Although two thirds of American men and one half of American women drink alcohol,[1] three fourths of drinkers experience no serious consequences from alcohol use.[2] Among those who abuse alcohol, many reduce their drinking without formal treatment after personal reflection about negative consequences.[3] Physicians can help prevent the serious effects of alcohol-related problems by stimulating such reflection and moving patients toward a healthier lifestyle.[4] The purpose of this review is to encourage family physicians to prevent serious consequences of alcohol-related problems by using simple screening and brief intervention strategies.
Rationale for Early Screening
Preventive efforts on the part of family physicians are important because: (1) alcohol-related problems are prevalent in patients who visit family practices; (2) heavy alcohol use contributes to many serious health and social problems; and (3) physicians can successfully influence drinking behaviors. In the United States, the one-year prevalence of alcohol-use disorders, including alcohol abuse and alcohol dependence, is about 7.4 percent in the adult population.[5] In patients who visit family practices, the prevalence is higher. One study of 17 primary care practices found a 16.5 percent prevalence of "problem drinkers,"[4] and another study found a 19.9 percent prevalence of alcohol-use disorders among male patients.[6]
Heavy alcohol use can affect nearly every organ system and every aspect of a patient's life. Table 1 lists many direct and indirect effects of alcohol-related problems. Alcohol causes diseases such as cirrhosis of the liver and exacerbates symptoms in existing conditions such as diabetes.[1,7,8] In addition, alcohol is implicated in many social and psychologic problems, including family conflict, arrests, job instability, injuries related to violence or accidents, and psychologic symptoms related to depression and anxiety.[2,8] These problems take an enormous emotional toll on individuals and families, and are a great financial expense to health care systems and society.
Many of these problems may be avoided by early screening and intervention by family physicians. Several studies of early and brief physician interventions have demonstrated a reduction in alcohol consumption and improvement in alcohol-related problems among patients with drinking problems.[9,10] A 40 percent reduction in alcohol consumption in nondependent problem drinkers has been demonstrated following physician advice to reduce drinking.[4]
Definitions
Tables 2 and 3 list diagnostic criteria for alcohol abuse and dependence specified by the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV).[11] Alcohol abuse is manifested by recurrent alcohol use despite significant adverse consequences of drinking, such as problems with work, law, health or family life.
Adapted with permission from American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, D.C.: American Psychiatric Association, 1994:182-3. Copyright 1994.
Adapted with permission from American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, D.C.: American Psychiatric Association, 1994:181. Copyright 1994.
The diagnosis of alcohol dependence is based on the compulsion to drink. The dependent drinker devotes substantial time to obtaining alcohol, drinking and recovering, and continues to drink despite adverse social, psychologic or medical consequences. A physiologic dependence on alcohol, marked by tolerance or withdrawal symptoms, may or may not be present. Note that quantity and frequency of drinking are not specified in the criteria for either diagnosis; instead, the key elements of these diagnoses include the compulsion to drink and drinking despite adverse consequences.
Clinical Presentation
Alcohol-use disorders are easy to recognize in patients with longstanding problems, because these persons present to the family physician with diseases such as cirrhosis or pancreatitis (Table 1). Patients in the earlier stages of alcohol-related problems may have few or subtle clinical findings, and the physician may not suspect a high consumption of alcohol. Certain medical complaints, such as headache, depression, chronic abdominal or epigastric pain, fatigue and memory loss, should alert the family physician to consider the possibility of alcohol-related problems (Table 1).
The first signs of heavy drinking may be social problems. The compulsion to drink causes persons to neglect social responsibilities and relationships in favor of drinking. Intoxication may lead to accidents, occasional arrest or job loss. Recovering from drinking can decrease job performance or family involvement. Social problems that indicate alcohol-use disorders include family conflict, separation or divorce, employment difficulties or job loss, arrests and motor vehicle accidents.
History
The most effective tool for diagnosing alcohol-related problems is a thorough history of the drinking behavior and its consequences. The National Institute on Alcohol Abuse and Alcoholism (NIAAA) has published The Physician's Guide to Helping Patients with Alcohol Problems, which presents a brief model for screening and assessing problems with alcohol.[12] NIAAA recommends screening for alcohol-related problems during routine health examinations, before prescribing a medication that interacts with alcohol and in response to the discovery of medical problems that may be related to alcohol use (Table 1).
