Alcohol-Related Problems: Recognition and Intervention SANDRA K. BURGE, PH.D., and F. DAVID SCHNEIDER, M.D., M.S.P.H. University of Texas Health Science Center, San Antonio, Texas

A patient information handout on deciding whether drinking is a problem, written by the authors of this article, is provided on page 372.

Early identification of alcohol-related problems is important because these problems are prevalent, pose serious health risks to patients and their families, and are amenable to intervention. Physicians may be able to help patients change their drinking behaviors. The most effective tool for screening is a thorough history of the patient's drinking behavior, designed to identify patterns of alcohol-related difficulties with physical and mental health, family life, legal authorities and employment. Alcohol drinkers can be categorized as at-risk, problem or alcohol dependent, according to a protocol developed by the National Institute on Alcohol Abuse and Alcoholism. The severity of the alcohol problem and the patient's readiness to change should determine the intervention selected by the family physician.

Although two thirds of American men and one half of American women drink alcohol,¹ three fourths of drinkers experience no serious consequences from alcohol use.² Among those who abuse alcohol, many reduce their drinking without formal treatment after personal reflection about negative consequences.³ Physicians can help prevent the serious effects of alcohol-related problems by stimulating such reflection and moving patients toward a healthier lifestyle.⁴ The purpose of this review is to encourage family physicians to prevent serious consequences of alcohol-related problems by using simple screening and brief intervention strategies.

Rationale for Early Screening

Preventive efforts on the part of family physicians are important because: (1) alcohol-related problems are prevalent in patients who visit family practices; (2) heavy alcohol use contributes to many serious health and social problems; and (3) physicians can successfully influence drinking behaviors. In the United States, the one-year prevalence of alcohol-use disorders, including alcohol abuse and alcohol dependence, is about 7.4 percent in the adult population.⁵ In patients who visit family practices, the prevalence is higher. One study of 17 primary care practices found a 16.5 percent prevalence of "problem drinkers,"⁴ and another study found a 19.9 percent prevalence of alcohol-use disorders among male patients.⁶

Disorders related to alcohol use are estimated to affect over 7 percent of adults in the United States.

Heavy alcohol use can affect nearly every organ system and every aspect of a patient's life. Table 1 lists many direct and indirect effects of alcohol-related problems. Alcohol causes diseases such as cirrhosis of the liver and exacerbates symptoms in existing conditions such as diabetes.^1,7,8 In addition, alcohol is implicated in many social and psychologic problems, including family conflict, arrests, job instability, injuries related to violence or accidents, and psychologic symptoms related to depression and anxiety.^2,8 These problems take an enormous emotional toll on individuals and families, and are a great financial expense to health care systems and society.

Many of these problems may be avoided by early screening and intervention by family physicians. Several studies of early and brief physician interventions have demonstrated a reduction in alcohol consumption and improvement in alcohol-related problems among patients with drinking problems.^9,10 A 40 percent reduction in alcohol consumption in nondependent problem drinkers has been demonstrated following physician advice to reduce drinking.⁴

TABLE 1 Consequences of Alcohol Abuse or Dependence System/category Early consequences Late consequences Liver disease Elevated liver enzyme levels Fatty liver, alcoholic hepatitis, cirrhosis Pancreatic disease Acute pancreatitis, chronic pancreatitis Cardiovascular disease Hypertension Cardiomyopathy, arrhythmias, stroke Gastrointestinal problems Gastritis, gastroesophageal reflux disease, diarrhea, peptic ulcer disease Esophageal varices, Mallory-Weiss tears Neurologic disorders Headaches, blackouts, peripheral neuropathy Alcohol withdrawal syndrome, seizures, Wernicke's encephalopathy, dementia, cerebral atrophy, peripheral neuropathy, cognitive deficits, impaired motor functioning Reproductive system disorders Fetal alcohol effects, fetal alcohol syndrome Sexual dysfunction, amenorrhea, anovulation, early menopause, spontaneous abortion Cancers Neoplasm of the liver, neoplasm of the head and neck, neoplasm of the pancreas, neoplasm of the esophagus Psychiatric comorbidities Depression, anxiety Affective disorders, anxiety disorders, antisocial personality Legal problems Traffic violations, driving while intoxicated, public intoxication Motor vehicle accidents, violent offenses, fires Employment problems Tardiness, sick days, inability to concentrate, decreased competence Accidents, injury, job loss, chronic unemployment Family problems Family conflict, erratic child discipline, neglect of responsibilities, social isolation Divorce, spouse abuse, child abuse or neglect, loss of child custody Effects on children Overresponsibility, acting out, withdrawal, inability to concentrate, school problems, social isolation Learning disorders, behavior problems, emotional disturbance

