuse/dependence and specificity of 80%.

4. Michigan Alcohol Screening Test (MAST)           

i. 25 items (there is also a 10 item version)

ii. Self-administered or interview

iii. 10 minutes to complete

iv. 5 minutes to score

v. Identifies alcohol use problems

5. The Alcohol Use Disorders Identification Test (AUDIT) – note to lecturer: a copy of the AUDIT is included at end of the lecture notes. It can be used as a handout with the acknowledgement that the copyright for the AUDIT is held by the World Health Organization but permission to use the test does not have to be obtained when it is being used for noncommercial purposes.

i. 10 items

ii. Self-administered or interview

iii. 2 minutes to complete

iv. 1 minute to score

            v. Includes questions on quantity/frequency and alcohol use problems

            vi. Originally developed as screening instrument for primary care settings

                                   vii. Specifically designed to identify hazardous and harmful drinking

                        viii. Sensitivity and specificity >90% in general medical populations

I. Interviewing Techniques (Slide 25)

1.How to open a discussion

a.     Engage in dialogue (avoid rapid firing of questions)

b.     Non-judgmental approach

c.     Can use questionnaire responses

d.     Avoid close-ended questions (e.g. Do you drink alcohol?)

            e. Gentle assumption (e.g. How much do you drink?)

2. Follow-up on a positive leads

 

V. Summary

 

            A. Alcohol Frequently Impacts Health And Heath Care Delivery

B. Knowing Of Barriers To Screening Will Prevent Barriers From Becoming An Obstacles

C. Assess For Problems

1. Alcohol use problems are diagnosed by problems associated with alcohol use

2. Health problems are associated with patterns of use

3. Assessing both areas provides a more comprehensive picture of potential risks

D. Utilize Effective Screening Techniques Described In This Lecture

 

 

References:

 

Allen JP, Reinert DF, Volk RJ. The alcohol use disorders identification test: an aid to recognition of alcohol problems in primary care patients. Preventive Medicine. 33:428-33, 2001.

 

Andréasson S, Hjalmarsson K, Rehnman C. Implementation and dissemination of methods for prevention of alcohol problems in primary health care: a feasibility study. Alcohol and Alcoholism 35: 525-530, 2000.

 

Anton, R.F., Litten, R.Z., Allen, J.P. Biological assessment of alcohol consumption. In: Allen, J.P., Columbus, M. (Eds.), Assessing Alcohol Problems: A Guide for Clinicians and Researchers, National Institute on Alcohol Abuse and Alcoholism, pp. 31-41, NIAAA NIH publication No. 95-3745, 1995.

Bellentani S. Tiribelli C. The spectrum of liver disease in the general population: lesson from the Dionysos study. Journal of Hepatology. 35:531-7, 2001.

 

Connors, G. Screening for alcohol problems. In: Allen, J.P., Columbus, M. (Eds.), Assessing Alcohol Problems: A Guide for Clinicians and Researchers, National Institute on Alcohol Abuse and Alcoholism, pp. 17-29, NIAAA NIH publication No. 95-3745, 1995.

 

Gerbert, B. G., Bronstone, A., Pantilat, S., McPhee, S., Allerton, M., & Moe, J. When asked, patients tell: Disclosure of sensitive health-risk behaviors. Medical Care. 37: 104-111, 1999.

 

Klatsky A. Should patients with heart disease drink alcohol? JAMA 285: 2004-2006, 2001.

 

Maisto S, Saitz R. Alcohol Use Disorders: Screening and Diagnosis. Am. J. Addictions. 12: S12-S25, 2003.

 

McCusker MT. Basquille J. Khwaja M. Murray-Lyon IM. Catalan J. Hazardous and harmful drinking: a comparison of the AUDIT and CAGE screening questionnaires. Qjm. 95:591-5,2002.

 

Rehm J. Room R. Graham K. Monteiro M. Gmel G. Sempos CT. The relationship of average volume of alcohol consumption and patterns of drinking to burden of disease: an overview. Addiction. 98:1209-28, 2003.

 

Reid, M.C., Fiellin, D. A., & O'Connor, P.G. Hazardous and harmful alcohol consumption in primary care. Archives of Internal Medicine. 159: 1681-1689, 1999.

 

Schuckit M. Alcohol and Alcoholism. Chapter 387 in Harrison's Principles of Internal Medicine 15th edition, Braunwald, Fauci, Kasper, Hauser, Longo, Jameson (editors), McGraw-Hill 2001.

 

Stein, M. D. Medical consequences of substance abuse. The Psychiatric Clinics of North America. 22: 351-370, 1999.

 

Thun MJ. Peto R. Lopez AD. Monaco JH. Henley SJ. Heath CW Jr. Doll R. Alcohol consumption and mortality among middle-aged and elderly U.S. adults. New England Journal of Medicine. 337:1705-14, 1997.

