Approach to the Patient with an Alcohol Problem

Michael F. Bierer

Alcohol abuse is a national problem. Surveys reveal that 5% of US adults meet criteria for alcohol abuse; up to 20% of adults attending primary care clinics have alcohol abuse or dependence. The rates of abuse and dependence in persons 18 to 29 years of age are twice those for the nation as a whole. The overall estimated societal costs of alcohol-related health problems, lost productivity, crime, accidental deaths, and fires are staggering (>$185 billion). The estimated direct cost of treatment for alcohol problems and medical consequences approaches $26 billion, with more than $18 billion for medical care alone.

Promoting healthy behaviors is basic to primary care, so too is understanding every patient’s drinking behavior. Although the detection of plainly unhealthy levels of intake and dramatically negative health consequences of drinking is straightforward, problem drinking or specific risk may be subtler. Persons whose drinking falls into the otherwise “low-risk” range may still require attention because of comorbid conditions. Unhealthy drinking (above low-risk quantities) prior to the development of any resultant complications needs to be identified and modified. Timely recognition, coupled with appropriate intervention, is critical. While the suffering by individuals and their families may be greater with alcohol dependence, the societal burden due to unhealthy drinking of less severity is huge, in large part related to involuntary trauma under the influence. The primary care physician and team are uniquely positioned to identify and address harmful patterns of alcohol use and a host of related medical and social problems.

DEFINITIONS (1, 2 and 3)

Definitions

Alcoholism is an inexact but popular term, more formally referred to as disorders of alcohol use, which range from alcohol abuse to alcohol dependence, depending on severity. Alcohol use in excess of lowrisk cutoffs is epidemiologically associated with excess morbidity and mortality. Unhealthy drinking is anything above these cutoffs, with or without problems due to drinking of any severity.

Low-Risk Drinking

The behavioral hallmark of low-risk drinking is that it does not exceed epidemiologically determined cutoffs and is under voluntary control. With the caveat that a given dose of alcohol affects different people differently, low-risk drinking may be defined quantitatively as on average two or fewer drinks per day for men and one or fewer for women and the elderly. Furthermore, for drinking to be low risk, no single episode of drinking should exceed four drinks for men or three drinks for women, where a standard drink contains roughly 12 g, 15 mL, or 0.5 oz of alcohol (which is the approximate content of 12 oz of beer, 5 oz of wine, or 1.5 oz of liquor, respectively) (Fig. 228-1).

Unhealthy Drinking

Unhealthy drinking is defined as any drinking above the lowrisk cutoffs and is associated epidemiologically with excess morbidity and mortality. It encompasses at-risk drinking and problematic drinking.

At-risk drinking is defined as drinking above cutoffs but without evident adverse medical or psychosocial consequences.

Problematic drinking is defined as drinking above cutoffs with consequences but not of a severity to meet formal (DSM) diagnostic criteria of an alcohol use disorder.

Disorders of Alcohol Use

Alcohol Abuse.

The latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5 considers alcohol abuse) a maladaptive pattern of use leading to impairment in one of several sociobehavioral domains for a 1-year period (Table 228-1). It is no longer considered a separate entity; rather it represents a less severe stage of alcohol use disorder, on a continuum with alcohol dependence.

Alcohol Dependence.

Alcohol dependence is defined as a maladaptive pattern of use, resulting in substantial distress or dysfunction, characterized by at least three of seven symptoms that include tolerance, withdrawal, unsuccessful attempts at cutting down, and preoccupation with and recurrent use of alcohol despite adverse consequences in important areas of life. Patients drink more than they intend and may give up important activities because of drinking.

PATHOPHYSIOLOGY, CLINICAL PRESENTATION, AND COURSE (4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26 and 27)

Causes and Risk Factors

The causes of alcohol abuse and dependence are incompletely understood, but the etiology is clearly multifactorial. Biogenetic, sociocultural, psychological, and behavioral influences have been identified. Understanding several typical paths to alcohol disorders improves the ability to take a relevant history and to arrive at salient therapeutic recommendations. Therapeutic plans ought to address specific vulnerabilities and comorbidities, understanding that there is considerable variability as to the natural history of alcohol dependence among and within individuals.

