Alcohol Problems: Effective Interviews With Moderate, At-Risk, and Dependent Drinkers

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[edit] Alcohol Problems: Effective Interviews With Moderate, At-Risk, and Dependent Drinkers

William D. Clark

People with alcohol problems act irresponsibly despite sanctions, and are therefore heavily stigmatized. Physicians report that conversations about drinking are stressful and conflict-laden, and that patients are unmotivated and do not change. Physicians' negative feelings derive also from family experiences or from encounters with intoxicated patients who are hostile, uncooperative, and often violent. These dynamics, in combination with the sense that drinking is not a “medical” issue, silence physicians, patients, and families. However, conclusive evidence demonstrates that physicians who intervene with drinkers succeed in reducing harm caused by alcohol. Not only do physicians lower morbidity for patients and family members, but they also strengthen family and social relationships, self-esteem, and emotional stability.

[edit] EPIDEMIOLOGY

Alcohol problems exist on a continuum, and in an individual case, diagnosis may be elusive because of scant or imprecise information. Nevertheless, experts agree on an evidence-based classification system that is useful in guiding physician actions^[1] (Table 51-1). People with the prototype syndrome, alcohol dependence (often called alcoholism), suffer medical and social consequences from uncontrolled drinking. A striking 5% to 10% of adults develop this syndrome. People with alcohol dependence are recognizable across cultures (and countries) because a distinctive, defensive interactive style develops in conjunction with typical medical and social complications. They hide important facts, defend their “right” to drink, and respond with hostility and reticence to attempts to talk about drinking.

Table 51-1 Terms and Criteria for Patterns of Alcohol Use

People with problems of lower severity have alcohol abuse, a “maladaptive pattern that leads to impairment or distress.” Expert consensus holds that moderate drinking is defined by low quantity of intake (<14 drinks per week for men, <seven for women), a social setting for drinking, and little intoxication (not more than four drinks per occasion for men, three for women)^[2][1][3] (see Table 51-1). Drinking above these limits is variously called at-risk or hazardous, and is likely to cause harm, according to long-term studies. The neurologic complications of alcohol are reviewed extensively in Chapter 166 .

Prevalence of alcohol problems is high, with a lifetime prevalence of alcohol abuse and alcohol dependence of 10% to 20%. A population-based study in British physicians' offices found that 10% of men were CAGE-positive (see Box 51-2), 7.6% averaged more than 3.5 daily drinks, and 3.2% thought they had problems with drinking. A Wisconsin primary care study found 17% of primary care patients in several sites were drinking above the moderate level. Women consistently show 30% to 50% fewer problems. Yearly health care costs for people with alcohol dependence average 100% higher than for comparable nonalcoholic people. Total medical costs directly attributable to alcohol are estimated at $10.5 billion, only a fraction of the more than $100 billion total alcohol-abuse costs.

[edit] ETIOLOGY AND PATHOPHYSIOLOGY

No one asks to develop alcoholism, nor is any person immune to nervous tissue actions of alcohol. Most people drink to have good times in the company of others, modulating their drinking according to feedback from internal states such as shame or hangover, and external cues such as reprimands, criticism, and sanctions. People succeed or fail in limiting drinking because of the interplay of physiologic, psychologic, and social/cultural factors. Data that confirm a physiologic and genetic influence include, for example, the dysphoria (flushing, nausea) that prevents many Asians from drinking; the finding that sons of alcoholic fathers predict their alcohol level less accurately than men from nonalcoholic backgrounds; and the finding that intensity of anxiety under the influence of alcohol varies with familial alcoholism. Twin and adopted sibling investigations implicate genetic factors, and extensive animal studies are confirmatory.

