Behavioral Health

Alcohol use disorder: How best to screen and intervene

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

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 NIAAA single-question screen asks how many times in the past year the patient had ≥4 drinks (women) or ≥5 drinks (men) in a day.¹⁵ The sensitivity and specificity of single-question screening are 82% to 87% and 61% to 79%, respectively, and the test has been validated in several different settings.¹² The AUDIT screening tool, freely available from the World Health Organization, is a 10-item questionnaire that probes an individual’s alcohol intake, alcohol dependence, and adverse consequences of alcohol use. Administration of the AUDIT typically requires only 2 minutes. AUDIT-C¹⁷ is an abbreviated version of the AUDIT questionnaire that asks 3 consumption questions to screen for AUD.

It was found that AUDIT scores in the range of 8 to 15 indicate a medium-level alcohol problem, whereas a score of ≥16 indicates a high-level alcohol problem. The AUDIT-C is scored from 0 to 12, with ≥4 indicating a problem in men and ≥3 a problem in women.

THE CASE

The physician had used the NIAAA single- question screen to determine that Ms. E drank more than 4 beers per day during social events and weekends, which occurred 2 to 3 times per month over the past year. She lives alone and said that she’d been seeing less and less of her boyfriend lately. Her score on the Patient Health Questionnaire (PHQ), which screens for depression, was 11, indicating moderate impairment. Her response on the CAGE questionnaire was negative for a problem with alcohol. However, her AUDIT score was 17, indicating a high-level alcohol problem. Based on these findings, her physician expressed concern that her alcohol use might be contributing to her symptoms and difficulties.

The CAGE questionnaire has lower sensitivity when alcohol intake is lower.

Although she did not have a history of increasing usage per day, a persistent desire to cut down, significant effort to obtain alcohol, or cravings, she was having work troubles and continued to drink even though it was straining relationships, promoting weight gain, and causing abdominal pain.

The physician asked her to schedule a return visit and ordered several blood studies. He also offered to connect her with a colleague with whom he collaborated who could speak with her about possible alcohol use disorders and depression.

Continue to: Selecting blood work in screening for AUD