 

Materials from NIAAA

The materials below can be ordered from the NIAAA Publications Distribution Center, P.O. Box 10686, Rockville, MD 20849-0686; phone: (301) 443-3860. They are also available in full text on NIAAA's Web site (www.niaaa.nih.gov). NIAAA continually develops and updates materials for practitioners and patients; please check the Web site for new offerings.

 

For Practitioners:

Helping Patients with Alcohol Problems: A Health Practitioner's Guide
(includes A Pocket Guide: Alcohol Screening and Brief Intervention)

http://www.niaaa.nih.gov/publications/Practitioner/HelpingPatients.htm

 

Alcohol and Disease Interaction Vol.25, No. 4, 2001.

http://www.niaaa.nih.gov/publications/arh25-4/toc25-4.htm

 

What Is Moderate Drinking? Vol. 23, No. 1, 1999

http://www.niaaa.nih.gov/publications/arh23-1/toc23-1.htm

 

Alcohol's Effect on Organ Function Vol, 21, No. 1, 1997

http://www.niaaa.nih.gov/publications/arh21-1/toc21-1.htm

 

Alcohol-Medication Interactions - Alcohol Alert No. 27-1995

http://www.niaaa.nih.gov/publications/aa27-text.htm

 

For patients:

Alcohol: A Women's Health Issue--Describes the effects of alcohol on women's health at different stages in their lives. NIH Publication No. 02-5152. Also available: a 12-minute video, with the same title, that describes the health consequences of heavy drinking in women.

 

Alcohol: What You Don't Know Can Harm You--Provides information on drinking and driving, alcohol-medication interactions, interpersonal problems, alcohol-related birth defects, long-term health problems, and current research issues. English version: NIH Publication No. 99-4323; Spanish version: NIH Publication No. 99-4323-S.

 

Alcoholism: Getting the Facts--Describes alcoholism and alcohol abuse and offers useful information on when and where to seek help. English version: NIH Publication No. 96-4153; Spanish version: NIH Publication No. 99-4153-S.

 

Drinking and Your Pregnancy--Briefly conveys the lifelong medical and behavioral problems associated with fetal alcohol syndrome and advises women not to drink during pregnancy. Revised 2001. English version: NIH Publication No. 96-4101; Spanish version: NIH Publication No. 97-4102.

 

Frequently Asked Questions About Alcoholism and Alcohol Abuse--English version: NIH Publication No. 01-4735; Spanish version: NIH Publication No. 02-4735-S.

Rethinking Drinking--Provides patients with a self-evaluation and tips for cutting down on drinking. Scheduled for publication in English and Spanish in 2003.

 

Copy of the Alcohol Use Disorders Identification Test (AUDIT)

 

Copyright permission for use of the AUDIT:

 

The following quotation from the AUDIT User’s manual (Babor et al. 2002) describes the fact that the copyright is held by WHO but permission to use the test does not have to be obtained when it is being used for noncommercial purposes. “This document is not a formal publication of the World Health Organization (WHO), and all rights are reserved by the Organization. The document may, however, be freely reviewed, abstracted, reproduced, and translated, in part or in whole but not for sale or for use in conjunction with commercial purposes. Inquiries should be addressed to the Department of Mental Health and Substance Dependence, World Health Organization, CH-1211 Geneva 27, Switzerland, which will be glad to provide the latest information on any changes made to the text, plans for new editions and the reprints, regional adaptations and translations that are already available.”

 

 

 

 

Procedure For Scoring AUDIT

 

 

 

Questions 1-8 are scored 0, 1, 2, 3 or 4.

Questions 9 and 10 are scored 0, 2 or 4 only. The response is as follows:

 

 

0

1

2

3

4

 

Question 1       Never               Monthly     Two to                  Two to             Four or more

                                                or less         four times             three times       times per week                                                                                 per month                        per week

 

Question 2       1 or 2               3 or 4           5 or 6                   7 or 9              10 or more

 

Question 3-8    Never               Less than      Monthly              Weekly                        Daily or

                                                Monthly                                                                  almost daily

 

Question 9-10  No                                           Yes, but                                        Yes, during

                                                                        not in the                                                the last year

                                                                        last year

 

 

The minimum score (for non-drinkers) is 0 and the maximum possible score is 40.

 

A score of 8 or more indicates a strong likelihood of hazardous or harmful alcohol consumption.

 

 

 

 

9. Have you or has someone else been injured as a result of your drinking?

 

         No   Yes, but not in the past year             Yes, during the past year

 

10. Has a relative of friend or a doctor or other health worker been concerned about your drinking or suggested that you cut down?

 

         No               Yes, but not in the past year   Yes, during the past year