Effects of Alcohol Abuse

Questions to ask the ADULT patient
The National Institute on Alcohol Abuse and Alcoholism (NIAAA) has developed the following low-risk drinking guidelines:

• For men, drinking no more than two drinks a day and no more than four drinks on a single occasion.

• For women and patients over 65 years of age, drinking no more than one drink a day and no more than three drinks on a single occasion.
• Pregnant patients and those with medical problems complicated by alcohol use should abstain completely (NIAAA, 1995).

At sometime during the first interview, certain questions need to be asked to assess alcohol problems. They have to be answered honestly to give you a clear picture of the extent of the drinking. Most patients who have alcohol problems will be evasive or deny their alcohol abuse, so the questions should be asked of the patient, as well as a reliable family member.
The following questions and flags are taken from the American Society of Addiction Medicine (https://www.asam.org):
1. Have you ever tried to cut down on your drinking?
2. Have you ever felt annoyed when someone talked to you about your drinking?
3. Have you ever felt bad or guilty about your drinking?
4. Have you ever had a drink in the morning to settle yourself down?
5. Has alcohol or drugs ever caused you family problems?
6. Has a physician ever told you to cut down on or quit use of alcohol?
7. When drinking/using drugs, have you ever had a memory loss (blackout)?
If patients answer yes to any one of these questions that’s a red flag for alcoholism. If they answer yes to two questions, that’s probable alcoholism. Make sure you don’t just ask the patient. Ask family members, friends and anyone else who can give you collateral information. Table 1.1 – Patient History/Behavioral Observation Red Flags for Adult Alcohol Abuse

• Tremor/perspiring/tachycardia.
• Evidence of current intoxication.
• Prescription drug seeking behavior.
• Frequent falls; unexplained bruises.
• Diabetes, elevated BP, ulcers non-responsive to treatment.
• Frequent hospitalizations.
• Gunshot/knife wound.
• Suicide talk/attempt; depression.
• Pregnancy (screen all).

Table 1.2 Laboratory Red Flags for Adult Alcohol/Drug Abuse

• MCV-over 95
• MCH-High
• GGT-High
• SGOT-High
• Bilirubin-High
• Triglycerides-High
• Anemia
• Positive UA for alcohol

[INSERT TABLE 1.2 PAGE 21]
Table 1.3 – Patient History/Behavioral Observation Red Flags for Adolescent Alcohol Abuse

• Physical injuries; MVA, gunshot/knife wound, unexplained or repeated

       injuries.

• Evidence of current use, e.g. dilated/pinpoint pupils, tremors, perspiring,

tachycardia, slurred/rapid speech.

• Persistent cough (cigarette smoking is a risk factor).
• Engages in risky behavior, e.g. unprotected sex.
• Marked fall in academic/extracurricular performance.
• Suicide talk/attempt; depression.
• Sexually transmitted diseases.
• Staphylococcus infection on face, arms, legs.
• Unexplained weight loss.
• Pregnancy (screen all).

Table 1.4 Laboratory Red Flags for Adolescent Alcohol/Drug Abuse

• Positive UA for alcohol/illicit drugs
• Hepatitis A-B-C
• GGT-High
• SGOT-High
• Bilirubin-High

Table 1.5 - INTERVIEW questions for suspected alcoholism among adolscents
Questions to ask the Adolescent Patient

• When did you first use alcohol on your own, away from       family/caregivers?
• How often to you use alcohol? Last use?
• How often have you been drunk or high?
• Has your alcohol use caused you problems with: your friendships, family, school, community? Have your grades slipped?
• Have you had problems with the law?
• Have you ever tried to quit/cut down? What happened?
• Are you concerned about your alcohol use?

Questions to ask the Parent/Caregiver

• Do you know/suspect your child is using alcohol/other drugs?
• Has your child’s behavior changed significantly in the past six months?

(e.g., sneaky, secretive, isolated, assaultive, aggressive, hostile)

• Has school, community or legal system talked to you about your child?
• Has there been a marked fall in academic/extracurricular performance?
• Do you believe an alcohol/other drug assessment might be helpful? End table 1.5

What to Do If There are One or More Red Flags
Once you have one or more red flags, you have several important actions to take.

