 |
 |
|
||||||||||||||||||||||||||||
| A PUBLICATION OF CME OUTFITTERS | VOLUME 1, ISSUE 29 - December 19, 2006 | |||||||||||||||||||||||||||||
 |
||||||||||||||||||||||||||||||
|
|
|||||||||||||||||||||||||||||
|
FROM THE CLINICAL KNOWLEDGE CENTER Helping Patients with Alcohol Problems: A Clinician's Guide This recently updated guide, produced by the National Institute on Alcohol Abuse and Alcoholism (NIAAA), is written for primary care and mental health clinicians with guidance from physicians, nurses, advanced practice nurses, physician assistants, and clinical researchers. It is intended to help clinicians talk with their patients in an open and honest manner to determine which patients might be at risk for heavy drinking, and to offer management strategies to help patients cut back on their drinking. How much is "too much?" Drinking becomes too much when it causes or elevates the risk for alcohol-related problems or complicates the management of other health problems. Men who drink 5 or more standard drinks in a day (or 15 or more per week) and women who drink 4 or more in a day (or 8 or more per week) are at increased risk for alcohol-related problems, according to epidemiologic research. Individual responses to alcohol vary, however. Drinking at lower levels may be problematic depending on many factors, such as age, co-existing conditions, and medication use. Because it is not known whether any amount of alcohol is safe during pregnancy, the Surgeon General urges abstinence for women who are or may become pregnant. Why screen for heavy drinking, and what can I do to help patients change their drinking behaviors? At-risk drinking and alcohol problems are common. About 3 in 10 U.S. adults drink at levels that elevate their risk for physical, mental health, and social problems. Of these heavy drinkers, about 1 in 4 currently has alcohol abuse or dependence. All heavy drinkers have a greater risk of hypertension, gastrointestinal bleeding, sleep disorders, major depression, hemorrhagic stroke, cirrhosis of the liver, and several cancers. You are in a prime position to make a difference. Clinical trials have demonstrated that brief interventions can promote significant, lasting reductions in drinking levels in at-risk drinkers who are not alcohol dependent. Some drinkers who are dependent will accept referral to addiction treatment programs. Even for patients who do not accept a referral, repeated alcohol-focused visits with a health provider can lead to significant improvement. If you are not already doing so, you are encouraged to incorporate alcohol screening, brief intervention, and treatment referral into your practice. Changing drinking behavior is a challenge, especially for those who are alcohol dependent. The first 12 months of abstinence are especially difficult, and relapse is most common during this time. If patients do relapse, recognize that they have a chronic disorder that requires continuing care, just like patients who have asthma, hypertension, or diabetes. Recurrence of symptoms is common and similar across each of these disorders, perhaps because they require the patient to change health behaviors to maintain gains.
With this free guide, you have what you need to begin. http://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/clinicians_guide.htm The NIAAA has also provided frequently asked questions about alcohol behaviors: How do I factor the potential benefits of moderate drinking into my advice to patients who drink rarely or not at all? Moderate consumption of alcohol (defined by U.S. Dietary Guidelines as up to two drinks a day for men and one for women) has been associated with a reduced risk of coronary heart disease. Achieving a balance between the risks and benefits of alcohol consumption remains difficult, however, because each person has a different susceptibility to diseases potentially caused or prevented by alcohol. Your advice to a young person with a family history of alcoholism, for example, would differ from the advice you would give to a middle-aged patient with a family history of premature heart disease. Most experts do not recommend advising nondrinking patients to begin drinking to reduce their cardiovascular risk. However, if a patient is considering this, discuss safe drinking limits and ways to avoid alcohol-induced harm. Why are the recommended drinking limits lower for some patients? The limits are lower for women because they have proportionally less body water than men do and thus achieve higher blood alcohol concentrations after drinking the same amount of alcohol. Older adults also have less lean body mass and greater sensitivity to alcohol's effects. In addition, there are many clinical situations where abstinence or lower limits are indicated, due to a greater risk of harm associated with drinking. Examples include women who are or may become pregnant, patients taking medications that may interact with alcohol, young people with a family history of alcohol dependence, and patients with physical or psychiatric conditions that are caused or exacerbated by use of alcohol. What