Biogenetic and Epigenetic Factors

Alcohol abuse clearly involves genetic determinants. Genetic factors appear to influence the metabolism of alcohol and the effects of alcohol on neurotransmitters, receptors, and cell membranes. More than 100 alcohol-responsive genes and numerous genetic risk factors have been characterized, including the genes for alcohol dehydrogenase, aldehyde dehydrogenase (ALDH), monoamine oxidase, and catechol-O-methyltransferase; more are likely to be identified. The odds ratio of developing alcohol abuse or dependence is about 10 for monozygotic twins versus about 5 for dizygotic twins. Offspring of parents with alcohol dependence frequently have an altered biologic response to alcohol, and young adult offspring with such a response are more likely to develop an alcohol diagnosis within a decade.

Evidence is accumulating that nongenetic material, such as histones, may be altered by alcohol exposure and affect transcription relevant to reward perception and drinking over the long term.

Figure 228-1 The standard drink. (From U.S. Department of Health and Human Services. Helping patients who drink too much: a clinician’s guide. Rockville, MD: 2005.)

Sociocultural Factors

Poverty, socialization patterns, and cultural variables affect the probability of development of disease. Parental and peer values, attitudes, and behaviors all contribute. This helps to explain the increasing use of alcohol among women and youth and use patterns of ethnic minorities, despite an overall national decline in consumption. Price variation and local availability of alcohol (reflected by, for instance, the density of liquor stores in a neighborhood) affect the amount of drinking and, in turn, the probability of developing an alcohol diagnosis. The field of behavioral economics also helps define the types of reinforcement or punishment that might affect problematic drinking—a relevant construct in all but the most involuntary drinkers.

Psychological-Psychodynamic Factors

Underlying psychopathology and traits (e.g., dependence conflict, excessive need for power or sensation seeking, gender identification problems) contribute to predisposing a person to drink excessively, either to mask or to solve a psychological problem (the so-called self-medication). Drinking in this context is viewed primarily as a symptom of the underlying psychopathology or trait. These traits may be heritable (for instance, enhanced need to seek sensations or intolerance of negative affective states). A trauma history, by influencing levels of anxiety (even in the absence of full-blown posttraumatic stress disorder), may predispose to development of alcohol addiction.

TABLE 228-1 Criteria for Disorders of Substance Use^*

Substance Abuse
	A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by at least one of the following occurring within the same 12-mo period:
		▪ Recurrent substance use resulting in a failure to fulfill major role obligations at work, school, or home ▪ Recurrent substance use in situations in which it is physically hazardous ▪ Recurrent substance craving ▪ Continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance
	The symptoms have never met the criteria for Substance Dependence for this class of drugs.
Substance Dependence
	A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by at least three of the following occurring in the same 12-mo time period:
		▪ Tolerance, as defined by either of the following:
			• A need for markedly increased amounts of the substance to achieve intoxication or desired effect • Markedly diminished effect with continued use of the same amount of the substance
		▪ Withdrawal as manifested by either of the following:
			• The characteristic withdrawal syndrome for the substance • The same (or closely related) substance is taken to relieve or avoid withdrawal symptoms.
		▪ The substance is often taken in larger amounts or over a longer period that was intended. ▪ There is a persistent desire or unsuccessful efforts to cut down or control substance use. ▪ A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects. ▪ Important social, occupational, or recreational activities are given up or reduced because of substance use. ▪ The substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is caused or exacerbated by the substance use.
Specify if
	With physiologic dependence if either tolerance or withdrawal is present
	Without physiologic dependence if neither is present
^*Adapted from Diagnostic and Statistical Manuel of Mental Disorders, 4th and 5th editions. American Psychiatric Association

Behavioral Factors

From the behavioral perspective, alcoholism is viewed as a learned behavior that is reversible, time limited, on a continuum with normal drinking behavior, and established by a series of learning and reinforcement experiences. The strength and pace of acquiring the habit vary with the intensity and rapidity of reinforcement. Social interactions, emotional stress, guilty or negative thoughts, and the need for sleep or pain relief precipitate and sustain drinking. Any of these precipitants coupled with learned expectations about the reinforcing, pleasurable effects of alcohol may initiate and maintain the drinking behavior.