The predictable, inevitable, and multitudinous brain effects of heavy drinking facilitate a vicious circle of drinking more, developing problems, and discounting the role of alcohol. The insidious development of tolerance to intoxication, the cognitive deficits, and the dysphoric aspects of related states (e.g., hangover) engender unhealthy social dynamics. These relationship problems are exaggerated because friends and family resent the (apparently) voluntary “having fun and being irresponsible” nature of overindulgence. People become adept at ignoring reality and suppressing negative feelings. Longer time spent in brain-altered states results in the dramatic neurophysiologic changes of addiction. Furthermore, emotional isolation develops because people make excuses for their behavior, direct blame onto others, and show hostility whenever sensible limits are discussed. They select friends and partners who tolerate drinking and tacitly agree to overlook consequences. Higher problem rates are found among homeless persons, those with a major psychiatric disorder, and people in the criminal justice system. Which comes first remains uncertain.

[edit] PATIENT EVALUATION

Physicians were urged to screen for alcohol dependence, but substantial costs derive from overindulgence by at-risk drinkers who are not “alcoholic.” The prior focus on screening for alcoholism is too narrow according to research and consensus panels. New studies on costs and effectiveness of brief interventions suggest that physicians can help at-risk drinkers avoid complications. This is analogous to working with the patient with angina or high cholesterol, rather than waiting for the heart attack. Current recommendations urge physicians to expand their interventions to all drinkers.

Research indicates that physicians should look for three types of patients with whom to talk about drinking. One group drinks in a moderate manner and will benefit from discussion of potential benefits and hazards. A second group is at risk (drinking too heavily), and needs information and advice about why to cut down, and how to do so. Finally, those who drink in a poorly controlled fashion (alcohol abuse or dependence) need action recommendations and referral for more expert professional treatment. Physicians require a combination of reminders, incentives, and skill building to succeed at making alcohol-related inquiry and intervention the routine matters that they should be. We suggest simple strategies that separate healthy drinkers from potentially problematic ones. Subsequent sections advise physicians about what to do in each case.

[edit] HISTORY

Because drinking is not an illness, but a behavior that carries with it societal myths and stigmas, talking with any person about drinking is a sensitive matter. The history-taking style and techniques strongly affect patients' subsequent willingness to participate in treatment activities. Many studies suggest that a structured, stepped approach is both efficient in practice and effective with patients.

[edit] Step One

In step one (Box 51-1), the physician asks about alcohol use in the past year. If the patient has had no beer, wine, or hard liquor in the past year, nothing else need be done. The abstinent subgroup with past alcohol problems usually discloses this spontaneously.

[edit] Step Two

In step two, the physician seeks to identify current drinkers who deserve substantial attention.^[4] We favor a screen for alcohol dependence as the next step. As with hypertension or cervical cancer, lives can be saved by screening. Because the typical defensive interactive style of people with alcohol dependence promotes minimization and cover-up rather than exposure, there may be no discernible clue unless a screening strategy is used. At present, physicians miss 60% to 80% of cases. A good option is the CAGE test (Box 51-2), a thoroughly studied simple screen. It is less accurate for women and African-Americans. The two questions (“In the last year, have you ever drunk or used drugs more than you meant to?” and “Have you felt you wanted or needed to cut down on your drinking or drug use in the last year?”) assess drug use at the same time as alcohol.^[5] A single question from the Alcohol Use Disorders Inventory Test (AUDIT) was effective in one study. Consistent application of a validated strategy is a more powerful determinant of clinical effectiveness than which strategy a physician chooses for routine use.

We recommend that physicians avoid using the natural question, “How much do you drink?” as step two. Asking “How much?” not only reminds people of shameful overindulgence and fails to encourage reflection, but also limits patients' responses to subsequent questioning if asked too early, as research demonstrates.

[edit] Step Three

If step two is negative, ask the National Institute on Alcohol and Alcoholism (NIAAA) recommended questions about quantity and frequency (Boxes 51-3 and 51-4).^[2] According to the NIAAA expert panel, the “safe limits” for men are 14 or fewer drinks a week, with no more than four on any one occasion, and for women are seven or fewer per week, and no more than three per occasion (Box 51-5). If a person drinks below these limits, and step two shows no positive response, and no other hints exist that the patient has alcohol problems, no urgent intervention is needed.

