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		Subscribe to Clinical Compass™			VOLUME 2, ISSUE 8 - APRIL 10, 2007
		FROM THE CLINICAL KNOWLEDGE CENTER In Recognition of Alcohol Awareness Month by Jill Shuman, MS, ELS April 2007 has been designated as Alcohol Awareness Month by the National Council on Alcoholism and Drug Dependence. To better understand the scope of alcohol use disorders in the United States, consider the following statistics from the National Institute on Alcoholic Abuse and Alcoholism: • Nearly 14 million Americans - 1 in every 13 adults - abuse alcohol or meet the criteria for alcoholism. Several million more adults engage in risky drinking that could lead to alcohol problems. These patterns include binge drinking and heavy drinking on a regular basis. • In addition, 53 percent of men and women in the United States report that one or more of their close relatives have a drinking problem. • Alcohol abuse and alcoholism can worsen existing conditions such as depression or induce new problems such as memory loss, depression, or anxiety. Heavy drinking can increase the risk for cancer of the liver, esophagus, throat, and larynx. Heavy drinking can also cause liver cirrhosis, immune system problems, brain damage, and fetal alcohol syndrome. • Alcohol is causally related to more than 60 medical conditions, including heart disease, liver disease, infectious disease, and cancer, and contributes to more than 100,000 deaths in the U.S. each year. • In addition, drinking increases the risk of death from automobile crashes as well as recreational and on-the-job injuries; homicides and suicides are also more likely to be committed by persons who have been drinking. • In purely economic terms, alcohol-related problems cost society approximately $185 billion per year. Despite these statistics, it is estimated that only 2.4 million individuals received treatment in 2004 for alcohol dependence and moreover, of those in treatment, less than 20% received a medication to assist their quit attempt. This is due in part to the discomfort that clinicians feel about asking patients questions that might help to elucidate a problem with alcohol. In one study, fewer than half of patients with alcohol problems were so identified by their physicians, and in another study only 24 percent were offered treatment. Women with alcohol problems are less likely to be identified than men. In addition to inadequate training about substance abuse, factors that may be associated with nondetection include clinicians' negative attitudes about patients with substance abuse, skepticism about the effectiveness of treatment, and the perception that alcohol problems are not in the realm of generalists. However, early detection by healthcare providers is critical to prevent side effects of alcohol problems. In addition, the potential interactions of alcohol with a variety of prescription and nonprescription medications make routine screening critical. During any clinician-patient encounter, all patients should be asked whether they drink alcohol. An affirmative response can be followed up with three more questions: • Frequency: On average, how many days per week do you drink alcohol? • Quantity: On a typical day, how many drinks do you have? • Heaviest Use: What is the maximum number of drinks you've had on any given occasion during the past month? Several straightforward and validated screening tools are available to further identify those patients who may be abusing alcohol. The four-question CAGE instrument focuses on impaired control (Cut down), use despite consequences (Annoyed by criticism, experiencing Guilt), and dependence (Eye-opener drink in the morning). When evaluated in health care settings, the sensitivity of the CAGE questionnaire for identifying lifetime alcohol problems in patients seen in healthcare settings ranges from 60 percent to 95 percent, but is likely less useful in specific populations, such as in older patients and pregnant women. Two assessment tools, the TWEAK and the Alcohol Use Disorder Identification Test (AUDIT), have been found to be more reliable in women than the CAGE instrument. TWEAK is an acronym for the following five questions: • Tolerance: How many drinks can you hold? (Six or more 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? • [K] Cut down: Do you sometimes feel the need to cut down on your drinking? The AUDIT, which includes 10 questions regarding the quantity and frequency of current and past drinking, has a sensitivity of 92 percent and a specificity of 94 percent in medical patients in six countries, and a sensitivity of 96 percent and a specificity of 96 percent in an academic general medical clinic. Clinicians may also use the CAGE questionnaire plus the three AUDIT quantity-and-frequency questions to identify potential alcohol abuse and dependence or current hazardous drinking. If the results of any of the screening tests lead you to believe that a patient has a problem with alcohol, a number of more specific questions should be asked. These questions are used to evaluate the patient in terms of the criteria for alcohol abuse and dependence and to look for evidence of medical, psychiatric, and behavioral complications of alcohol use or use of other substances and to ascertain prior treatment. Given the high rates of concomitant use of tobacco and drugs by people with alcohol problems, it is particularly important to screen patients for tobacco and drug abuse. Thus, careful screening for use of other substances is critical. The National Institute of Alcohol Abuse and Alcoholism suggests that all of the following are opportunities for screening: • As part of a routine examination • Before prescribing a medication that interacts with alcohol • In the emergency department or urgent care center • When seeing patients who • are pregnant or trying to conceive • are likely to drink heavily, such as smokers, adolescents, and young adults • have health problems that might be alcohol-induced, such as: • cardiac arrhythmia • dyspepsia • liver disease • depression or anxiety • insomnia • trauma • have a chronic illness that isn't responding to treatment as expected, such as: • chronic pain • diabetes • gastrointestinal disorders • depression • heart disease • hypertension For more information about screening and treating alcohol use disorders: Helping Patients Who Drink Too Much: A Clinician's Guide American Psychiatric Association Practice Guidelines. Treatment of patients with substance use Disorders. Am J Psychiatry 2007;164:A-58. Do you have feedback for the author? Click here to send us an email. References O'Connor PG, Schottenfeld RS. Patients with alcohol problems. N Engl J Med 1998;338:592-602. Allen JP, Maisto SA, Connors GJ. Self-report screening tests for alcohol problems in primary care. Arch Intern Med 1995;155:1726-1730. American Psychiatric Association. Understanding Alcohol Use Disorders and Their Treatment, 2001. Helping Patients Who Drink Too Much: A Clinician's Guide, 2nd edition. National Institute of Alcohol Abuse and Alcoholism, 2005. Alcoholism: Getting the Facts. National Institute on Alcohol Abuse and Alcoholism.
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