Definitions

Tables 2 and 3 list diagnostic criteria for alcohol abuse and dependence specified by the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV).¹¹ Alcohol abuse is manifested by recurrent alcohol use despite significant adverse consequences of drinking, such as problems with work, law, health or family life.

The diagnosis of alcohol dependence is based on the compulsion to drink. The dependent drinker devotes substantial time to obtaining alcohol, drinking and recovering, and continues to drink despite adverse social, psychologic or medical consequences. A physiologic dependence on alcohol, marked by tolerance or withdrawal symptoms, may or may not be present. Note that quantity and frequency of drinking are not specified in the criteria for either diagnosis; instead, the key elements of these diagnoses include the compulsion to drink and drinking despite adverse consequences.

TABLE 2 DSM-IV Criteria for Alcohol Abuse A maladaptive pattern of alcohol use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period: Recurrent alcohol use resulting in a failure to fulfill major role obligations at work, school or home (e.g., repeated absences or poor work performance related to alcohol use; alcohol-related absences, suspensions or expulsions from school; neglect of children or household) Recurrent alcohol use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by alcohol use) Recurrent alcohol-related legal problems (e.g., arrests for alcohol-related disorderly conduct) Continued alcohol use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the alcohol (e.g., arguments with spouse about consequences of intoxication, physical fights) The symptoms have never met the criteria for alcohol dependence (see Table 3). Adapted with permission from American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, D.C.: American Psychiatric Association, 1994:182-3. Copyright 1994.

TABLE 3 DSM-IV Criteria For Alcohol Dependence A maladaptive pattern of alcohol use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period: Tolerance, as defined by either of the following: A need for markedly increased amounts of alcohol to achieve intoxication or the desired effect Markedly diminished effect with continued use of the same amount of alcohol Withdrawal, as manifested by either of the following: The characteristic withdrawal syndrome several hours to a few days following cessation (two or more of the following): autonomic hyperactivity (e.g., sweating or pulse rate greater than 100), increased hand tremor, insomnia, nausea or vomiting, transient visual, tactile or auditory hallucinations or illusions, psychomotor agitation, anxiety or grand mal seizures Alcohol or other substances are taken to relieve or avoid withdrawal symptoms Alcohol is taken in larger amounts or over a longer period than was intended There is a persistent desire or unsuccessful efforts to cut down or control drinking A great deal of time is spent to obtain alcohol, drink alcohol, or recover from its effects Important social, occupational or recreational activities are given up or reduced because of drinking alcohol Alcohol use is continued despite knowledge of having a persistent or recurrent physical or psychologic problem that is likely to have been caused or exacerbated by alcohol Specify if: With physiological dependence: evidence of tolerance or withdrawal (i.e., either item 1 or item 2 is present) Without physiological dependence: no evidence of tolerance or withdrawal (i.e., neither item 1 nor item 2 is present) Adapted with permission from American Psychiatric Association. Diagnostic and statistical manual of mental disorders. 4th ed. Washington, D.C.: American Psychiatric Association, 1994:181. Copyright 1994.

Clinical Presentation

Patients in the early stages of alcohol-related problems may have few or subtle clinical findings.

Alcohol-use disorders are easy to recognize in patients with longstanding problems, because these persons present to the family physician with diseases such as cirrhosis or pancreatitis (Table 1). Patients in the earlier stages of alcohol-related problems may have few or subtle clinical findings, and the physician may not suspect a high consumption of alcohol. Certain medical complaints, such as headache, depression, chronic abdominal or epigastric pain, fatigue and memory loss, should alert the family physician to consider the possibility of alcohol-related problems (Table 1).