Of course, when withdrawal symptoms are apparent, liver disease is accompanied by odor of alcohol, or the spouse confides about problems, physicians do not need screening strategies.

If any CAGE question is positive, if intake exceeds safe limits, or if another clue from examination or the family suggests a drinking problem, the physician needs more detail. A search for characteristic elements of alcohol problems is warranted and not time-consuming if thoughtfully structured. Box 51-6 provides ample data for the primary care assessment. Interviews with others, including family, nurses, and social workers, enlarge the inquiry if the patient furnishes insufficient data. Records from other physicians or hospitals may contain unanticipated information that establishes a diagnosis.

Obtaining a thorough evaluation allows the physician to discuss impressions in a compassionate manner. In fact, experimental data show that thoughtful diagnostic conversation itself produces beneficial therapeutic effects.

[edit] PHYSICAL EXAMINATION AND LABORATORY STUDIES

Physical and laboratory examinations are useful adjuncts to structured interviewing and help doctors set priorities for the pacing and vigor of subsequent discussions. Odor of alcohol is alarming, and distinctly abnormal in medical encounters. If one easily smells alcohol in the room, the blood alcohol level (BAL) is likely greater than 125 mg/dl; a less dramatic odor indicates a BAL between 75 and 125 mg/dl. The nose is a good breath analyzer. Alcohol on the breath is a convincing sign, and always signals a serious alcohol disorder.

Intoxication in any encounter is worrisome, and means a high likelihood of alcohol disorder, even in the emergency situation. To underscore this important point, assume that the alcoholic 10% of the population are drunk once a week, and assume that the 60% who are moderate drinkers are intoxicated once yearly. Thus, in a year, from a population of 100, 30 abstainers yield no episodes of intoxication, 60 moderate drinkers yield 60, and 10 alcohol-dependent people yield 520! Furthermore, moderate drinkers seldom become as intoxicated and are more likely to drink in controlled environments (e.g., where someone else can drive). Intoxicated people in the emergency situation are not healthy drinkers who “have had one too many.”

If the odor of alcohol is apparent, and if the patient manifests no evidence of intoxication (slurred speech, incoordination, and emotional lability), tolerance to alcohol effect is present. Tolerance indicates brain adjustment to intoxicating alcohol levels, which is caused by heavy drinking, is inevitably toxic, and means alcohol dependence is present. Withdrawal syndromes (see next section) indicate additional brain dysfunction, and are easier to discern than tolerance.

Other physical and laboratory findings are poor screening tests (low sensitivity and specificity). Because of alcohol's broad toxicity, however, an abnormality may prove useful in context. First, an unexplained finding may begin a fruitful investigatory process. For example, despite a negative CAGE test, the concerned physician of a young woman with palmar erythema continues the assessment, allowing the patient to reveal her alcohol problem. Second, in the presence of a clue, physical or laboratory findings substantially raise the posttest probability. Physicians should order a mean corpuscular volume (MCV) and liver enzymes (include a γ-glutamyltransferase [GGT] the most sensitive to alcohol intake). For example, a 55-year-old man with chronic pulmonary disease is admitted for atrial fibrillation. His wife complained about his drinking, and elevated MCV and aspartate aminotransferase (AST) confirmed not only alcoholism, but also “holiday heart.”

Box 51-7 presents findings of high utility and underscores the value of thorough examination.

[edit] MANAGEMENT OF WITHDRAWAL AND MEDICAL COMPLICATIONS

Treatment of alcohol withdrawal is of special concern to the primary care physician. Other urgent complications such as dysrhythmia, hepatic failure, bleeding, gastritis, and pancreatitis are covered in specialty chapters.

As physical dependence develops, initial manifestations of anxiety, sleep disorder, tremor, and vague discomforts are mild, sometimes not attributed to alcohol, but easily relieved by drinking. As months pass, however, alcohol less reliably controls symptoms, and intoxication is fleeting, occurring only at high BAL (greater than 250 mg/dl). Withdrawal is not an all-or-nothing state, and addicted patients experience symptoms whenever their BAL falls. The altered neurophysiology in the brain perceives a drop in BAL as disruptive to the new steady state condition of addiction, and expresses the disruption through withdrawal symptoms. Soon the person drinks steadily to alleviate withdrawal, but relief is brief. The range of BAL at which the person feels “not sick” diminishes, and severe symptoms, even delirium tremens, may develop despite a BAL of 300 mg/dl or more.

Severity of an episode of withdrawal is hard to predict. Outpatient treatment is sensible in mild cases, but inpatient support is required for severe ones. Physicians should hospitalize patients with clouded sensorium, fever, hyperventilation, or a concomitant medical problem (e.g., hepatic failure, pancreatitis). In addition, the presence of three factors from Box 51-8 suggests inpatient management. Degree of tremor, anxiety, tachycardia, and stomach symptoms are poor predictors of need for inpatient care (see Chapter 166 ).

When outpatient management is feasible, pharmacologic support helps with symptom relief (Box 51-9) and should be integrated with patient education and referral options designed to help patients change entrenched behaviors.

[edit] CHANGING DRINKING PATTERNS: LIFESTYLE CHANGE

Prochaska and colleagues^[6] have found that people progress through a series of stages on the way to successful lifestyle change. This is true across studies of at least a dozen behaviors. In the first stage, precontemplation, a person is not thinking that the behavior (e.g., drinking) is a problem, and naturally has no interest in changing. People thinking about changing are in contemplation. Ambivalence is the hallmark of this stage, and people find reasons to stay the same as well as reasons to change. As the balance tips toward change, people enter preparation and imagine change strategies or new behaviors (e.g., wondering where to find an Alcoholics Anonymous [AA] meeting). In the action stage, people take action and try out new behaviors (e.g., changing from liquor to beer, or quitting for a time). When persistently successful and no longer sliding back to old behaviors, people are in the maintenance stage.

Experienced physicians find the concept of stages intuitively useful. Tracking whether a preponderance of patient conversation suggests progression through stages is useful for physicians, as they evaluate readiness to change and consider potential interventions. However, this advance in thinking has some important limitations. First, a patient's stage is neither fixed nor all inclusive. Patients may say, “I'll go to AA, but I'm not going to stop drinking” (or vice versa), “My liver is sick, so I'll cut back for a time,” or “I'd like to stop drinking to improve my family relationships, but I have to drink with my professional clients.” The patient may take action to dry out and relieve withdrawal symptoms but fail to understand the need for continued treatment. In a single interview, a patient may display aspects of many stages, and move frequently between stages. Also, the skills that researchers have described that help people effect change overlap the stages, so the functional aspects of helping people change are not linked directly to the stages.

Physicians complain that patients are not motivated. Researchers have developed new perspectives about motivation.^[7] Motivation is not a unitary phenomenon, nor is it entirely an individual phenomenon. Successful lifestyle change is blocked by myriad inner pressures, both psychologic and physiologic (neuronal adaptation), as well as by external forces committed to the status quo, such as drinking partners, social needs, and dysfunctional family dynamics. The thoughts and questions that hold patients back are familiar to physicians: “Do I have a problem? What is the nature of the problem? I don't know what to do for this problem. The work of changing is too hard. I'm not strong enough or good enough to do this. No one cares if I change. Will it make a difference if I try?” Physicians' ability to help patients express these doubts and physicians' responses to them can either facilitate movement toward successful change or contribute to a patient's demoralization and discouragement, thereby increasing resistance to change. As researchers untangle the threads of effective interventions, they have shifted emphasis from description of patients (e.g., are they strong or weak, compliant or not, motivated or not) to enhancement of physicians' skills.

Because only the patient can effect change, the physician's task is to trigger change. The general mechanism is to create a discrepancy between patients' perception of their current status and their desired short-or long-term goals. The specific strategies and skills vary according to patients' readiness to address important questions. Evidence shows that empathic, trusted physicians who build a sense of autonomy, optimism, and confidence help trigger change, if they are willing to intervene.

Physicians should initiate dialog whenever they perceive a potential problem with alcohol. Patients who drink too heavily have high levels of ambivalence and resistance. Physicians do not have to be certain how serious problems are (except to recognize and treat withdrawal or other medical problems), since their initial interventions need to address similar dynamics about the change process. As the work continues, physicians obtain more data, improve the accuracy of their diagnoses, and fine-tune their interventions. Studies show that recurrent brief encounters using the style and skills discussed in the following sections are more critical to success than getting any one encounter “exactly right.” People and lifestyle are too complex and entrenched to expect that one “right answer” or “correct” conversation can accomplish the goals of change.

[edit] AN INDISPENSABLE INTERVENTION STRATEGY

Reflection, also called active listening, is a basic interview skill that helps increase motivation in all types of drinkers (Box 51-10). Reflection, especially when the patient seems negative or hostile, is not an intuitive response. Physicians usually prefer asking questions (getting more data), giving advice, or shifting the interview focus. When physicians reflect back the message they receive from patients, they generate an atmosphere of alliance and partnership because reflection shows a desire to understand the speaker and lets the speaker choose where to go next (unlike, for example, questions, advice, agreement or disagreement, or statements of values). Reflection demonstrates acceptance of the person, and a willingness to listen more. Because it is neither aggressive nor defensive, reflection helps minimize arguing, fighting, hostility, and negativity. Studies demonstrate that physicians who reflect negative, resistant, or reluctant statements help patients to voice the more positive view. (For example, if the patient says, “I drink a lot because of the neuropathy and pain in my feet, so that I can sleep,” the physician might respond, “So, alcohol helps you a lot.” This might prompt the patient to say, “Well, it's probably not so good for my internal organs.”) This is one aspect of helping patients find a discrepancy between their current status and what they might desire. Physicians can reflect a person's statements about feeling, thinking, attribute, choice, action, or behavior.

Reflection encourages the patient to share more of his or her perspectives, feelings, and thoughts, and thus engenders more trust and a feeling of safety in both persons. As patients who initially show disinterest, hostility, sullenness, or confusion reveal more of themselves, physicians become less judgmental and critical, becoming more inclined to join patients and to support them in their struggles with life. Patients who feel joined become better able to listen to their physicians, and have more strength to take responsibility for attempting change that might at first seem unimaginable.

The following section discusses use of autonomy supportive skills in working with alcohol-dependent drinkers, who must abstain from alcohol to regain health, and whose difficulty doing so is dramatic.

[edit] GIVING ADVICE TO ALCOHOL-DEPENDENT DRINKERS

The section on pathophysiology emphasizes the deep roots of alcohol dependence. It is sustained by alcohol-induced brain changes, unhealthy social dynamics, and emotional isolation, as well as by the intense feeling that the “devil you know” must be better than changing. People in recovery say that asking the dependent drinker to stop drinking is tantamount to asking the unimaginable, to confront obstacles as insurmountable as learning to fly (without airplanes). Change seems like jumping into a black, featureless abyss. This illness dynamic ensures that patients will ignore reality, suppress negative feelings, and so flawlessly, as if by second nature, reject sound advice. The challenge for physicians is correspondingly great, and finding the motivation and developing discrepancy are complex tasks.

Patients' behaviors are negative, confusing, and hurtful. Often, roles are reversed, and the physician, directly or unwittingly, rejects and humiliates the patient. This fundamental distortion in physicians' experience of caring for patients is painful and profoundly unsatisfying. So, it is no surprise that physicians fail to intervene, and mirror patients' lack of awareness, reluctance, and often hopelessness. Physicians come to believe that any intervention is unwarranted interference in the patient's life. The situation becomes framed as, “Shall I now confront the patient and waste valuable time for unlikely gain, or address the patient's high blood pressure?” Drinking remains unaddressed.