• Advise the patient of the risk.
• Advise abstinence or moderation. Men should be advised to drink no more than three drinks at a time and no more than three nights a week. Women should be advised to drink no more than two drinks at a time and no more than three nights per week. More drinking than this will result in progression of the disease. This is a harm reduction approach where you teach a patient how to drink responsibly. This would not be appropriate for someone who has a serious drinking problem. People who are chemically dependent cannot cut down on their use because they are chemically dependent.
• Advise against any illegal drug use.   
• Schedule a follow-up visit to monitor progress.

Natural History of Alcoholism
Alcoholism develops slowly over a patient’s lifetime and it can begin at any age. It often occurs in individuals with no history of psychological problems. When the substance causing addiction is readily available, inexpensive, and rapid acting, abuse will increase. Whenever the individual is ignorant of healthy alcohol use, susceptible to heavily using peers, or has a high genetic predisposition to abuse or to antisocial personality disorder, abuse may increase. This is also true if the patient is poorly socialized into the culture, in pain, or if the culture makes the substance the recreational drug of choice.
Risk Factors
Risk factor 1: Alcohol is readily available.
Risk factor 2: Alcohol is cheap.
Risk factor 3: Alcohol reaches the brain quickly.
Risk factor 4: Alcohol is effective as a tranquilizer.
Risk factor 5: Alcoholism is more common in certain occupations (bartending).
Risk factor 6: Drinking peer group.
Risk factor 7: Alcohol is preferred in deviant subcultures.
Risk factor 8: Social instability.
Risk factor 9: Genetic predisposition.
Risk factor 10: Dysfunctional families.
Risk factor 11: Comorbid psychiatric disorders (Vaillant, 2003).
How to diagnose an alcohol problem
            In the assessment, you must determine if the patients fit into your range of experience and care. Do you have the ability to help them with their problem or do you need to refer? Do they have a problem with chemicals? Are they motivated to get better? Do they have the resources necessary for treatment? Are they well enough to see you? For the most part, you will start by asking yourself certain basic questions: Does this person have a problem with alcohol? Does she or he need treatment? Is he or she motivated for treatment? What kind of treatment does she or he need? For the benefit of third party payors, it is important to use assessment instruments to properly document (1) diagnosis, (2) severity of addiction, and (3) motivation and rehabilitation potential. Reviewers will often have more faith in a test battery than your clinical opinion. 
There are a number of companies that sell inexpensive, disposable breathalyzers and drug screening instruments, including Prevent (1-800-624-1404); Bi-TechNostix (1-888-339-9964); Random Drug Screens, Inc. (1-803-772-0027); Drug Screens, Inc. (1-800-482-0693) and many others. Order a number of these tests and have them readily available for assessment, treatment and continued care monitoring. Positive tests are only suggestive of drug and alcohol use so before any legal or workplace action is taken, the test should be confirmed by both an approved immunoassay and gas chromatography/mass spectrometry, which can be administered and analyzed by a healthcare provider (? Ron—where do you get these results?). 
Two quick screening tests for alcoholism have been developed: the Short Michigan Alcoholism Screening Test SMAST (Appendix 2) and the CAGE Questionnaire (Appendix 1), (Journal of Studies on Alcohol, 1975; Ewing, 1984). The SMAST is a 13-question version of the original Michigan Alcoholism Screening Test (MAST). The SMAST has been shown to be as effective as the MAST. It has greater than 90% sensitivity to detect alcoholism. It can be administered to either the patient or the spouse.
The Substance Abuse Subtle Screening Inventory (SASSI) (1-800-726-0526) (https://www.sassi.com) was developed to screen patients when defensive and in denial. The SASSI measures defensiveness and the subtle attributes that are common in chemically dependent persons. It is a difficult test to fake, unlike the MAST or the CAGE. Patients can complete the SASSI in ten to 15 minutes, and it takes a minute or two to score. It identifies accurately 98% of patients who need residential treatment, 90% of non-users, and 87% of early stage abusers. This is a good test for those patients with whom you are still unsure about the diagnosis after your first few interviews, patients who continue to be evasive (G. A. Miller, 1985).
The Addiction Severity Index (ASI) and the Teen-Addiction Severity Index (T-ASI) (1-215-399-0980) are widely used, structured interviews for adults and teens, which are designed to provide important information about the severity of the patient's substance abuse problem. These instruments assess seven dimensions typically of concern in chemical dependency, including medical status, employment/support status, drug/alcohol use, legal status, family history, family/social relationships, and psychiatric status. The tests are designed to be administrated by a trained technician and take about an hour. The ASI is an excellent tool for delineating the patient’s case management needs (McLellan, Luborsky & Woody, 1980; Kaminer, Bukstein, & Tarter, 1991).
The Adolescent Alcohol Involvement Scale (AAIS) is a 14-item, self-report questionnaire that takes about 15 minutes to administer. It evaluates the type and frequency of drinking, the last drinking episode, reasons for the onset of drinking behavior, drinking context, short- and long-term effects of drinking, perceptions about drinking and how others perceive his or her drinking (Mayer & Filstead, 1979).
The Adolescent Drinking Index (ADI) (1-813-968-3003) is a 24-item, self-administered test that evaluates problem drinking in adolescents through assessment of psychological symptoms, physical symptoms, social symptoms and loss of control (Harrell, Honaker & Davis, 1991).
The RAATE-CE (Mee-Lee, Hoffman & Smith, 1992) (1-800-755-6299) is a 35-item scale that assesses treatment readiness and examines patient awareness of problems, behavioral intent to change, capacity to anticipate future treatment needs and medical, psychiatric or environmental complications. The RAATE-CE determines the patient’s level of acceptance and readiness to engage in treatment and targets impediments to change.
How to Intervene