The neurobiology of adaptation and tolerance affects the learning process. In the presence of reinforcing neurochemistry, environmental cues acquire greater salience, and learning is more likely to occur as the brain forges strong associations among behavior, environment, and reward, thus increasing the likelihood of repeating behavior that will lead to the reward. There are many candidates for the neuroanatomic substrate of such enhanced learning (e.g., dopamine in the nucleus accumbens), and they may not be specific for one reinforcing drug or another.

Epidemiologic Patterns

Alcohol use varies by age, gender, and socioeconomic group.

Young People.

Alcohol use and abuse among young people is high. Two thirds of high school seniors have used alcohol in the past year, and nearly one half report being intoxicated in that time span. Over 40% of young adults have had five or more drinks on an occasion in the last month. Adults who began smoking or drinking regularly in their early teens suffer the most serious alcohol, drug, and psychiatric problems.

Women.

As a result of social change, women are consulting alcohol abuse clinics at double the former rates, and the gap between men and women in terms of alcohol consumption and problems continues to narrow.

The Elderly.

Older patients may begin to use alcohol excessively for stress, especially in reaction to the loss of a loved one, loss of physical function or role, or other stressful transitions or because of sleep difficulties. The use of alcohol along with the multiple medications that are prescribed to the elderly can be especially problematic.

Ethnic Minorities.

Certain ethnic groups are relatively protected from alcohol dependence. Some subgroups of Asians have a form of ALDH that metabolizes acetaldehyde slowly, therefore yielding higher concentrations of this chemical, which is perceived as unpleasant. People with more of this isoform of ALDH enjoy drinking less than those with proportionally less and have a lower likelihood of developing dependence.

Clinical Presentation and Course

There is a wide spectrum of drinking behaviors, from low-risk drinking to frank alcohol abuse, dependence, and deterioration.

Low-Risk Drinking

Low-risk drinking is characterized by varying consumption and beverage according to internal cues and external circumstances. The hallmarks of such moderate drinking are that it is under voluntary control and does not exceed recommended maxima. Otherwise, low-risk quantities of drinking may be considered either risky or problematic in a patient with signs or symptoms made worse by alcohol or with strong family histories. Such patients should be informed about the increased risk.

At-Risk Drinking

Persons drinking more than the recommended maxima but without negative consequences and who do not meet criteria for abuse or dependence can be classified as “at-risk drinkers.” Patients must drink more than the recommended maxima or in risky situations to fit into this category, but if there are problems stemming from drinking, then it is more useful to classify them as problem drinkers.

Problem Drinking

Such persons experience negative consequences of drinking, which might be minor and of distress only to the drinker or may cause significant problems for family, friends, or colleagues. Thus, problematic drinking may range from preclinical to severe and obvious.

Alcohol Abuse

This person meets the criteria for heavy social drinking, gets drunk on occasion, and also exhibits the negative medical, legal, social, or psychological consequences of excessive alcohol consumption. He or she makes or thinks of making attempts at cutting down or quitting. Functioning may vary from seemingly intact behavior to difficulty coping. The person may deny a drinking problem and blame external events or persons; denial is common even among those with multiple arrests for drunk driving. By definition, patients with alcohol abuse have not reached a severity sufficient for them to be diagnosed with dependence.

