Screening and Brief Interventions for Heavy Drinking

 

Laura Jean Bierut, MD

Alcohol Medical Scholars

 

Slide 1:  The overall goal of this talk is to assist primary care physicians in the recognition and treatment of “at risk drinking”.  “At risk drinking” and alcohol dependence are common and major public health problems.  19% of men and 8% of women have a lifetime diagnosis of alcohol dependence.  Since heavy drinking and alcohol dependence are associated with many medical and psychiatric problems, individuals with “at risk drinking” and alcohol dependence are commonly seen in physicians’ offices.  The purpose of this talk is to discuss a screening procedure for alcohol dependence and “at risk drinking” and brief interventions that can be done in a primary care office.

 

Slide 2:  This is a clinical scenario of a man with “at risk drinking” who has no associated alcohol related problems.

 

Slide 3:  Alcohol use at low levels may have a beneficial effects, such as decreased cardiovascular disease (Camargo et al., 1997; Fuchs et al., 1995).  However, at higher levels of alcohol use, there are increasing rates of alcohol associated medical problems such as accidents and illnesses.  In primary care physicians offices, “at risk alcohol use” is common (Fleming et al., 1998). 

 

Slide 4:  Alcohol dependence is a clinical syndrome in which there is a cluster of alcohol related symptoms.  Despite problems with alcohol, an individual continues to drink.  The criteria for alcohol dependence are: 

 

A maladaptive pattern of alcohol use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12 month period:

 

(1)        tolerance, as defined by either of the following:

(a)                a need for markedly increased amounts of alcohol to achieve intoxication or desired effect

(b)     markedly diminished effect with continued use of the same amount of alcohol

(2)        withdrawal, as manifested by either of the following:

(a)      a characteristic withdrawal syndrome for alcohol

(b)     alcohol use to relieve or avoid withdrawal symptoms

(3)        alcohol is often taken in larger amounts or over a longer period than was intended

(4)        there is a persistent desire or unsuccessful efforts to cut down or control alcohol use

(5)        a great deal of time is spent in activities necessary to obtain alcohol, use alcohol, or recover from its effects

(6)        important social, occupational, or recreational activities are given up or reduced because of alcohol use

(7)        alcohol use is continued despite knowledge of having a persistent or recruuent physical or psychological problem that is likely to have been caused or exacerbated by alcohol

 

Slide 5:  “At risk drinking is a level of “At risk drinking” is a level of alcohol consumption that is directly harmful  or is correlated with a greater risk for the development of health problems.  “At risk drinking” is defined for men and women as follows:

·         Men

Greater than 14 drinks per week

5 or more drinks per occasion

·         Women

Greater than 7 drinks per week

4 or more drinks per occasion

 

Slide 6: Heavy drinking and alcohol dependence occurs in both men and women and across all socioeconomic groups.  Physicians should screen all patients for alcohol use and alcohol related problems.  Despite the high prevalence of alcohol related problems in medical settings, physicians often do not feel prepared to screen or treat alcohol problems. 

 

Slide 7:  Time is of the essence in medical practice and screening can be done effectively by asking three questions relating to amount of alcohol consumption (Bush et al., 1998).

 

·         How often do you have a drink containing alcohol?

(0)  Never

(1)   Monthly or less

(2)    2 to 4 times a month

(3)    2 to 3 times a week

(4)    4 or more times a week

 

·         How many drinks containing alcohol do you have on a typical day when you are drinking?

(0)    1 or 2

(1)    3 or 4

(2)    5 or 6

(3)    7, 8, or 9

(4)    10 or more

 

·         How often do you have six or more drinks on one occasion?

(0)    Never

(1)    < Monthly

(2)    Monthly

(3)    Weekly

(4)    Daily or almost daily

 

By adding the numbers of each answer, a score is developed that ranges from 0 to 12.  Using a cutoff of 3 or more, 90% of current alcohol dependent individuals are detected and 98% of heavy drinkers are detected (Bush et al., 1998).

 

Slide 8:  Brief interventions are often used by primary care physicians and can be effective in non alcohol dependent subjects.  Most interventions are 4 sessions or fewer and are even effective if they are just a few minutes. 

 

Slide 9:  The goal of brief intervention is for patients to moderate their drinking to below an “at risk drinking” level.  Abstinence is not the goal.

 

Slide 10:  The steps involved in brief interventions are FACT-

            Feedback

            Advice

            Commitment

            Tracking

 

Slide 11: Feedback:  Physicians need to provide feedback to patients regarding their drinking habits.  This feedback should include any physical and laboratory findings that are consequences of drinking. 

 

Slide 12:  Advice:  Explicit advice to reduce drinking needs to be given.  Also, education about levels of drinking that are moderate should be discussed.  The drinking goal needs to negotiated by  the physician and patient.  This goal should be written – in the form of a prescription to be followed.

 

Slide 13:  Commitment:  Brief intervention to emphasize the patient’s responsibility and opportunity to choose to change.  Telling the patient, “No one can make you change.  What you do about your drinking is up to you.”  is important in placing the commitment to change in the hands of the patient.

 

 

Slide 14:  Tracking:  Follow up of the intervention is important and may involve telephone calls, repeat office visitsand laboratory tests.  Follow up allows the physician to assess progress (or lack of progress), identify problems that may impede successful change, and offer ongoing support.

 

Slide 15:  A randomized controlled study performed in 22 primary care physician offices was completed in which patients were screened for “at risk drinking”.  8% to 20% of patients were identified as drinking at “risky” levels”.  The intervention arm of the study, certain offices were instructed on brief interventions.  In the control are of the study, usual care was given. 

 

Slide 16:  Brief interventions reduce drinking levels (Fleming et al., 1997).

 

            Results of Brief Physician Advice for Problem Drinkers

                                                                        Initial                           Follow Up

            Weekly Alcohol Use: 

                        Intervention                            19.1 drinks                  11.5 drinks

                        Control                                    18.9 drinks                  15.5 drinks

 

            Binge Drinking                      

                        Intervention                            5.7 per month              3.1 per month

                        Control                                    5.3 per month              4.2 per month

 

            Excessive Drinking                

                        Intervention                            47.5%                          17.8%

                        Control                                    48.1%                          32.5%

 

 


 

Reference List

 

Bush, K., Kivlahan, D.R., McDonell, M.B., Fihn, S.D. and Bradley, K.A. The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test.  Archives of Internal Medicine 158:1789-1795, 1998.

Camargo, C.A.J., Stampfer, M.J., Glynn, R.J., et al. Moderate alcohol consumption and risk for angina pectoris or myocardial infarction in U.S. male physicians.  Annals of Internal Medicine 126:372-375, 1997.

Fleming, M.F., Barry, K.L., Manwell, L.B., Johnson, K. and London, R. Brief physician advice for problem alcohol drinkers. A randomized controlled trial in community-based primary care practices [see comments].  JAMA 277:1039-1045, 1997.

Fleming, M.F., Manwell, L.B., Barry, K.L. and Johnson, K. At-risk drinking in an HMO primary care sample: prevalence and health policy implications.  American Journal of Public Health 88:90-93, 1998.

Fuchs, C.S., Stampfer, M.J., Colditz, G.A., et al. Alcohol consumption and mortality among women [see comments] [published erratum appears in N Engl J Med 1997 Feb 13;336(7):523].  New England Journal of Medicine 332:1245-1250, 1995.