Studies of interventions show that effective interviewers enhance motivation and discrepancy by using the following skills: create dialog; create an objective, scientific climate; develop options and choices; and create commitment. These are important elements of the autonomy supportive style.^[8]

[edit] Create Dialog

True dialog is difficult in conversations that involve differentials in perspectives, expertise, and/or power. Patients tend to defend a point of view or to be passive and silent. Physicians can encourage dialog by consciously employing a format of “tell, ask, tell, ask,” which supports taking turns in talking. Briefly tell bits of information or feedback (Box 51-11) and then ask the patient what he or she thinks about it, or how it feels to hear it, or what he or she intends to do about it. Keeping the “telling” brief helps clarity, and “asking” allows the patient to choose a change-enhancing or change-obstructing response. The manner in which patients respond to being asked also suggests to the physician which steps to use next. Change-enhancing responses include statements of agreement, commitment, or optimism, and suggest that exploring the facts might be helpful. Change-obstructing responses, such as statements of disagreement, reservation, pessimism, defensiveness, and noncommitment, as well as all questions that do not ask for clarification of meaning, suggest that the physician should reflect back the response as the next step in the conversation. Reflection invites patients to look inside themselves, and encourages motivation and discrepancy. “Asking” thus fosters exploration and choice.

[edit] Create an Objective, Scientific Climate for Educating Patients

Create a climate of fact, not opinion, by giving all information, feedback, and advice/recommendations in an objective or scientific way, with the cautions that apply to science (today's truth is tomorrow's fiction, and every case is unique). In short, start with the facts, not conclusions or opinions about meaning. Then, when giving advice, do so tentatively and conditionally, as part of a search for options or alternatives. “Wagging one's finger,” actually or figuratively, pushes patients into a corner, highlights any feelings of shame or stigma, and generally inhibits discussion. The following paragraphs give examples as well as more details.

Tell information about what is known about alcohol problems^[9] in an impersonal way, scrupulously avoiding reference to the patient (Box 51-12). This might sound like: “Research shows that treatment helps”; “Steady drinking changes brain function”; “Having a high tolerance for alcohol means that a person is deprived of the early warning system that tells him to stop drinking before the alcohol level gets so high as to be dangerous”; “90% of men drink less than 35 drinks per week”; “Many people are terrified to imagine stopping drinking”; or “Generally, being sick in the morning until after a drink means a person's brain has become hooked on alcohol.” Next, ask the patient what he or she thinks of this information.

Tell feedback about the patient's situation as a fact, a number, or score, rather than a conclusion (Box 51-13). You might say, “Three of your liver tests are abnormal,” rather than “Alcohol has damaged your liver”; “Your alcohol level when you arrived in the ED was .160,” rather than “You were drinking heavily before you came into the ED”; “You have a broken arm and stitches in your face,” rather than “You were injured because of your drinking”; “You mentioned three important things—that your relationship with your wife is going poorly, that you are having a lot of stomach trouble, and that you lost your license to drive,” rather than “Alcohol is wrecking your marriage, your career, and your body”; or “You are very shaky and sick until you have your first drink each morning,” rather than “You are addicted to alcohol.” Next, ask the patient what he or she thinks of this information. The patient's response to the “ask” indicates whether motivation and discrepancy are enhanced, and gives the physician ideas about the next steps.

Tell advice and explicit recommendations with two characteristics. First, give an objective rationale derived from a broader data base than simply this case, and second, give advice tentatively and conditionally. This might sound like: “One option that I recommend, based on data in the medical literature, and my experience with experts who have advised me about similar patients, is that you stop drinking all alcohol. Of course, no one can be certain that this is the right thing for you to do, or that it will work for you,” or “Most people find that talking with people in Alcoholics Anonymous is helpful. AA might or might not be right for you. I recommend you go there.” Next, ask the patient what he or she thinks of this advice (Box 51-14).

Patients will not do things that they themselves do not choose to do—commanding or ordering rather than checking the results of giving advice and making recommendations ensures lack of adherence. If physicians push ahead and try persuading patients in spite of reluctance, they foster continued ambivalence, raise resistance to change, and begin an enervating downward spiral in which both participants become further demoralized and discouraged.

