Alcoholism

Objectives

Refer to the alcohol card while reading the following information.

Problem alcohol use, abuse and dependence are common and cause considerable morbidity and mortality.

Early intervention targets patients at risk for alcohol problems and in th early stages of disease in order to prevent morbidity and mortality.

 
Common Presentations
  • abdominal complaints
  • hypertension
  • trauma
  • anxiety/depression/sleep disorders
  • gyn complaints/pregnancy

Patients with early alcohol related problems often present with predictable medical conditions. These common presentations should serve as a trigger for you to obtain a more detailed alcohol history.
History
  • alcohol consumption/day
  • "at risk" consumption is defined by the number of standard drinks per week and per occasion (Table 1)
  • ever a heavy drinker?
  • family history
  • tolerance
  • blackouts/memory loss
  • cut-back
  • annoyed by others
  • guilty
  • eye opener
  • consequences: family, job, legal, emotional, medical

The history should include an estimate of the usual amount consumed for a given time frame. Avoid "occasional" or "social" as a substitute for the amount. Compare the patient's use to Table 1. "At risk" amounts reflect the cut off between low and moderate risk for current alcohol related problems. If someone doesn't drink at all, explore why not. Former heavy drinking may indicate greater risk of problems related to lower current consumption.

The history also includes the family history, the CAGE questions (one positive indicates a potential problem), tolerance, and consequences of alcohol use. Note that consequences are best revealed through general lifestyle questioning (remember family, social, occupational, and financial aspects of the continuity project). Patients rarely relate the consequences to their drinking behavior unless they believe the consequences are responsible for their drinking.
Impression
  • non-problematic use or abstinence
  • past hx of problematic use (complete reverse side)
  • at risk for development of problematic use (complete reverse side)
  • potential problematic use (complete reverse side)
  • definite alcohol abuse or dependence (complete reverse side)
 The history will usually indicate if the patient has essentially no risk, some risk, or probable alcohol related problems. "Continued use despite negative consequences" signifies problematic use. Unless the patient has "non-problematic use or abstinence" without a past history of problems, further evaluation, education, and/or confrontation is indicated.

 

Table 1. "At Risk " Consumption.
1 standard drink=0.5 to 0.6oz or 15cc of absolute alcohol 
1 standard drink=one 12 oz beer or
one 5oz glass of wine or 
1-1/2 oz liquor
"at risk" consumption for a male= >14 standard drinks/week or > 4/occasion
"at risk" consumption for a female= > 7 standard drink/week or > 2/occasion

 
Diagnosis

Alcohol problems may be represented by the continuum: abstinence -> non-problematic use -> misuse -> abuse -> dependence. To make a diagnosis of abuse or dependence, the patient should meet the criteria established by the DSM-IV.

 

Additional Tests
  • GGT
  • MCV
  • non-specific (anemia, pancytopenia, elevated triglycerides, cholesterol, uric acid)
  • ETOH levels
    • 100 microgram/DL scheduled visit
    • 150 microgram/DL without toxicity
    • 300 microgram/DL anytime
  • short MAST
  • trial of abstinence or controlled use

Additional tests are completely optional. Only fill them in if you already have the information readily available or if you and the patient want to perform them.
Intervention

Confrontation

  • alcohol problem

If you think the patient is at risk or has alcohol related problems, tell them in a caring and non-judgmental way.

 

Education

  • inherited problem
  • key issues are loss of control and denial
 Educate patients (especially if they have a family history) that alcohol problems are inherited. Also educate them about the key issues of control and denial. A loss of control means that "you drink at times you didn't plan to drink, and that you drink more than you planned to drink". Denial means "even though bad things happen related to your drinking, you are able to tell yourself the the drinking is not causing problems and may even help."

Natural progression

  • family problems
  • job problems
  • legal problems
  • emotional problems
  • medical problems
 Alcohol problems are related to early death and cause a predictable pattern of problems affecting the patient's physical and emotional health, family, job, and legal standing. Review any consequences you have identified as common in patients who have alcohol problems. Educate the patient about your concerns and let them know that you are confronting them because you do care.

 

PROGNOSIS:FATAL

 
Recommendations
  • Reinforce healthy lifestyle.
  • Abstinence as key; most people need help.

Patients with at-risk alcohol consumption but without any additional concerns found on history should be educated about risk, encouraged to decrease usage to low-risk amounts, and advised to ask for help if they experience difficulty in restricting usage or other problems.
Sources of help: Any patient with suspected alcohol abuse, dependence, or problematic use should be advised to stop all alcohol use and to seek help. The Council on Alcohol and Drug Abuse of NW Louisiana is my favorite referral source. They have access to all other resources and will see patients on a sliding fee scale usually within a few days. Some of your cards have the wrong address. It should be 2000 Fairfield.
 
Follow-up Plan follow-up with the patient to help reinforce the treatment plan and to assist with overalll health care.
J. Hood, MD
updated 8/30/05
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