The first signs of heavy drinking may be social problems. The compulsion to drink causes persons to neglect social responsibilities and relationships in favor of drinking. Intoxication may lead to accidents, occasional arrest or job loss. Recovering from drinking can decrease job performance or family involvement. Social problems that indicate alcohol-use disorders include family conflict, separation or divorce, employment difficulties or job loss, arrests and motor vehicle accidents.

TABLE 4 Screening Questions for Alcohol-Related Problems All patients Use Do you drink alcohol, including beer, wine or distilled spirits? Current drinkers Frequency On average, on how many days per week do you drink alcohol? Quantity On a typical day when you drink, how many drinks do you have? Heaviest use What is the maximum number of drinks you had on any given occasion during the past month? Information from The physicians' guide to helping patients with alcohol problems. U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism, 1995; NIH publication no. 95-3769.

History

The most effective tool for diagnosing alcohol-related problems is a thorough history of the drinking behavior and its consequences. The National Institute on Alcohol Abuse and Alcoholism (NIAAA) has published The Physician's Guide to Helping Patients with Alcohol Problems, which presents a brief model for screening and assessing problems with alcohol.¹² NIAAA recommends screening for alcohol-related problems during routine health examinations, before prescribing a medication that interacts with alcohol and in response to the discovery of medical problems that may be related to alcohol use (Table 1).

TABLE 5 CAGE Questionnaire* The rightsholder did not grant rights to reproduce this item in electronic media. For the missing item, see the original print version of this publication.

Screening questions are listed in Table 4. The first four questions are related to alcohol consumption. One drink is defined as 12 g of pure alcohol, which is equal to one 12-oz can of beer, one 5-oz glass of wine or 1.5 oz (one jigger) of hard liquor.^7,12 NIAAA also recommends using the CAGE¹³ questionnaire to screen patients for alcohol use (Table 5). The CAGE questions are widely used in primary care settings and have high sensitivity and specificity for identifying alcohol problems.¹⁴ Among patients who screen positive for alcohol-related problems, additional questions should include the family history of alcohol abuse as well as family, legal, employment and health problems related to drinking.

Other screening questionnaires are available and may perform better than the CAGE questionnaire. A recent study demonstrated the superiority of the AUDIT instrument in a Veterans Administration population (Table 6).¹⁵ The TWEAK and AUDIT questionnaires performed better than the CAGE questionnaire in women (Table 7).¹⁶

Physical Examination

In the early stages of alcohol-related problems, the physical examination provides little evidence to suggest excessive drinking. Patients who abuse alcohol may have mildly elevated blood pressure but few other abnormal physical findings. Later, patients may develop significant and obvious signs of alcohol overuse, including gastrointestinal findings such as an enlarged and sometimes tender liver; cutaneous findings such as spider angiomata, varicosities and jaundice; neurologic signs such as tremor, ataxia or neuropathies; and cardiac arrhythmias. When patients arrive at the doctor's office inebriated, one should suspect a longstanding drinking problem.

TABLE 6 The AUDIT* Questionnaire The following questions pertain to your use of alcoholic beverages during the past year. A "drink" refers to a can or bottle of beer, a glass of wine, a wine cooler, or one cocktail or shot of hard liquor. How often do you have a drink containing alcohol? (Never, 0 points; ¾ monthly, 1 point; 2 to 4 times per month, 2 points; 2 to 3 times per week, 3 points; >=4 times per week, 4 points) How many drinks containing alcohol do you have on a typical day when you are drinking? (1 to 2 drinks, 0 points; 3 to 4 drinks, 1 point; 5 to 6 drinks, 2 points; 7 to 9 drinks, 3 points; >=10 drinks, 4 points) How often do you have 6 or more drinks on 1 occasion? (Never, 0 points; < monthly, 1 point; monthly, 2 points; weekly, 3 points; daily or almost daily, 4 points) How often during the past year have you found that you were not able to stop drinking once you had started? (Scoring same as question No. 3) How often during the past year have you failed to do what was normally expected from you because of drinking? (Same as question No. 3) How often during the past year have you needed a first drink in the morning to get yourself going after a heavy drinking session? (Same as question No. 3) How often during the past year have you had a feeling of guilt or remorse after drinking? (Same as question No. 3) How often during the past year have you been unable to remember what happened the night before because you were drinking? (Same as question No. 3) Have you or someone else been injured as a result of your drinking? (No, 0 points; yes, but not in the past year, 2 points; yes, during the past year, 4 points) Has a relative or friend, or a doctor or other health care worker, been concerned about your drinking or suggested you cut down? (Same as question No. 9) *--Alcohol Use Disorders Identification Test. Scoring: sum all points; total, 0 to 40 points. NOTE: For complete scoring information, see reference 15.