Alcohol Dependence

The dependent patient’s consumption of alcohol may be independent of usual precipitants or social situations, that is, the internal drive to drink is paramount and usually overwhelming. External circumstances might constrain drinking for a time, yielding a “binge pattern” syndrome. Most continue to work, even some in positions of high responsibility. Alcohol is usually given high priority (e.g., one goes to a party to drink, not to socialize). Tolerance to alcohol develops, and withdrawal symptoms (mood disturbance, tremor, nausea, sweats) may be noted during the day when the blood alcohol level drops. Drinking periodically during the day is often needed to ward off or relieve withdrawal symptoms. The patient is aware of the compulsion to drink but may have rationalized it and turn a blind eye to the experience of harm. Recognizing and overcoming such denial may require the help of family, friends, or others affected by the drinking.

Severe Deterioration

Such individuals maintain a near-constant state of intoxication, having no care for their person or surroundings, and undergo periodic hospitalizations for detoxification and for medical care necessary after alcohol-related trauma or organ damage.

Clinical Course

There is considerable individual variation. Onset ranges from an initial phase of nonproblematic drinking to immediate heavy drinking. Early onset of drinking is associated with an increased risk of alcohol abuse, but the association is not necessarily causative. The course of alcohol dependence may be punctuated by periods of spontaneous remission. The prognosis remains relatively favorable until drinking reaches the severity that is obvious clinically.

Once the addiction becomes more severe, it can be difficult to break in the absence of treatment, and the clinical course is often progressive. Twenty to fifty percent of those who meet criteria for dependence may spontaneously remit, but this lucky group may cluster at the less severe end of the dependence spectrum. The early detection of at-risk or unhealthy alcohol use is important before the patient becomes alcohol dependent. At the point of addiction, continued drinking may be punctuated by periods of abstinence or controlled drinking followed by relapse and progression, especially if there is no expert intervention. Controversy continues regarding whether total abstinence is required to prevent relapse to dependent drinking.

Medical Complications

The risk of organ damage is related in part to the dose and duration of alcohol exposure, with some conditions (e.g., alcoholic cardiomyopathy, fatty liver, alcoholic hepatitis, or anemia) manifesting reversibility with abstinence and others (e.g., cirrhosis or neuropathy) seeming to progress inexorably once organ damage has occurred. Predicting the risk of irreversible organ damage is imperfect; occasionally, resilience is afforded by abstinence and good nutrition. Risk appears to be a function of genetic predisposition, alcohol dose, and chronicity of exposure.

Cardiovascular Complications.

Although moderate alcohol consumption (up to two drinks a day in men, one in women) is associated with reductions in coronary events and coronary mortality, the consumption of more than three drinks a day
is associated with an increased risk for hypertension and overall mortality. High levels of alcohol consumption place the patient at risk for atrial fibrillation (see Chapter 28) and more chronically for alcoholic cardiomyopathy (see Chapter 32).

Endocrine, Gynecologic and Reproductive Complications.

Increase in the risk of osteoporosis is associated with drinking on average more than two standard drinks daily. Invasive breast cancer risk has been found to increase with as little as one half drink per day: There may be no safe level of drinking with regard to breast cancer risk. Fetal alcohol syndrome occurs in infants born to mothers who drink heavily during pregnancy. Features include permanently stunted growth, mental retardation, musculoskeletal abnormalities, poor coordination, and cardiac malformations. Incidence approaches 33% among pregnant women who drink more than 150 g (>10 standard drinks) of alcohol per day. Another one third of children born to such women have mental retardation or severe behavior disorders. Intellectual impairment in offspring is associated with as few as one to two drinks per day during pregnancy. Controversy exists about a safe or low-risk cut point, with international guidelines varying considerably.

In men, persistent impotence and loss of libido reflect impaired gonadotropin release and accelerated testosterone metabolism that occur as consequences of chronic alcohol excess; they predate end-stage liver disease.

Gastrointestinal Complications.