Screening questions are listed in Table 4. The first four questions are related to alcohol consumption. One drink is defined as 12 g of pure alcohol, which is equal to one 12-oz can of beer, one 5-oz glass of wine or 1.5 oz (one jigger) of hard liquor.[7,12] NIAAA also recommends using the CAGE[13] questionnaire to screen patients for alcohol use (Table 5). The CAGE questions are widely used in primary care settings and have high sensitivity and specificity for identifying alcohol problems.[14] Among patients who screen positive for alcohol-related problems, additional questions should include the family history of alcohol abuse as well as family, legal, employment and health problems related to drinking.
Information from The physicians' guide to helping patients with alcohol problems. U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism, 1995; NIH publication no. 95-3769.
(*)--One or more "yes" responses constitute a positive screening test.
Other screening questionnaires are available and may perform better than the CAGE questionnaire. A recent study demonstrated the superiority of the AUDIT instrument in a Veterans Administration population (Table 6).[15] The TWEAK and AUDIT questionnaires performed better than the CAGE questionnaire in women (Table 7).[16]
TABLE 6 The AUDIT(*) Questionnaire
The following questions pertain to your use of alcoholic beverages during the past year. A "drink" refers to a can or bottle of beer, a glass of wine, a wine cooler, or one cocktail or shot of hard liquor.
1. How often do you have a drink containing alcohol? (Never, 0 points; [is less than] monthly, 1 point; 2 to 4 times per month, 2 points; 2 to 3 times per week, 3 points; [is greater than] 4 times per week, 4 points)
2. How many drinks containing alcohol do you have on a typical day when you are drinking? (1 to 2 drinks, 0 points; 3 to 4 drinks, 1 point; 5 to 6 drinks, 2 points; 7 to 9 drinks, 3 points; [is greater than or equal to] 10 drinks, 4 points)
3. How often do you have 6 or more drinks on 1 occasion? (Never, 0 points; [is less than] monthly, 1 point; monthly, 2 points; weekly, 3 points; daily or almost daily, 4 points)
4. How often during the past year have you found that you were not able to stop drinking once you had started? (Scoring same as question No. 3)
5. How often during the past year have you failed to do what was normally expected from you because of drinking? (Same as question No. 3)
6. How often during the past year have you needed a first drink in the morning to get yourself going after a heavy drinking session? (Same as question No. 3)
7. How often during the past year have you had a feeling of guilt or remorse after drinking? (Same as question No. 3)
8. How often during the past year have you been unable to remember what happened the night before because you were drinking? (Same as question No. 3)
9. Have you or someone else been injured as a result of your drinking? (No, 0 points; yes, but not in the past year, 2 points; yes, during the past year, 4 points)
10. Has a relative or friend, or a doctor or other health care worker, been concerned about your drinking or suggested you cut down? (Same as question No. 9)
(*)--Alcohol Use Disorders Identification Test.
Scoring: sum all points; total, 0 to 40 points.
NOTE: For complete scoring information, see reference 15.
TABLE 7 The TWEAK Questionnaire
Tolerance: How many drinks can you hold ("hold" version; [is greater than] 6 drinks indicates tolerance), or how many drinks does it take before you begin to feel the first effects of the alcohol? ("high" version; [is greater than] 3 indicates tolerance)
Worried: Have close friends or relatives worried or complained about your drinking in the past year?
Eye openers: Do you sometimes take a drink in the morning when you first get up? Amnesia: Has a friend or family member ever told you about things you said or did while you were drinking that you could not remember?
Kut down: Do you sometimes feel the need to cut down on your drinking?
Scoring: 2 points each for tolerance or worried; 1 point each for eye opener, amnesia or kut down; sum all points; total, 0 to 7 points.
For complete information about scoring, see reference 16.
Physical Examination
In the early stages of alcohol-related problems, the physical examination provides little evidence to suggest excessive drinking. Patients who abuse alcohol may have mildly elevated blood pressure but few other abnormal physical findings. Later, patients may develop significant and obvious signs of alcohol overuse, including gastrointestinal findings such as an enlarged and sometimes tender liver; cutaneous findings such as spider angiomata, varicosities and jaundice; neurologic signs such as tremor, ataxia or neuropathies; and cardiac arrhythmias. When patients arrive at the doctor's office inebriated, one should suspect a longstanding drinking problem.
Laboratory Findings
Certain chemical markers are indicative but not diagnostic of alcohol-use disorders.[1,8,17] Among liver function tests, the [Gamma]-glutamyl transferase (GGT) level is usually the first to become elevated, followed by the aspartate aminotransferase (AST) level, which is often twice the level of alanine aminotransferase (ALT).