[edit] Create Commitment and Confidence About Change

Commitment can only be augmented in an atmosphere that tolerates a genuine and full expression of ambivalence, and of negatives as well as positives, including both facts and feelings. Using reflection and emphasizing autonomy and choice create and support such an atmosphere. People develop commitment when credible, trusted, reliable advisors explicitly witness the special and unique strengths of those persons. People also develop commitment when they find a new chance to explicitly witness their own strengths and successes. Two skills that might achieve the goal of generating a discrepancy by suggesting to the patient a different aspect of reality or a new framing of reality follow, the first more direct, the second more subtle.

First, at a suitable moment when the conversation is going well (a true dialog, and not argumentative or discouraging), the patient should be told why he or she has a chance of success, based on facts the physician knows about the patient's unique characteristics, past successes, attitude, and other attributes. For example, the physician might say, “You've told me how independent, even stubborn, you can be, and that may mean that when you decide to do something difficult, you can stick to it”; “You quit drinking for 5 years once before, so you know it is possible”; or “You said you are pretty depressed, and I also see that you have come through similar moments in the past by getting involved with people in AA.” Experts call this action supporting self-efficacy.

Another, sometimes more effective method is to help people express their own commitment, especially if they can do so emphatically. Again, find a suitable moment when the conversation is going well. Then, when the patient makes a statement that is positive, or hopeful, or promises success, the physician expresses the patient's previously stated skepticism, doubt, or ambivalence. This reminder (a reflection) of earlier patient statements encourages the patient to take the other side in the dialog. The patient can emphatically state a commitment, perhaps even claim strength, or cite a new reason for hope. For example, if a physician says, “From what you said earlier, it does not seem to me that you are quite ready to attempt quitting,” the patient might respond, “I feel my only good choice is to get to AA!” The physician can then build on this discrepancy between prior and current expectations.

[edit] TREATMENT OPTIONS FOR ALCOHOL-DEPENDENT PATIENTS

Available options depend on competing priorities (e.g., pancreatitis, homelessness) and previous treatment experience. A list of options often includes those shown in Box 51-15. Patients entrenched in precontemplation may limit action to a return visit. Observing the consequences of future drinking and generating a list of pros and cons about change represent more active steps.^[10]

Physicians should recommend abstinence as the preferred option and refer people for treatment; research data show that attempted referral is helpful, whether or not the referral is completed. This finding reflects the dynamics previously discussed regarding exploring ambivalence, giving choices, not rushing decisions, and clearly expressing support and concern. Physicians must know local resources in order to provide quality referrals. Patients who are cognitively impaired (intoxicated or in withdrawal) need to “dry out” before treatment referral is attempted. Patients should be referred to outpatient treatment unless they are medically ill, psychotic, or homeless or have previously failed outpatient counseling. Most communities have specialized services available in both public and private sectors. Community mental health centers employ substance abuse specialists. Specialized licensing in substance abuse is available in all states for credentialed therapists, such as social workers and psychologists.

AA should be part of the referral for each patient, whether the perceived problem is early or late, mild or severe; all patients can benefit. The experienced physician presents AA attendance as a joint educational effort and suggests that talking over experiences at meetings will help the physician and patient more fully understand the situation. Recovery from dependence is facilitated by participation because patients identify with others who have faced the abyss and are now doing well. Patients can learn the “how to” as well as the “why” for being sober. For patients without dependence, meetings provide nonverbal, intuitive opportunities to discover that their “alcoholic” stereotype is too narrow. Participating with recovering people who seem otherwise like themselves enables patients to witness the discrepancy between what they thought and what they experience, and provides motivation.^[11]

[edit] GIVING ADVICE TO MODERATE DRINKERS

Patients who drink within safe limits (see Box 51-5) need advice and reassurance. The advice might acknowledge the health benefits of 6 to 10 drinks per week,^[12] and clearly state the safe limits. People drinking less should not be encouraged to drink up to the limits, since the benefits are small, and the risks of adverse effects (primarily brain effects that facilitate loss of control) increase with amount. Alcohol is always a sensitive topic, so physicians should use reflection and autonomy support strategies to promote a healthy physician-patient relationship.

