cont. from

Lab Studies:

• A blood alcohol level might be helpful in the office if the patient appears intoxicated but is denying alcohol abuse. It is not a sensitive screening test.
• A blood alcohol level in excess of 300 mg/dL, a blood alcohol level of greater than 150 mg/dL without gross evidence of intoxication, or a blood alcohol level of greater than 100 mg/dL upon routine examination indicates alcoholism with a high degree of reliability.
• The possibility of polysubstance abuse justifies performing a urine toxic screen for other drugs of abuse.

Medical Care:

Many physicians believe no effective treatment is available for alcoholism; therefore, these physicians do not refer alcoholic patients for treatment. However, more than 13 studies representing more than 4000 patients demonstrate that brief interventions make a difference. Most of the patients in these studies drank heavily but did not yet have a problem with alcohol.

One study performed in Norway demonstrated that brief advice given early can affect gamma glutamyl transferase levels and reported alcohol consumption. Early warning makes a difference to persons who drink heavily. In a study of 200 alcoholic workers, recalling a physician's warning about drinking at the beginning of the study was associated with a better prognosis 2 years later. Unfortunately, less than 25% had received warnings from their physicians, again illustrating the problem of missed diagnosis.

• The first step in treatment is brief intervention. The physician states unequivocally that the patient has a problem with alcohol and emphasizes that this determination stems from the consequences of alcohol in that patient's life, not from the quantity of alcohol consumed. Emphasizing the effects on family, friends, and occupation, as well as any physical manifestations, is important. Pointing out that loss of control and compulsive use indicate alcohol dependence also is important.
  • Present the diagnosis.
    • Use explicit evidence; emphasize the consequences endured by the patient as a result of alcohol abuse.
    • Be empathic and nonjudgmental.
    • Avoid arguments about the diagnosis.
    • Avoid use of the word alcoholic.
  • Indicate the responsibility for change is with the patient. Listen to the patient's goals and point out discrepancies between his or her goals and actions.
  • Determine the patient's readiness for change.
    • If the patient does not believe a problem exists, suggest bringing a family member to the next appointment or suggest a 2-week trial of abstinence.
    • If the patient is thinking about changing his or her lifestyle, give pamphlets concerning alcohol abuse and suggest an abstinence trial.
    • If the patient is ready to change, reinforce and praise the decision. Emphasize that the biggest error at this stage is for the patient to underestimate the amount of help needed to quit drinking. Give the patient a list of options, especially AA, and consider medications for treatment (pharmacotherapy).
• The physician must state firmly that alcohol is a problem for the patient and that the patient determines the solution. A good strategy is to learn about patients' goals and indicate discrepancies between their goals and their choices. Pointing out discrepancies is more effective initially than statements such as, "You have to quit," or, "You have to go to AA."
• The patient's response determines the physician's next step. If the patient denies the problem, recommending joining AA will not work. Involving the family and/or suggesting a trial of abstinence is useful, and, importantly, the physician should follow up with the patient in a few weeks. The patient might be angry initially and storm out of the office, but then the patient might recall the physician's warning months or years later and stop drinking. For patients who recognize a problem and will consider referral, the cheapest (free) and most accessible option is AA.
  • The AA 12-step approach involves psychosocial techniques used in changing behavior (eg, rewards, social support networks, role models). Each new person is assigned an AA sponsor (a person recovering from alcoholism who supervises and supports the recovery of the new member). The sponsor should be older and should be of the same sex as the patient (opposite sex if the patient is homosexual).
  • Patients do not need a strong religious background to be successful in AA; they only need the belief in a power higher than themselves. Urge patients to use aspects of the program that can help them stay sober and ignore aspects that are not helpful.
  • Patients who have tried AA may have had a bad past experience. Patients should try at least 5-10 different meetings before giving up on the AA approach because each meeting is different. For example, women often do better at meetings for women only because the issues for female alcoholic patients are different from the issues for male alcoholic patients. A meeting in the suburbs might not be appropriate for someone from the inner city and vice versa.
  • The physician should have AA literature in the office (dates and places of meetings), have the AA phone number available, and know about other treatment services in the community, including referrals for medical consultants or specialists in chemical dependency. No randomized trials of AA have been performed, but a US Veterans Administration study suggested that patients who attended meetings did much better than those who refused to go.
  • AA can be reached via their Web site (Alcoholics Anonymous) or by mail (AA General Service; PO Box 459; Grand Central Station; New York, NY 10163). Physicians can order pamphlets and other patient education material from these sources.
• Additional sources of help include the Substance Abuse Treatment FACILITY LOCATOR, Self-Help Group Sourcebook Online, and SMART Recovery. The acronym SMART is for Self-Management and Recovery Training.
• Treatment of alcoholism involves the following:
  • Brief physician advice makes a difference.
  • While a trial period of controlled drinking with careful follow-up might be appropriate for a diagnosis of alcohol abuse, this approach increases a physician's professional liability. Complete abstinence is the only treatment for alcohol dependence. Emphasize that the most common error is underestimating the amount of help that will be needed to stop drinking. The differential diagnosis between alcohol abuse and dependence can be a difficult judgment call.
  • Hospitalize patients if they have a history of delirium tremens or if they have significant comorbidity. Consider inpatient treatment if the patient has poor social support, significant psychiatric problems, or a history of relapse after treatment.
  • Strongly recommend AA.
  • Encourage hospitalized patients to call AA from the hospital. AA will send someone to talk to them if the patient makes the contact. Patients need to attend meetings regularly (daily at first) and for a sufficient length of time (usually 2 y or more) because recovery is a difficult and lengthy process.
  • In the beginning of treatment, and perhaps ongoing, patients should remove alcohol from their homes and avoid bars and other establishments where strong pressures to drink may influence successful abstinence.
  • If the patient has an antisocial personality (ie, severe problems with family, peers, school, and police before age 15 y and before the onset of alcohol problems), recovery is less likely. If the patient has primary depression, anxiety disorder, or another potentially contributory disorder (The other disorder must antedate the problems with alcohol or it must be a significant problem during long periods of sobriety.), treat this primary problem aggressively.
• Strongly encourage family members of alcoholic patients to contact Al-Anon and Alateen via its Web site (Al-Anon/Alateen) or mailing address (Al-Anon Family Group Headquarters; PO Box 182; Madison Square Garden Station; New York, NY 10159-0182).

Consultations:

Diet:

Alcoholic persons often have a poor diet. Folate deficiency is common. Advise patients to eat plenty of fruits and vegetables and consider a multivitamin supplement. Supplemental enteral nutrition improves survival in persons with advanced liver disease.

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Reviewed: 01/2006

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