The complete blood cell count may display a number of abnormalities. In cases of end-stage disease, all cell lines are reduced as a direct toxic effect of alcohol on the bone marrow. The prothrombin time (PT) is elevated because of decreased production of clotting factors by the liver. However, in early disease mean corpuscular volume (MCV) may be slightly elevated as a result of folate deficiency and the direct effects of alcohol on red blood cells. Patients with alcoholic gastritis may lose blood through the gastrointestinal tract, causing anemia and the production of smaller red blood cells, resulting in a low MCV. If both processes occur, the MCV will be normal, but the red cell distribution width will be elevated (around 20). Blood loss in the gastrointestinal tract may also cause iron deficiency.
Diagnosis and Classification
An accurate diagnosis of alcohol abuse or dependence requires a thorough medical history. Medical markers such as gastrointestinal problems or elevated liver enzymes are cause for suspicion but are not diagnostic. For example, using a GGT level higher than 40 to detect alcohol problems in a primary care population results in a sensitivity of 44 to 54 percent and a specificity of 80 to 84 percent.[17] In contrast, a CAGE questionnaire with three or more positive responses is 100 percent sensitive and 81 percent specific for current alcohol dependence.[18]
NIAAA categorizes heavy drinkers into three groups: at-risk drinkers, problem drinkers (parallel to the DSM-IV diagnosis of "alcohol abuse"), and alcohol-dependent drinkers (parallel to the DSM-IV diagnosis of "alcohol dependence"). Table 8 describes the NIAAA assessment of alcohol-related problems.[12]
Information from The physicians' guide to helping patients with alcohol problems. U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism, 1995; NIH publication no. 95-3769.
AT-RISK DRINKERS
In the absence of medical, social or psychologic consequences of drinking, men who have more than 14 drinks per week or more than four drinks per occasion are considered "at risk" for developing problems related to drinking. Similarly, women who have more than 11 drinks per week or more than three drinks per occasion are "at risk" Because some drinkers significantly underreport their alcohol use, physicians should define patients as "at risk" when they have a positive CAGE score or a personal or family history of alcohol-related problems (Table 8).
PROBLEM DRINKERS
Patients who have current alcohol-related medical, family, social, employment, legal or emotional problems are considered "problem drinkers" regardless of their drinking patterns or responses to the CAGE questions (Table 8). Typically, these patients score 1 or 2 on the CAGE questionnaire and drink above "at-risk" levels.
ALCOHOL-DEPENDENT DRINKERS
Patients drinking above the "at-risk" level who have CAGE scores of 3 or 4 should be questioned about their drinking compulsions, tolerance to alcohol and withdrawal symptoms (Table 2). Those who display these traits are considered "alcohol dependent."
Primary Care Interventions
The physician should direct intervention efforts based on consideration of two important factors: the severity of the alcohol problem and the patient's readiness to change the drinking behavior.
SEVERITY OF THE ALCOHOL PROBLEM
In patients who show evidence of alcohol dependence, the therapeutic end points should be abstinence from alcohol and referral to a specialized alcohol treatment program. Decisions about inpatient or outpatient treatment depend on the patient's likelihood of alcohol withdrawal, resources, employment status, family support system, access to treatment programs and motivation. Patients who resist formal treatment may prefer peer-directed groups, such as those offered by Alcoholics Anonymous, in conjunction with physician counseling and support. Al-Anon groups are available for adult family members of alcohol-dependent individuals. Abstinence is also indicated for non-alcohol-dependent patients who are pregnant, have comorbid medical conditions, take medications that interact with alcohol or have a history of repeated failed attempts to reduce their alcohol consumption.[12]
In patients who are at risk for developing alcohol-related problems or who have evidence of current problems, the therapeutic end point should be drinking at low-risk limits: for men, no more than two drinks with alcohol per day; for women or older persons (over 65) no more than one drink per day.[12]
READINESS TO CHANGE
A rare patient will present to the physician with the request for help in giving up alcohol. When persons change lifestyle behaviors such as tobacco or alcohol use, they typically move through stages of change: precontemplation (not ready for change), contemplation (ambivalence about change), preparation (planning for change), action (the act of change) and maintenance (maintaining the new behavior).[19] This model of change can be pictured as a continuum, with a person moving back and forth among the stages, depending on the personal day-to-day costs and benefits of that behavior. Relapse is common and does not indicate a "failed" intervention. Contemplation (ambivalence) is the most common stage of change. One study found that 29 percent of hospitalized patients with alcohol disorders were uninterested in changing, 45 percent were ambivalent and 26 percent were ready to change their drinking behavior.[20]
Some experts consider precontemplation to be a synonym for alcoholic denial, that is, a refusal to acknowledge problems. However, others[21] do not find the concept of denial useful when working with patients with alcohol disorders. They note that direct or confrontational counseling strategies are likely to evoke resistance in patients, which, in turn, will be labeled "denial." Furthermore, their work demonstrates that even patients who do not admit to an alcohol problem can change their behaviors. Personal decisions about lifestyle changes evolve slowly over time, requiring much reflection, with repeated attempts at change and repeated setbacks. Patients will not leap from the precontemplation stage into the action stage after one clinic visit, no matter how insightful or aggressive the practitioner. The goal of each visit should be to help the patient move along the continuum of change toward a reduction in alcohol use.