Alcoholic hepatitis, pancreatitis, and gastritis may follow binge drinking. Fatty liver and esophagitis ensue from chronic use. Late-stage complications include cirrhosis and oral and colorectal cancers.

Neurologic Complications.

Cerebellar degenerative disease, peripheral neuropathy, Wernicke encephalopathy, and Korsakoff dementia are among the serious neurologic consequences of alcohol excess (see Chapters 166, 176, and 173). Thiamine supplementation can prevent the latter two conditions and should be broadly recommended.

DIAGNOSIS (1, 2 and 3)

The Diagnostic and Statistical Manual of Mental Disorders (DSM) specifies the most widely used criteria for the formal diagnoses of alcohol abuse and alcohol dependence (see Table 228-1). These criteria have undergone some revision for DSM-5. As noted, the diagnostic distinction between abuse and dependence has been converted into a single disorder of alcohol use with different levels of severity varying with number of criteria met. Most of the DSM-5 criteria have been retained, with the exception that legal difficulties has been removed and craving has been added. The challenge is the early detection in daily primary care practice.

WORKUP (1,3,11,26,28, 29 and 30)

Overall Strategy

Formal diagnosis involves the identification of excessive quantity and duration of consumption, physiologic manifestations of ethanol addiction, loss of control over drinking, and chronic damage to physical health and social functioning. The tenor and words used to discuss alcohol use should be nonjudgmental and empathic. There is no great separation between the diagnostic interview and therapeutic counseling.

If problem drinking is identified, one helps the patient to understand and acknowledge the problem, its potential consequences, and the need for change. The objective then shifts to negotiating and carrying out an acceptable plan of care, one that is personalized and multifaceted. These elements may be encompassed in a brief intervention and include referral for specialized care for more complex problems.

Screening

The high prevalence of unhealthy drinking, including alcohol abuse, its serious consequences, and good response to intervention, argues for routinely screening all adolescents and adults who come for primary care. The U.S. Preventive Services Task Force recommends universal screening and brief intervention to reduce alcohol misuse. Screening coupled with brief intervention for unhealthy alcohol use is among the handful of most costeffective and highest-impact preventive services in primary care.

Drinking is addressed as would any health-related behavior, such as exercise or seat belt use. A high index of suspicion for alcoholism is indicated for the patient who presents with a family history positive for alcoholism, anxiety, insomnia, recurrent infection, a potentially alcohol-related illness, child abuse, domestic violence, multiple psychosomatic problems, suicidality, depression, or interpersonal, occupational, financial, or legal problems. Recently, tobacco smoking has emerged as a marker for alcohol abuse and dependence.

The two dimensions of the screening evaluation are quantity of and problems related to the use of alcohol.

Screening for Quantity/Frequency

A simple set of questions designed to elicit quantity consumed is the first step in assessing whether a patient drinks less or greater than the recommended levels. Because beer and wine may not be recognized as “alcohol” by many patients, those who say that they do not drink should be questioned about these beverages. For abstainers, clarifying why they do not drink may be important: The patient may be abstaining due to prior problems. The task then becomes assisting in relapse prevention and maintaining the healthy change. For patients who drink any alcohol at all, the following questions may be useful, either in a written, on line, or verbal exchange:

How many times in the past year have you had 5 or more drinks in a day (for men) or 4 or more drinks in a day (for women)?

If the answer is one or more occasions, then the patient has screened positive for unhealthy drinking, and further questioning may be warranted. If not, support and advice about low-risk drinking cutoffs should be offered. For those screening positive, ask:

On average, how many days per week to you have an alcoholic drink?

and

On a typical drinking day, how many drinks do you have?

The answers to these questions permit a weekly consumption calculation.

Assessing Behaviors and Consequences

For the patient who consumes alcohol, a number of validated approaches to assess problems are available. These include the CAGE questions (see next paragraph) and self-administered questionnaires.

The CAGE Questions (Table 228-2).