percentage of people drink at, above, or below moderate levels? About 7 in 10 adults abstain, drink rarely, or drink within the daily and weekly limits noted in Step 1 of the assessment algorithm. The rest exceed the daily limits, the weekly limits, or both. Some of my patients who are pregnant do not see any harm in having an occasional drink. What is the latest advice? A recent survey estimates that 1 in 10 pregnant women in the United States drinks alcohol. In addition, among sexually active women who are not using birth control, more than half drink and 12.4 percent report binge drinking, placing them at particularly high risk for an alcohol-exposed pregnancy. Each year in the United States, an estimated 2,000 to 8,000 infants are born with fetal alcohol syndrome and many thousands more are born with some degree of alcohol-related effects. These problems range from mild learning and behavioral problems to growth deficiencies to severe mental and physical impairment. Together, these adverse effects comprise Fetal Alcohol Spectrum Disorders. Because it is not known what, if any, amount of alcohol is safe during pregnancy, the Surgeon General recently reissued an advisory that urges women who are or may become pregnant to abstain from drinking alcohol. The advisory also recommends that pregnant women who have already consumed alcohol stop to minimize further risks, and that health professionals inquire routinely about alcohol consumption by women of childbearing age. What if a patient reports some symptoms of an alcohol use disorder but not enough to qualify for a diagnosis? Alcohol use disorders are similar to other medical disorders such as hypertension, diabetes, or depression in having "gray zones" of diagnosis. For example, a patient might report a single arrest for driving while intoxicated and no other symptoms. Since a diagnosis of alcohol abuse requires repetitive problems, that diagnosis could not be made. Similarly, a patient might report one or two symptoms of alcohol dependence, but three are needed to qualify for a diagnosis. Any symptoms of abuse or dependence are a cause for concern and should be addressed, as an alcohol use disorder may be present or developing. These patients may be more successful with abstaining as opposed to cutting down to recommended limits. Closer follow-up is indicated, as well as reconsidering the diagnosis as more information becomes available. Should I recommend any particular behavioral therapy for patients with alcohol use disorders? Several types of behavioral therapy are used to treat alcohol use disorders. These may be based on cognitive-behavioral techniques, enhancing motivation, the 12 steps of Alcoholics Anonymous (e.g., the Minnesota Model), or a combination of these and other psychosocial approaches. All seem to be equally effective, suggesting that seeking help in itself is more important than which particular approach is used. Other self-help organizations that offer secular approaches, groups for women only, or support for family members can be found on the National Clearinghouse for Alcohol and Drug Information website under "Resources." Are laboratory tests available to screen for or monitor alcohol problems? For screening purposes in primary care settings, interviews and questionnaires have greater sensitivity and specificity than blood tests for biochemical markers, which identify only about 10 to 30 percent of heavy drinkers. Nevertheless, biochemical markers may be useful when heavy drinking is suspected but the patient denies it. The most sensitive and widely available test for this purpose is the serum gamma-glutamyl transferase (GGT) assay. However, GGT is not very specific, so reasons for GGT elevation other than excessive alcohol use need to be eliminated. GGT and other transaminases may also be helpful for monitoring progress and identifying relapse if elevated at baseline, and serial values can provide valuable feedback to patients after an intervention. If I refer a patient for alcohol treatment, what are the chances for recovery? A review of seven large studies of alcoholism treatment found that about one-third of patients either were abstinent or drank moderately without negative consequences or dependence in the year following treatment. Although the other two-thirds had some periods of heavy drinking, on average they reduced consumption and alcohol-related problems by more than half. These reductions appear to last at least 3 years. This substantial improvement in patients who do not attain complete abstinence or problem-free reduced drinking is often overlooked. These patients may require further treatment, and their chances of benefiting the next time do not appear to be influenced significantly by having had prior treatments. As is true for other medical disorders, some patients have more severe forms of alcohol dependence that may require long-term management. Do you have feedback for the author? Click here to send us an email. References
|
||||||||||||||||||||||||||||||
 |
||||||||||||||||||||||||||||||
| ©2006 CME Outfitters, LLC |
||||||||||||||||||||||||||||||