[edit] GIVING ADVICE TO AT-RISK DRINKERS (HAZARDOUS DRINKERS)

People who drink more than the safe limits and those who abuse alcohol are reluctant to discuss drinking at any length. They want to keep drinking as they do, but have a lot to gain from their physicians' concern and advice.^[13][14] What is pertinent for this group, not yet in deep trouble, to hear and heed? Like dependent drinkers, they need information about pathophysiology, feedback about their own condition, and advice to change. Patients need to know what research has shown. Studies show that some patients remain stable over long periods, and others progress to more serious problems. People who succeed at moderating their drinking to the safe limits or below usually do so after a period of abstinence (a minimum of about 3 months but often several years); statistically they are more often women, young, and not using other mood-altering drugs (prescribed or illicit), and they have had relatively few adverse consequences. Most have never met criteria for alcohol dependence. Patients who have already encountered problems from drinking only rarely succeed in avoiding further consequences if they continue to drink above safe limits. Patients who wish to cut back to safe limits can be encouraged to do so and referred to substance abuse professionals who can teach skills and monitor effectiveness. This particular lifestyle change is complex and troublesome for most people.

For this mixed group of heavy drinkers, some with no apparent problems and others with relatively minor problems, the safest option is to abstain, and physicians should recommend abstinence, at least for a few weeks. These patients are especially difficult for physicians, since they are reluctant to abstain or cut back. Negotiations may carry on for months or years in pursuit of continuing good health. Physicians are frustrated by the difficulty in convincing patients to see the same reality that the physician does concerning the nature of the problem. Persuasion, threats, a mountain of facts, and excellent suggestions for action steps seem only to harden the patient's resistance, maddeningly so. In fact, slogans from the self-help community such as, “No one but the patient can make a diagnosis” or “He won't do anything until he hits bottom,” reflect lay wisdom derived from the frustration of pressing for change when people are not ready.

Effective physicians tolerate ambivalence and minimize resistance through use of reflection. They continue to explore drinking and its consequences with patients, and to provide feedback and new information. Standing by autonomy principles is precisely the proper course. Giving clear recommendations, but also helping patients make their own decisions and supporting any effort to change, is effective.

[edit] PHARMACOLOGIC CONSIDERATIONS IN PRIMARY CARE MANAGEMENT

One option that a primary care physician might suggest is disulfiram or naltrexone. Each has been shown effective in certain circumstances. Disulfiram provokes acetaldehyde accumulation after the ingestion of alcohol, producing a toxic state manifest by nausea, headache, unpleasant flushing, and respiratory distress. Severity depends on dose of alcohol and blood level of disulfiram. It takes several days without medication to avoid a toxic reaction, and it takes several doses of disulfiram to produce an appropriate blood level. Randomized studies of disulfiram use are negative. However, physicians who are using the skills discussed earlier and who present disulfiram as one option to patients not doing well find patients who clearly benefit from disulfiram. The recommended prescription is two 250-mg tablets daily for 4 days, then one daily. Anticipate use in 3-month blocks.

Randomized studies show naltrexone, an opioid antagonist, has beneficial effects in treatment of alcohol problems. Naltrexone diminishes craving, and treated patients who drank did not move into full relapse as often as control subjects did. Naltrexone may be a useful addition to the menu of treatment options. Referral for professional treatment is always appropriate when physicians prescribe naltrexone.

[edit] SUMMARY

This chapter presents guidelines for physician action regarding the broad spectrum of alcohol problems. Conversations about drinking are painful. Successful intervention requires that physicians value patient autonomy and use skills that encourage patients' reflection, dialog, the choice for change, confidence, and help seeking. When patients express little motivation for change, physicians who attend to their own frustration and reframe it as an incentive to better witness patients' ambivalence and resistance will improve patients' outcomes.

[edit] REFERENCES