This validated tool for behavioral screening is widely used in primary care settings. A score of 2 (the standard cutoff) has a sensitivity for alcohol abuse or dependence that ranges from 70% to 85% and specificity of 85% to 91%. In the elderly, in whom the clinical presentation may be harder to ascertain, sensitivity falls to 50%, whereas specificity remains greater than 90%. Including questions on
the quantity and frequency of drinking improves detection in the elderly. The CAGE questions focus on consequences of drinking and provide a natural entry into discussions about the patient’s perception of negative consequences. For example, if a patient endorses being annoyed by others’ comments about his or her drinking, then exploring what aspects are annoying and what the patient thinks of them is a natural next step.

TABLE 228-2 The CAGE Test

Have you ever felt the need to Cut down on drinking?

Have you ever felt Annoyed by criticism of drinking?

Have you ever had Guilty feelings about drinking?

Have you ever taken a morning Eye opener?

Other Tests.

Alcohol Use Disorders Identification Test (AUDIT, Table 228-3) is a 10-item questionnaire keyed to a World Health Organization hierarchy of alcohol problems. It focuses on “harmful drinking,” which indicates drinking in harmful situations. A shorter questionnaire consisting of the three consumption questions of the AUDIT (the so-called AUDIT-C) performs well in detecting unhealthy drinking and DSM-IV alcohol diagnoses and is a clinical and research standard due to its efficiency and performance. Each of the 10 items can be scored 0 to 4 for all patients; a cutoff of 4 is a sensitive if not specific indication of harmful alcohol use.

TABLE 228-3 The Alcohol Use Disorders Identification Test^a

PATIENT: Because alcohol use can affect your health and can interfere with certain medications and treatments, it is important that we ask some questions about your use of alcohol. Your answers will remain confidential, so please be honest. Place an X in one box that best describes your answer to each question.
Questions	0	1	2	3	4
1. How often do you have a drink containing alcohol?	Never	Monthly or less	2 to 4 times a month	2 to 3 times a week	4 or more times a week
2. How many drinks containing alcohol do you have on a typical day when you are drinking?	1 or 2	3 or 4	5 or 6	7 to 9	10 or more
3. How often do you have 5 or more drinks on one occasion?	Never	Less than monthly	Monthly	Weekly	Daily or almost daily
4. How often during the last year have you found that you were not able to stop drinking once you had started?	Never	Less than monthly	Monthly	Weekly	Daily or almost daily
5. How often during the last year have you failed to do what was normally expected of you because of drinking?	Never	Less than monthly	Monthly	Weekly	Daily or almost daily
6. How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session?	Never	Less than monthly	Monthly	Weekly	Daily or almost daily
7. How often during the last year have you had a feeling of guilt or remorse after drinking?	Never	Less than monthly	Monthly	Weekly	Daily or almost daily
8. How often during the last year have you been unable to remember what happened the night before because of your drinking?	Never	Less than monthly	Monthly	Weekly	Daily or almost daily
9. Have you or someone else been injured because of your drinking?	No		Yes, but not in the last year		Yes, during the last year
10. Has a relative, friend, doctor, or other health care worker been concerned about your drinking or suggested you cut down?	No		Yes, but not in the last year		Yes, during the last year
					Total
Notes: This questionnaire (the AUDIT) is reprinted with permission from the World Health Organization. To reflect standard drink sizes in the United States, the number of drinks in question 3 was changed from 6 to 5. A free AUDIT manual with guidelines for use in primary care settings is available online at www.who.org. ^aReprinted from U.S. Department of Health and Human Services—National Institute on Alcohol Abuse and Alcoholism. Helping patients who drink too much: a clinician’s guide. Rockville, MD: Author, 2005.

Clinical Assessment

The acutely intoxicated patient represents a small proportion of the alcohol problem presenting to most outpatient primary care practices and poses little diagnostic challenge. For others, a detailed drinking history is in order for all patients suspected of having an alcohol problem on the basis of any of the following: