Behavioral Health

Alcohol use disorder: How best to screen and intervene

J Fam Pract. 2019 January;68(1):35-39

Author(s):

The USPSTF recommends the AUDIT, the AUDIT-C, or the single-question NIAAA screen. The CAGE screening tool has low sensitivity at lower levels of alcohol intake.

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References

1. Grant BF, Goldstein RB, Saha TD, et al. Epidemiology of DSM-5 alcohol use disorder: results from the National Epidemiologic Survey on Alcohol and Related Conditions III. JAMA Psychiatry. 2015;72:757-766.

2. APA. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. Washington DC; 2013.

3. HHS. Results from the 2015 National Survey on Drug Use and Health: summary of national findings. https://www.samhsa.gov/data/sites/default/files/NSDUH-DetTabs-2015/NSDUH-DetTabs-2015/NSDUH-DetTabs-2015.pdf. Accessed November 27, 2018.

4. Rehm J, Mathers C, Popova S, et al. Global burden of disease and injury and economic cost attributable to alcohol use and alcohol-use disorders. Lancet. 2009;373:2223-2233.

5. Chase V, Neild R, Sadler CW, et al. The medical complications of alcohol use: understanding mechanisms to improve management. Drug Alcohol Rev. 2005;24:253-265.

6. Grant BF, Chou SP, Saha TD, et al. Prevalence of 12-month alcohol use, high-risk drinking, and DSM-IV alcohol use disorder in the United States, 2001-2002 to 2012-2013: results from the National Epidemiologic Survey on Alcohol and Related Conditions. JAMA Psychiatry. 2017;74:911-923.

7. Williams EC, Achtmeyer CE, Young JP, et al. Barriers to and facilitators of alcohol use disorder pharmacotherapy in primary care: a qualitative study in five VA clinics. J Gen Intern Med. 2018;33:258-267.

8. Zhang DX, Li ST, Lee QK, et al. Systematic review of guidelines on managing patients with harmful use of alcohol in primary healthcare settings. Alcohol Alcohol. 2017;52:595-609.

9. Wackernah RC, Minnick MJ, Clapp P. Alcohol use disorder: pathophysiology, effects, and pharmacologic options for treatment. Subst Abuse Rehabil. 2014;5:1-12.

10. Kattimani S, Bharadwaj B. Clinical management of alcohol withdrawal: a systematic review. Ind Psychiatry J. 2013;22:100-108.

11. Gowin JL, Sloan ME, Stangl BL, et al. Vulnerability for alcohol use disorder and rate of alcohol consumption. Am J Psychiatry. 2017;174:1094-1101.

12. Moyer VA; Preventive Services Task Force. Screening and behavioral counseling interventions in primary care to reduce alcohol misuse: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2013;159:210-218.

13. Tarter RE, Alterman AI, Edwards KL. Vulnerability to alcoholism in men: a behavior-genetic perspective. J Stud Alcohol. 1985;46:329-356.

14. Brière FN, Rohde P, Seeley JR, et al. Comorbidity between major depression and alcohol use disorder from adolescence to adulthood [published online ahead of print, October 22, 2013]. Compr Psychiatry. 2014;55:526-533. doi: 10.1016/j.comppsych.2013.10.007.

15. Tan CH, Hungerford DW, Denny CH, et al. Screening for alcohol misuse: practices among U.S. primary care providers, DocStyles 2016. Am J Prev Med. 2018;54:173-180.

16. Aertgeerts B, Buntinx F, Kester A. The value of the CAGE in screening for alcohol abuse and alcohol dependence in general clinical populations: a diagnostic meta-analysis. J Clin Epidemiol. 2004;57:30-39.

17. Bush K, Kivlahan DR, McDonell MB, et al. The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test. Arch Intern Med. 1998;158:1789-1795.

18. Nanau RM, Neuman MG. Biomolecules and biomarkers used in diagnosis of alcohol drinking and in monitoring therapeutic interventions. Biomolecules. 2015;5:1339-1385.

19. Raddock M, Martukovich R, Berko E, et al. 7 tools to help patients adopt healthier behaviors. J Fam Pract. 2015;64:97-103.

20. AHRQ. Whitlock EP, Green CA, Polen MR, et al. Behavioral Counseling Interventions in Primary Care to Reduce Risky/Harmful Alcohol Use. 2004. https://www.ncbi.nlm.nih.gov/books/NBK42863/. Accessed November 17, 2018.

21. Miller WR, Baca C, Compton WM, et al. Addressing substance abuse in health care settings. Alcohol Clin Exp Res. 2006;30:292-302.

22. Maisel NC, Blodgett JC, Wilbourne PL, et al. Meta-analysis of naltrexone and acamprosate for treating alcohol use disorders: when are these medications most helpful? Addiction. 2013;108:275-293.

23. Rosner S, Leucht S, Lehert P, et al. Acamprosate supports abstinence, naltrexone prevents excessive drinking: evidence from a meta-analysis with unreported outcomes. J Psychopharmacol. 2008;22:11-23.

24. Anton RF, O’Malley SS, Ciraulo DA, et al. Combined pharmacotherapies and behavioral interventions for alcohol dependence: the COMBINE study: a randomized controlled trial. JAMA. 2006;295:2003-2017.

25. Reus VI, Fochtmann LJ, Bukstein O, et al. The American Psychiatric Association Practice Guideline for the Pharmacological Treatment of Patients With Alcohol Use Disorder. Am J Psychiatry. 2018;175:86-90.

THE CASE

Ms. E, a 42-year-old woman, visited her new physician for a physical exam. When asked about alcohol intake, she reported that she drank 3 to 4 beers after work and sometimes 5 to 8 beers a day on the weekends. Occasionally, she exceeded those amounts, but she didn’t feel guilty about her drinking. She was often late to work and said her relationship with her boyfriend was strained. A review of systems was positive for fatigue, poor concentration, abdominal pain, and weight gain. Her body mass index was 41, pulse 100 beats/min, blood pressure 125/75 mm Hg, and she was afebrile. Her physical exam was otherwise within normal limits.

How would you proceed with this patient?

Alcohol use disorder (AUD) is a common and often untreated condition that is increasingly prevalent in the United States.¹ The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) characterizes AUD as a combination of signs and symptoms typifying alcohol abuse and dependence (discussed in a bit).²

Data from the 2015 National Survey on Drug Use and Health (NSDUH) showed 15.7 million Americans with AUD, affecting 6.2% of the population ages 18 years or older and 2.5% of adolescents ages 12 to 17 years.³

Alcohol use and AUD account for an estimated 3.8% of all global deaths and 4.6% of global disability-adjusted life years.⁴ AUD adversely affects several systems (TABLE 1⁵), and patients with AUD are sicker and more likely to die younger than those without AUD.⁴ In the United States, prevalence of AUD has increased in recent years among women, older adults, racial minorities, and individuals with a low education level.⁶

Screening for AUD is reasonable and straightforward, although diagnosis and treatment of AUD in primary care settings may be challenging due to competing clinical priorities; lack of training, resources, and support; and skepticism about the efficacy of behavioral and pharmacologic treatments.^7,8 However, family physicians are in an excellent position to diagnose and help address the complex biopsychosocial needs of patients with AUD, often in collaboration with colleagues and community organizations.

Signs and symptoms of AUD

In clinical practice, at least 2 of the following 11 behaviors or symptoms are required to diagnose AUD²:

consuming larger amounts of alcohol over a longer period than intended
persistent desire or unsuccessful efforts to cut down or control alcohol use
making a significant effort to obtain, use, or recover from alcohol

In moderate-to-severe cases:

cravings or urges to use alcohol
recurrent failure to fulfill major work, school, or social obligations
continued alcohol use despite recurrent social and interpersonal problems
giving up social, occupational, and recreational activities due to alcohol
using alcohol in physically dangerous situations
continued alcohol use despite having physical or psychological problems
tolerance to alcohol’s effects
withdrawal symptoms.

Continue to: Patients meet criteria for mild AUD severity if...