Alcohol Screening in Primary Care

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Alcohol Screening in Primary Care

• Lai Wong
• Johns Hopkins University
• School of Nursing
• July 12, 2006

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Why the topic of Alcohol Use?

• Two-thirds of American adults drink alcohol.
• Associated with significant numbers of accidents
  and adverse health outcomes.
• Modest consumption can reduce the risk of MI and
  other heart disease.
• Treatable. First step is raising awareness.

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Epidemiology

• In primary care, prevalence of risky drinking is
  4 to 29 and alcohol dependence was 2 to 9.
• Highest prevalence of binge and heavy drinking
  young adults aged 18 to 25.
• Also common in elderly and increased their risk
  of drug-alcohol interactions.

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Risk Factors

• Associated with comorbid conditions e.g.
  anxiety, major depressive disorder and other
  substance abuse.
• People who smoke. Additive effects of alcohol
  and nicotine.
• First degree relatives have a three- to fourfold
  higher prevalence.

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Damage of Alcohol

• Associated with psychiatry conditions.
• Family and work related problems
• Chronic diseases cirrhosis, pancreatitis,
  alcoholic cardiomyopathy.

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What is a Moderate Intake?

• Less than 3 drinks per day for men
• Less than 2 drinks per day for women
• Less than 2 drinks per day for gt65y/o
• Lack of knowledge about safe upper limit of
  alcohol intake.

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One Drink Equals

• 12 g of alcohol
• 360 ml (12 oz) beer,
• 150 ml (5oz) of wine,
• 45 ml (1.5 oz) of 80 proof distilled spirits.

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Beverage Type

• French paradox
• Red wine contains phenolic and flavonoid
  substanceantithrobotic and antioxidant
  properties.
• Clinical trial data varied on this issue.

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Blood Alcohol Concentration

• Degree of impairment depends upon BAC
• Legal limit in most states, including VA, is 80
  mg/dL (0.08)
• Research shown significant impairments at BACs
  50mg/dL.

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Blood Alcohol Concentration for Women
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Definition of Alcohol Abuse

• DSM-IV definition maladaptive pattern of use
  associated with one or more of the following
• Failure to fulfill work, school, or social
  obligations.
• Recurrent substance use in physically hazardous
  situations
• Recurrent legal problems related to substance use
• Continued use despite alcohol-related social or
  interpersonal problems.

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Alcohol Dependence

• A maladaptive pattern of use associated with
  three or more of the following
• Tolerance
• Withdrawal
• Substance taken in larger quantity than intended
• Persistent desire to cut down or control use
• Time is spent obtaining, using or recovering from
  the substance
• Social, occupational, or recreational tasks are
  sacrificed
• Use continues despite physical and psychological
  problems.

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Alcohol Addiction

• Physiologic manifestations
• Increased tolerance to the drug,
• Blackouts or memory lapses following drinking
  episodes,
• Sleep disturbances,
• Tremors,
• Alcohol withdrawal symptoms, e.g. delirum
  tremens.

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Screening Questionnaires

• CAGE questionnaire
• AUDIT (Alcohol Use Disorder Identification Test)
• TWEAK (tolerance, worried, eye openers, amnesia,
  Kut down)
• T-ACE (pregnancy drinking)

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Physical Exam Findings with Alcohol Abuse

• Tremulousness,
• Elevated BP,
• Obstructive lung disease
• Unexplained tachycardia,
• Unexplained heptosplenomegaly,
• Unexplained peripheral neuropathy
• Evidence of physical trauma.
• No abnormalities need to be present to confirm
  the diagnosis of alcoholism.

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Tips on Addressing Alcoholism with Patients

• Use nonjudgmental language. Use the term
  disease tends to reduce patient guilt.
• Relate how problems with drinking affects health
  and well being.
• Be empathetic, but firm.
• Be alert for treatable co-morbidities. Use
  alcohol for disorders r/t mood, anxiety, sleep.
• Alcohol abuse and dependence are chronic diseases
  that can relapse and not a sign of failure.
• Untreated alcohol dependence is a fatal disease
  and with serious consequences, e.g. alcoholism
  accounts for 25 of suicides.
• Treatment options are available

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Treatments

• Alcohol Anonymous
• Motivation Enhancement therapy
• Brief Intervention
• Cognitive Behavioral therapy
• Hospitalization and Referral
• Inpatients
• Outpatient

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AHA Science Advisory conclusion

• Moderate intake of alcoholic beverages (one to
  two drinks per day) is associated with a reduced
  risk of CHD in populations. There is no clear
  evidence that wine is more beneficial than other
  forms of alcohol Many of the same additional
  biological effects may be achieved with grape
  juice. Although moderate use of wine and other
  alcoholic beverages does not appear to lead to
  significant morbidity, alcohol ingestion poses a
  number of health hazards.