Laboratory Findings

Certain chemical markers are indicative but not diagnostic of alcohol-use disorders.^1,8,17 Among liver function tests, the *-glutamyl transferase (GGT) level is usually the first to become elevated, followed by the aspartate aminotransferase (AST) level, which is often twice the level of alanine aminotransferase (ALT).

The complete blood cell count may display a number of abnormalities. In cases of end-stage disease, all cell lines are reduced as a direct toxic effect of alcohol on the bone marrow. The prothrombin time (PT) is elevated because of decreased production of clotting factors by the liver. However, in early disease mean corpuscular volume (MCV) may be slightly elevated as a result of folate deficiency and the direct effects of alcohol on red blood cells. Patients with alcoholic gastritis may lose blood through the gastrointestinal tract, causing anemia and the production of smaller red blood cells, resulting in a low MCV. If both processes occur, the MCV will be normal, but the red cell distribution width will be elevated (around 20). Blood loss in the gastrointestinal tract may also cause iron deficiency.

TABLE 7 The TWEAK Questionnaire Tolerance: How many drinks can you hold ("hold" version; >=6 drinks indicates tolerance), or how many drinks does it take before you begin to feel the first effects of the alcohol? ("high" version; >=3 indicates tolerance) Worried: Have close friends or relatives worried or complained about your drinking in the past year? Eye openers: Do you sometimes take a drink in the morning when you first get up? Amnesia: Has a friend or family member ever told you about things you said or did while you were drinking that you could not remember? Kut down: Do you sometimes feel the need to cut down on your drinking? Scoring: 2 points each for tolerance or worried; 1 point each for eye opener, amnesia or kut down; sum all points; total, 0 to 7 points. For complete information about scoring, see reference 16.

Diagnosis and Classification

An accurate diagnosis of alcohol abuse or dependence requires a thorough medical history. Medical markers such as gastrointestinal problems or elevated liver enzymes are cause for suspicion but are not diagnostic. For example, using a GGT level higher than 40 to detect alcohol problems in a primary care population results in a sensitivity of 44 to 54 percent and a specificity of 80 to 84 percent.¹⁷ In contrast, a CAGE questionnaire with three or more positive responses is 100 percent sensitive and 81 percent specific for current alcohol dependence.¹⁸

NIAAA categorizes heavy drinkers into three groups: at-risk drinkers, problem drinkers (parallel to the DSM-IV diagnosis of "alcohol abuse"), and alcohol-dependent drinkers (parallel to the DSM-IV diagnosis of "alcohol dependence"). Table 8 describes the NIAAA assessment of alcohol-related problems.¹²

At-risk Drinkers
In the absence of medical, social or psychologic consequences of drinking, men who have more than 14 drinks per week or more than four drinks per occasion are considered "at risk" for developing problems related to drinking. Similarly, women who have more than 11 drinks per week or more than three drinks per occasion are "at risk." Because some drinkers significantly underreport their alcohol use, physicians should define patients as "at risk" when they have a positive CAGE score or a personal or family history of alcohol-related problems (Table 8).

Problem Drinkers
Patients who have current alcohol-related medical, family, social, employment, legal or emotional problems are considered "problem drinkers" regardless of their drinking patterns or responses to the CAGE questions (Table 8). Typically, these patients score 1 or 2 on the CAGE questionnaire and drink above "at-risk" levels.

Alcohol-dependent Drinkers
Patients drinking above the "at-risk" level who have CAGE scores of 3 or 4 should be questioned about their drinking compulsions, tolerance to alcohol and withdrawal symptoms (Table 2). Those who display these traits are considered "alcohol dependent."