INTERVENTION STRATEGIES
With the stage-of-change continuum in mind, physicians should tailor interviews according to the patient's stage.[20] In clinical settings, a good assessment is itself an intervention, stimulating patients to reflect on their drinking behavior. Well-intentioned advice, a familiar tool among physicians, works best with patients who are preparing for change. A physician who tries direct persuasion with an ambivalent patient risks pushing the patient toward resistance. However, at any stage, urgent persuasion is appropriate in patients requiring immediate change: a pregnant woman who drinks heavily or patients with severe medical, psychologic or social problems related to alcohol use. Even in these circumstances, resistance to direct advice is likely. When giving advice, physicians should avoid prescriptive directions. Instead, physicians can educate patients about the consequences in an objective manner: "Drinking affects the fetus in this way...." This information is most effective when it addresses issues that directly concern the patient.
Rollnick and colleagues[18] have developed a menu of brief strategies for the primary caregiver, based on a model of counseling called "motivational interviewing" (Table 9).[20] In all patients, the physician should begin by directing the interview toward understanding the drinking behavior and how it fits into patients' lives. Among patients in the precontemplation stage, this assessment is the complete intervention. In the contemplation stage, the physician should explore patients' ambivalence toward change, including reasons to quit and reasons to continue drinking. At this point, patients may be receptive to information about the effects of alcohol. In the later stages, the physician may acquaint patients with helpful community resources such as Alcoholics Anonymous or formal treatment programs, and help them anticipate and prepare for temptations and setbacks.
TABLE 9 A Menu of Interviewing Strategies for Patients with Alcohol-Related Problems
Information from Rollnick S, Heather N, Bell A. Negotiating behaviour change in medical settings: the development of brief motivational interviewing. J Ment Health 1992; 1:25-37.
The goal of these strategies is to help patients develop their own rationale for change and to nudge them in the direction of a healthier lifestyle. This nondirective approach removes the element of resistance because the patient does the work: the patient reflects on the ways alcohol fits into his or her life, weighs the personal costs and benefits of drinking, provides the arguments for change and makes the decision to quit drinking. The physician's job is simply to elicit information, encourage patients to reflect and support their movement toward healthy change.
Final Comment
Excessive alcohol use can affect every part of a person's life, causing serious medical problems, family conflict, legal difficulties and job loss. Family physicians, with training in biomedical and psychosocial issues and access to family members, are in a good position to recognize problems related to alcohol use and to assist patients with lifestyle change. NIAAA provides simple guidelines for alcohol screening, based on a thorough drinking history and a sound understanding of the pattern of consequences. Physicians who are sensitive to these issues will find alcohol-use disorders easier to diagnose, and physicians who motivate their patients to reflect on their drinking will encourage recovery.
REFERENCES
[1.] Eighth special report to the U.S. Congress on alcohol and health from the Secretary of Health and Human Services. Rockville, Md.: Department of Health and Human Services, National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism, 1994; DHHS publication no. 94-3699.
[2.] Regier DA, Farmer ME, Rae DS, Locke BZ, Keith S J, Judd LL, et al. Comorbidity of mental disorders with alcohol and other drug abuse. Results from the Epidemiologic Catchment Area (ECA) Study. JAMA 1990;264:2511-8.
[3.] Sobell LC, Sobell MB, Toneatto T, Leo GI. What triggers the resolution of alcohol problems without treatment. Alcohol Clin Exp Res 1993;17:217-24.
