Screening and Management of Alcohol Misuse in Primary Care

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What Every PCP Should Know

Significance:

The primary care provider (PCP) is often the first and most integral player in the initial assessment of the addicted patient. This can be because the PCP is the most accessible, least costly, and most trusted source of information and/or initial intervention for the addicted patient, even above the addiction specialist.1,2 It is estimated that 30% of the population in the United States is affected by alcohol misuse, making it the third leading cause of preventable death in the United States.3

Alcohol misuse can be attributed to a wide range of health disorders, including depression, anxiety, cancer, pancreatitis, liver disease, hypertension, and cirrhosis. It also is a major factor of morbitity and mortality in regard to accidents, homocide, suicide, and major trauma. Alcohol misuse in pregnant women is linked to fetal alcohol syndrome, which affects 0.2 to 1.5 per 1000 births in the United States.3 Despite the prevalence and health impact of alcohol misuse, primary care providers report lack of preparation and confidence in the identification, treatment, and referral of substance abuse disorders.4

Current Literature:
Screening for Alcohol Misuse

Several validated and evidence-based screening, assessment, intervention, and treatment options are available and recommended by the The National Institute on Alcohol Abuse and Alcoholism (NIAAA), a division of the National Institute of Health (NIH), and the United States Preventative Services Task Force (USPSTF), an independent, volunteer panel of national experts in prevention and evidence-based medicine. The USPSTF recommends the Alcohol Use Disorder Identification Test (AUDIT) screening tool, Abbreviated AUDIT-Consumption (AUDIT-C), and the single question screening, e.g. “How many times in the past year have you had five (4 for women and all adults over age 65 years) or more drinks a day?”3 Patients that have a positive single question screen, or an AUDIT score greater than 8 should receive further assessment beyond an initial screening in primary care.3

Diagnosis

Health care providers often confuse all forms of excessive drinking with alcohol dependence. Alcohol Use Disorder (AUD) includes patients with alcohol dependence (3-5% of the population) and also patients with hazardous drinking (15-40% of the population).3 The USPSTF describes alcohol misuse as behaviors that include risky or hazardous alcohol use. This behavior involves drinking in excess of the recommended daily, weekly or per-occasion amounts of alcohol.3 The NIAAA defines ‘risky use’ as consumption of more than 4 drinks a day or 14 drinks a week for men or 3 drinks a day or 7 drinks a week for women.5

The American Psychiatric Association recently issued the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).6 While the DSM-IV previously identified two distinct disorders, alcohol abuse and alcohol dependence, the DSM-5 integrates both disorders into a single disorder, AUD, with mild, moderate, and severe sub-classifications. The presence of 2 to 3 criteria indicates mild severity, 4 to 5 criteria indicates moderate severity, and the presence of 6 or more criteria indicates a severe grade. DSM-5 also states that a patient meeting any two of the 11 criteria during the same 12-month period receives a diagnosis of AUD.6

Brief Intervention

The goals of a Screening and Brief Intervention (SBI) via a primary care practitioner are to bring awareness to the patient of his/her alcohol misuse and the associated consequences, and to encourage the patient to create a plan to change their behavior to stay within safe limits.7 There are two primary purposes: 1) to identify and refer people with alcohol dependence at early stages to prevent the progression of dependence, and 2) to identify and help hazardous drinkers that may or may not develop alcohol dependence.7

The steps to Brief Intervention include:

  • Step 1: Broach the Subject

The PCP is respectful and obtains permission to discuss the patient’s use of alcohol. Example: “Would it be okay to take a few minutes to talk about your drinking?” or “Has anyone ever talked to you before about your drinking?7