• Non-Problem Usage: If the patient does not drink or is within the low-risk consumption, you should provide positive prevention messages that support the patient’s continued positive lifestyle. Patients with a positive family history of alcoholism should be warned about their increased vulnerability to alcoholism and the need for vigilance.
• Problem Drinking/Drug Usage: The patient who has had recurrent problems due to alcohol use should be encouraged to abstain from, or at least reduce, his or her alcohol use. Such patients should be strongly encouraged to abstain from all illegal drugs. You should discuss the biopsychosocial complications of alcohol abuse (see Appendix 9). Patients that are encouraged to cut down on their drinking should be provided with the brochure from NIAAA (see Appendix 10). It is essential that these patients be reassessed frequently to monitor their ability to comply with your recommended limits.
• Alcohol or Other Drug Dependence: Alcoholics need to have their diagnoses carefully discussed with them and a treatment plan negotiated. You need to be empathic and address the problems that seem to be caused by or exacerbated by their alcohol use. Patients need to hear that this illness is not their fault and that there is excellent treatment available that will help them to stay clean and sober. Patients need to hear that only 4% of addicts can quit on their own over the course of a year, but 50% can quit over the course of a year if they go through treatment. Seventy percent can quit over the course of a year if they also attend AA meetings regularly and 90% can stay sober if they go through treatment, attend meetings, and go to aftercare once a week for a year (Hoffman & Harrison, 1987; Hoffmann, 1991; Hoffmann, 1994). Patients should also be told about the potential benefits of naltrexone and disulfiram when used along with formal treatment programs. Carefully discuss the ASAM patient placement criteria to help you and the patient negotiate the best treatment plan possible to bring the alcohol problem under control. The following questions may be helpful in negotiating a treatment plan:
1. Is the patient a danger to self or others? (Suicidal and homicidal ideation, impaired judgment while intoxicated, history of delirium tremens.)
2. Has the patient ever been able to stay sober for three or more days?
3. What happened when the patient stopped drinking in the past? How serious were the withdrawal symptoms?
4. Has the patient ever been able to stay completely abstinent for long periods of time?
5. Why did previous attempts at sobriety fail?
6. How does the family understand alcoholism and its treatment?

Table 1.6 – Positive and Negative Prognostic Factors
Positive Prognostic Factors

• Lack of physical dependence.
• Intact family.
• Stable job.
• Presence of prior treatment (prognosis improves for patients who have been through one to three treatments).
• Absence of psychiatric disease.
• Presence of long-term monitoring arrangement, like a Physician Effectiveness Program or Employee Assistance Program.

Negative Prognostic Factors

• More severe, advanced dependency.
• Presence of intoxication at office visits.
• Loss of job.
• Loss of home.
• Loss of family.
• Multiple, unsuccessful attempts at treatment.
• Severe physiological dependence.
• Co-existing psychiatric disorders.
• Absence of long term monitoring (Conigliaro, Reyes, Parran & Schultz, 2003).