Primary Care Interventions

The physician should direct intervention efforts based on consideration of two important factors: the severity of the alcohol problem and the patient's readiness to change the drinking behavior.

Interventions should be based on the severity of the alcohol problem and the patient's readiness to change the drinking behavior.

Severity of the Alcohol Problem
In patients who show evidence of alcohol dependence, the therapeutic end points should be abstinence from alcohol and referral to a specialized alcohol treatment program. Decisions about inpatient or outpatient treatment depend on the patient's likelihood of alcohol withdrawal, resources, employment status, family support system, access to treatment programs and motivation. Patients who resist formal treatment may prefer peer-directed groups, such as those offered by Alcoholics Anonymous, in conjunction with physician counseling and support. Al-Anon groups are available for adult family members of alcohol-dependent individuals. Abstinence is also indicated for non­alcohol-dependent patients who are pregnant, have comorbid medical conditions, take medications that interact with alcohol or have a history of repeated failed attempts to reduce their alcohol consumption.¹²

In patients who are at risk for developing alcohol-related problems or who have evidence of current problems, the therapeutic end point should be drinking at low-risk limits: for men, no more than two drinks with alcohol per day; for women or older persons (over 65) no more than one drink per day.¹²

TABLE 8 Assessment of Risk for Alcohol-Related Problems Severity of problem Criteria At risk Men: >14 drinks per week, >4 drinks per occasion Women: >11 drinks per week, >3 drinks per occasion, or CAGE score of 1 or higher for past year, or Personal or family history of alcohol problems Current problem CAGE score of 1 or 2 for past year, or Alcohol-related medical problems, or Alcohol-related family, legal or employment problems Alcohol dependent CAGE score of 3 or 4 for past year, or Compulsion to drink, or Impaired control over drinking, or Relief drinking, or Withdrawal symptoms, or Increased tolerance Information from The physicians' guide to helping patients with alcohol problems. U.S. Department of Health and Human Services, Public Health Service, National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism, 1995; NIH publication no. 95-3769.

Readiness to Change
A rare patient will present to the physician with the request for help in giving up alcohol. When persons change lifestyle behaviors such as tobacco or alcohol use, they typically move through stages of change: precontemplation (not ready for change), contemplation (ambivalence about change), preparation (planning for change), action (the act of change) and maintenance (maintaining the new behavior).¹⁹ This model of change can be pictured as a continuum, with a person moving back and forth among the stages, depending on the personal day-to-day costs and benefits of that behavior. Relapse is common and does not indicate a "failed" intervention. Contemplation (ambivalence) is the most common stage of change. One study found that 29 percent of hospitalized patients with alcohol disorders were uninterested in changing, 45 percent were ambivalent and 26 percent were ready to change their drinking behavior.²⁰

Some experts consider precontemplation to be a synonym for alcoholic denial, that is, a refusal to acknowledge problems. However, others²¹ do not find the concept of denial useful when working with patients with alcohol disorders. They note that direct or confrontational counseling strategies are likely to evoke resistance in patients, which, in turn, will be labeled "denial." Furthermore, their work demonstrates that even patients who do not admit to an alcohol problem can change their behaviors. Personal decisions about lifestyle changes evolve slowly over time, requiring much reflection, with repeated attempts at change and repeated setbacks. Patients will not leap from the precontemplation stage into the action stage after one clinic visit, no matter how insightful or aggressive the practitioner. The goal of each visit should be to help the patient move along the continuum of change toward a reduction in alcohol use.

Intervention Strategies
With the stage-of-change continuum in mind, physicians should tailor interviews according to the patient's stage.²⁰ In clinical settings, a good assessment is itself an intervention, stimulating patients to reflect on their drinking behavior. Well-intentioned advice, a familiar tool among physicians, works best with patients who are preparing for change. A physician who tries direct persuasion with an ambivalent patient risks pushing the patient toward resistance. However, at any stage, urgent persuasion is appropriate in patients requiring immediate change: a pregnant woman who drinks heavily or patients with severe medical, psychologic or social problems related to alcohol use. Even in these circumstances, resistance to direct advice is likely. When giving advice, physicians should avoid prescriptive directions. Instead, physicians can educate patients about the consequences in an objective manner: "Drinking affects the fetus in this way...." This information is most effective when it addresses issues that directly concern the patient.