  • Step 2: Provide FeedbackThe PCP reviews the patient’s current drinking patterns, compares them to the NIAAA drinking guidelines, expresses concerns, and makes connections between alcohol and health problems (both actual and potential). Examples: “From what we know, drinking too much can cause problems such as…” “I am concerned about your drinking.”7
  • Step 3: Enhance MotivationThe PCP assesses the patient’s readiness to make a change by engaging the patient in a non-judgmental way, listening effectively, and asking open-ended questions. Examples: “On a scale from 1-10, with 1 being not ready and 10 being very ready, how ready are you to make a change to any aspect of your drinking?”7
  • Step 4: Negotiate and AdviseThe PCP discusses options and develops a plan for the patient to decrease alcohol consumption. Clear steps on how to do this should be outlined, including having the patient sign a ‘drinking agreement’ and providing written informational materials. Examples: “Where do you want to go from here?” and “This drinking agreement can help you reinforce your new goals. It is really an agreement between you and yourself.”7

 

Treatment: Assessing and Managing Alcohol Withdrawal

Management of withdrawal symptoms is not addiction treatment, but rather a bridge to get the patient into treatment. Transitioning to a treatment and/or support program may need to be done to prevent relapse of alcohol use. A combined approach of interventions, treatment, behavioral counseling, support groups, and/or pharmacotherapy offer the best course to prevent relapse.8 The PCP is often perfectly positioned to provide stop-gap measures such as these that will help guide the patient with an AUD along the initial, and sometimes subsequent, steps toward recovery.

Alcoholics Anonymous (AA) has been one of the main treatment sources for alcoholism for almost eight decades. However, due to the inherent anonymous nature of AA, there is limited quantifiable evidence to prove the institution’s claims of a 50-75% success rate.9,10 In 2006, the Cochrane Collaboration published a study which concluded that there were simply not enough experimental studies to demonstrate the effectiveness of AA or any other 12-step approach in reducing alcohol use and/or achieving abstinence as compared with other methods.11 However, neither could the claims be completely refuted, and there continues to be anecdotal evidence of some level of success.

Outpatient management of mild-to-moderate withdrawal symptoms may be appropriate for certain patients that have an available support person willing to monitor their progress closely.13 Patients must be personally motivated, reliable, and committed to continuing with the treatment plan, even after the withdrawal period.2 A patient that is at risk of severe withdrawal, including delirium tremens or previous withdrawal seizure, abnormal labs, a drug screen positive for other substances, or that has medical or psychiatric co-morbidities should be managed in an inpatient setting.12,14

Every patient with a more severe AUD, as noted via screening tools, should be questioned about withdrawal symptoms.2 Patients that have consumed large amounts of alcohol for two weeks or longer may experience withdrawal symptoms if alcohol consumption is abruptly stopped. Withdrawal symptoms from alcohol usually occur within 6 to 24 hours after the last drink.12

To accurately assess withdrawal signs and symptoms, the Clinical Institute Withdrawal Assessment for Alcohol, Revised version (CIWA-Ar) is a validated tool useful in primary care that measures 10 categories of symptoms, scoring at 1 point each: sweating, anxiety, auditory or visual disturbances, agitation, nausea and vomiting, tremor, tactile disturbances, headache, and disorientation. A score of 8 or less indicates absent to very mild withdrawal symptoms, 9 to 14 points indicates mild withdrawal symptoms, 15 to 20 indicates moderate withdrawal symptoms, and a score of greater than 20 indicates severe withdrawal symptoms. Patients with a score less than 10 generally do not need medication to manage alcohol withdrawal symptoms.12

The type of medication and the frequency of monitoring should be guided by symptom severity, patient characteristics, and his/her environment and support system. In general, patients should be evaluated daily until their symptoms improve and the dose of medication needed is reduced. Vital signs should be monitored at each follow-up visit.

There are several medications commonly utilized to treat withdrawal symptoms, and there is currently no evidence that any medication is superior to another. Even so, benzodiazepines are the most commonly utilized choice. Severity of symptoms should also be reassessed at each follow-up visit using the same tool used upon initial assessment. If the CIWA-Ar score is less than 10, the doses of medication can be reduced and the medication can eventually be discontinued.12

Generally, no withdrawal symptoms are noted after seven days of sobriety. Once the patient is weaned off medication, referral to a long-term outpatient treatment program could be considered. Patients that do not follow-up as directed, or that resume drinking should be referred to a specialist. For the treatment of alcohol dependence, three medications are currently approved by the Food and Drug Administration, 1) disulfiram (Antabuse), 2) oral naltrexone, extended release naltrexone (Vivitrol) and, 3) acamprosate (Campral).12