[4.] Fleming MF, Barry KL, Manwell LB, Johnson K, London R. Brief physician advice for problem alcohol drinkers. A randomized controlled trial in community-based primary care practices. JAMA 1997: 277:1039-45.
[5.] Grant BF, Harford TC, Dawson DA, Chou P, Dufour M, Pickering R. NIAAA's Epidemiologic Bulletin no. 35: prevalence of DSM-IV alcohol abuse and dependence, United States, 1992. Alcohol Health Res World 1994;18:243-8.
[6.] Burge SK, Amodei N, Elkin B, Catala S, Andrew SR, Lane PA, et al. An evaluation of two primary care interventions for alcohol abuse among Mexican-American patients. Addiction 1997;92:1705-16.
[7.] Dufour MC, Caces ME Epidemiology of the medical consequences of alcohol. Alcohol Health Res World 1993;17:265-71.
[8.] O'Connor PG. The general internist. Supplement 1: identification and treatment of substance abuse in primary care settings. Am J Addict 1996;5:59-519.
[9.] WHO Brief Intervention Study Group. A cross-national trial of brief interventions with heavy drinkers. Am J Public Health 1996;86:948-55.
[10.] Richmond R, Heather N, Wodak A, Kehoe L, Webster I. Controlled evaluation of a general practice-based brief intervention for excessive drinking. Addiction 1995;90:119-32.
[11.] American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, D.C.: American Psychiatric Association, 1994.
[12.] The physicians' guide to helping patients with alcohol problems. U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism, 1995; NIH publication no. 95-3769.
[13.] Ewing JA. Detecting alcoholism. The CAGE questionnaire. JAMA 1984;252:1905-7.
[14.] Girela E, Villanueva E, Hernandez-Cueto C, Luna JD. Comparison of the CAGE questionnaire versus some biochemical markers in the diagnosis of alcoholism. Alcohol Alcohol 1994;29:337-43.
[15.] Bradley KA, Bush KR, McDonnell MB, Malone T, Fihn SD. Screening for problem drinking. Comparison of CAGE and AUDIT. J Gen Intern Med 1998;13:379-88.
[16.] Bradley KA, Boyd-Wickizer J, Powell SH, Burman ML. Alcohol screening questionnaires in women. A critical review. JAMA 1998;280:166-71.
[17.] Hoeksema HL, de Bock GH. The value of laboratory tests for the screening and recognition of alcohol abuse in primary care patients. J Fam Pract 1993; 37:268-76.
[18.] Magruder-Habib K, Stevens HA, Ailing WC. Relative performance of the MAST, VAST, and CAGE versus DSM-III-R criteria for alcohol dependence. J Clin Epidemiol 1993;46:435-41.
[19.] Prochaska JO, Velicer WF, Rossi JS, Goldstein MG, Marcus BH, Rakowski W, et al. Stages of change and decisional balance for 12 problem behaviors. Health Psychol 1994;13:39-46.
[20.] Rollnick S, Heather N, Bell A. Negotiating behaviour change in medical settings: the development of brief motivational interviewing. J Ment Health 1992;1:25-37.
[21.] Miller WR, Rollnick S, eds. Motivational interviewing: preparing people to change addictive behavior. New York: Guilford, 1991.
SANDRA K. BURGE, PH.D., is an associate professor and director of behavioral science education in the Department of Family Practice at the University of Texas Health Science Center at San Antonio. Dr. Burge received her doctorate in family social science from Purdue University, Lafayette, Ind.
F. DAVID SCHNEIDER, M.D., MS.P.H., is an associate professor and director of medical student education in the Department of Family Practice at the University of Texas Health Science Center at San Antonio. He is a graduate of Boston University School of Medicine and served a residency in family practice at the Duke Family Practice Residency Program, Durham, N.C. Dr. Schneider also received a master's degree in public health from the University of Missouri, Columbia.
Address correspondence to Sandra K. Burge, Ph.D., Department of Family Practice, University of Texas Health Science Center-San Antonio, 7703 Floyd Curl Dr., San Antonio, TX 78284. Reprints are not available from the authors.
Each year members of a different family practice department develop articles for "Problem-Oriented Diagnosis." This series is coordinated by the Department of Family Practice at the University of Texas Health Science Center at San Antonio. Guest editors of the series are David A. Katerndahl, M.D., and Clinton Colmenares.
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