Alcohol Screening

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Alcohol Screening

• Mark Publicker, MD FASAM

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addiction

• a chronic but treatable brain disease
  characterized by
• loss of control
• compulsive use
• use despite known harm
• relapse

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definition

• addiction is a cycle of spiraling dysregulation
  of brain reward systems that progressively
  increases, resulting in compulsive drug use and a
  loss of control over drug taking. george koob

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neural circuitry of reward

• produces pleasure for behaviors needed for
  survival
• eating
• drinking
• sex

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alcohol spect scan
intoxication
sober
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alcohol spect scan
normal
intoxication
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alcoholism epidemiology

• 14 lifetime prevalence
• 5-8 12 month prevalence
• Up to 20 of outpatient medical visits
• 20-40 of hospitalizations
• 40-60 of trauma admissions

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impact of physician warning on alcoholism
treatment outcome

• walshJAMA 1992 Feb 267(5)663-7
• two years later, those warned were more likely to
  be abstaining, and sober, and were less impaired.
  
• fewer than a quarter remembered physician warning
  although three quarters had been seen

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screening

• ask all patients about their alcohol use.
• assess for alcohol-related problems.
• advise appropriate actions.
• monitor progress.

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ask current drinkers

• on average, how many days a week do you drink
  alcohol?
• on a typical day when you drink, how many drinks
  do you have?
• what is the maximum number of drinks you had on
  any given occasion during the last month?

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CAGE

• C have you ever felt you should Cut down on your
  drinking?
• A have people Annoyed you by criticizing or
  complaining about your drinking?
• G have you ever felt bad or Guilty about your
  drinking?
• E have you ever had to have an Eye-opener in the
  morning to settle your nerves or get rid of a
  hangover?

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RAPS4 and RAPS4-QF

• Remorse or guilt
• Amnesia
• Performance
• Starter (eye-opener)
• Quantity
• Frequency

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TWEAK

• Tolerance how many drinks does it take before you
  begin to feel the first effects of the alcohol?
• Worry have your friends or relatives worried or
  complained about your drinking in the past year?
• Eye-opener do you sometimes take a drink in the
  morning when you first get up?
• Amnesia are there times when you drink and
  afterwards you can't remember what you said or
  did?
• Kut down do you sometimes feel the need to cut
  down on your drinking?

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T-ACE

• Tolerance How many drinks does it take to make
  you feel high?
• Annoyed Have people annoyed you by criticizing
  your drinking?
• Cut down Have you ever thought you should cut
  down on your drinking?
• Eye-opener Have you ever had a drink first thing
  in the morning to steady your nerves or to get
  rid of a hangover?

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CRAFFT

• C - Have you ever ridden in a Car driven by
  someone (including yourself) driven by someone
  who was high or had been using alcohol or drugs?
• R - Do you ever use alcohol or drugs to Relax, to
  feel better about yourself or to fit in?
• A - Do you ever use alcohol or drugs by yourself?
  Alone

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CRAFFT

• F - Do you ever Forget things you did while using
  alcohol or drugs?
• F - Do your Family or Friends ever tell you that
  you should cut down on your alcohol or drug use?
• T - Have you ever gotten into Trouble while using
  alcohol or drugs?

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family CAGE

• C- have you ever felt that anyone in your family
  should cut down on their alcohol or drug abuse?
• A- has anyone in your family been annoyed by
  complaints about their alcohol or drug abuse?

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family CAGE

• G- has anyone in your family ever felt guilty
  about their alcohol or drug use?
• E- has anyone in your family ever taken a drink
  or a drug the first thing in the morning to
  steady nerves or relieve a hangover? (Eye-opener)

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red flags
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red flags

• sweating
• tachycardia
• hypertension
• pancreatitis
• hepatitis
• dyspepsia, diarrhea, gastritis, abdominal pain,
  nausea

• cardiomyopathy
• tremors, paresthesias
• seizures
• amnestic episodes
• cognitive impairment
• cancer

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red flags

• smoking, heavy coffee use
• sexual dysfunction
• menstrual irregularity
• family dysfunction
• Absenteeism

• job loss
• spousal abuse
• poor nutrition and personal neglect
• depression, anxiety, panic, insomnia
• trauma

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increased vulnerability

• family history
• ADHD
• mood disorders
• anxiety disorders
• PTSD
• negative life events

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laboratory indicators

• positive BAL in a medical setting
• elevated MCV
• elevated uric acid
• elevated GGT, AST, ALT
• CDT

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