Referral to Specialty Treatment

Patients exhibiting more severe symptoms of AUD are less likely to change their drinking behaviors with a single brief intervention and may need referral to specialty treatment.2 To properly refer the patient, it is important for the PCP to establish reliable contacts and familiarize themselves with local resources: counselors, psychologists, hospitals, and treatment facilities (both inpatient and outpatient) that would benefit patients who need additional help.15

The Substance Abuse and Mental Health Services Administration (SAMHSA)16 has a website designed to help primary care providers and patients find services that can help, and the site Planning and Implementing Screening and Brief Intervention for Risky Alcohol Use provides A Step-by-Step Guide for Primary Care Practices.15

References

  1. Barnes H. Listening for stories: Addiction, psychotherapy, and primary care. Subst Abus. 1995;16(1):31-38.
  2. Spithoff S, Kahan M. Moving the management of alcohol use disorders from specialized care to primary care. Can Fam Physician. 2015;(61):491-493.
  3. Oliva E, Maisel N, Gordon A, Harris AHS. Barriers to use of pharmacotherapy for addiction disorders and how to overcome them. Curr Psych Rep. 2011;13:374-381.
  4. Moyer V. Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: Clinical summary of US Preventive Services Task Force recommendations. Ann Intern Med. 2013;159(3):210-218.
  5. National Institute on Alcohol Abuse and Alcoholism (NIAAA). 2015. Alcohol use disorder. http://niaaa.nih.gov/alcohol-health/overview-alcohol-consumption/alcohol-use-disorders. Accessed November 1, 2015.
  6. American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 5th ed. Arlington, VA:American Psychiatric Association; 2013.
  7. Babor TF, McRee B, Kassebaum PA, Grimaldi PL, Ahmed K, Bray J. Screening, brief intervention, and referral to treatment (SBIRT): Toward a public health approach to the management of substance abuse. Subst Abus. 2007;28(3):7-30.
  8. Lee J, Kresina, TF, Campopiano M, Lubran R, Clark W. Use of Pharmacotherapeutics in the treatment of alcohol use disorders and opioid dependence in primary care. BioMed Res Int. 2015; http://www.hindawi.com/journals/bmri/2015/137020/#B2 Accessed October 25, 2015.
  9. Dodes L, Dodes Z. The sober truth: Debunking the bad science behind 12-step programs and the rehab industry. Boston, MA: Beacon Press; 2015.
  10. Glaser G. The irrationality of Alcoholics Anonymous. The Atlantic. April, 2015. http://www.theatlantic.com/magazine/archive/2015/04/the-irrationality-of-alcoholics-anonymous/386255/. Accessed November 1, 2015.
  11. Ferri M, Amoato L, Davoli M. Alcoholics Anonymous and other 12-step programmes for alcohol dependence (Review) 2006. Cochrane Database Syst Rev. http://www.thecochranelibrary.com. Accessed November 1, 2015.
  12. Muncie H, Yasinian Y, Oge L. Outpatient management of alcohol withdrawal syndrome. Am Fam Physician. 2013;88(9):589-595.
  13. Kosten TR, O’Connor PG. Management of drug and alcohol withdrawal. N Engl J Med. 2003;348(18):1786-1795.
  14. Shapiro B, Coffa D, McCance-Katz EF. A primary care approach to substance misuse. Am Fam Physician. 2013;88(2):113–121.
  15. Centers for Disease Control and Prevention (CDC). Planning and implementing screening and brief intervention for risky alcohol use: A step-by-step guide for primary care practices. Atlanta, Georgia: Centers for Disease Control and Prevention, National Center on Birth Defects and Developmental Disabilities 2014. http://www.cdc.gov/ncbddd/fasd/documents/alcoholsbiimplementationguide.pdf. Accessed November 1, 2015.
  16. Substance Abuse and Mental Health Services Administration (SAMHSA) 2015. https://www.findtreatment.samhsa.gov/. Accessed November 1, 2015.
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