Rollnick and colleagues¹⁸ have developed a menu of brief strategies for the primary caregiver, based on a model of counseling called "motivational interviewing" (Table 9).²⁰ In all patients, the physician should begin by directing the interview toward understanding the drinking behavior and how it fits into patients' lives. Among patients in the precontemplation stage, this assessment is the complete intervention. In the contemplation stage, the physician should explore patients' ambivalence toward change, including reasons to quit and reasons to continue drinking. At this point, patients may be receptive to information about the effects of alcohol. In the later stages, the physician may acquaint patients with helpful community resources such as Alcoholics Anonymous or formal treatment programs, and help them anticipate and prepare for temptations and setbacks.

The goal of these strategies is to help patients develop their own rationale for change and to nudge them in the direction of a healthier lifestyle. This nondirective approach removes the element of resistance because the patient does the work: the patient reflects on the ways alcohol fits into his or her life, weighs the personal costs and benefits of drinking, provides the arguments for change and makes the decision to quit drinking. The physician's job is simply to elicit information, encourage patients to reflect and support their movement toward healthy change.

TABLE 9 A Menu of Interviewing Strategies for Patients with Alcohol-Related Problems Strategies Stage of change Description Lifestyle, stresses and alcohol use Precontemplation Discuss lifestyle and life stresses "Where does your use of alcohol fit in?" Health and alcohol use Precontemplation Ask about health in general "What part does your drinking play in your health?" A typical day Precontemplation "Describe a typical day, from beginning to end. How does alcohol fit in?" "Good" things and "less good" things Contemplation "What are some good things about your use of alcohol? "What are some less good things?" Providing information Contemplation Ask permission to provide information Deliver information in a nonpersonal manner "What do you make of all this?" The future and the present Contemplation "How would you like things to be different in the future?" Exploring concerns Preparation or action Elicit the patient's reasons for concern about alcohol use List concerns about changing behavior Helping with decision-making Preparation or action "Given your concerns about drinking, where does this leave you now?" Information from Rollnick S, Heather N, Bell A. Negotiating behaviour change in medical settings: the development of brief motivational interviewing. J Ment Health 1992;1:25-37.

Final Comment

Excessive alcohol use can affect every part of a person's life, causing serious medical problems, family conflict, legal difficulties and job loss. Family physicians, with training in biomedical and psychosocial issues and access to family members, are in a good position to recognize problems related to alcohol use and to assist patients with lifestyle change. NIAAA provides simple guidelines for alcohol screening, based on a thorough drinking history and a sound understanding of the pattern of consequences. Physicians who are sensitive to these issues will find alcohol-use disorders easier to diagnose, and physicians who motivate their patients to reflect on their drinking will encourage recovery.

Each year members of a different family practice department develop articles for "Problem-Oriented Diagnosis." This series is coordinated by the Department of Family Practice at the University of Texas Health Science Center at San Antonio. Guest editors of the series are David A. Katerndahl, M.D., and Clinton Colmenares.

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The Authors

SANDRA K. BURGE, PH.D.,
is an associate professor and director of behavioral science education in the Department of Family Practice at the University of Texas Health Science Center at San Antonio. Dr. Burge received her doctorate in family social science from Purdue University, Lafayette, Ind.

F. DAVID SCHNEIDER, M.D., M.S.P.H.,
is an associate professor and director of medical student education in the Department of Family Practice at the University of Texas Health Science Center at San Antonio. He is a graduate of Boston University School of Medicine and served a residency in family practice at the Duke Family Practice Residency Program, Durham, N.C. Dr. Schneider also received a master's degree in public health from the University of Missouri, Columbia.

Address correspondence to Sandra K. Burge, Ph.D., Department of Family Practice, University of Texas Health Science Center­San Antonio, 7703 Floyd Curl Dr., San Antonio, TX 78284. Reprints are not available from the authors.

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