DIAGNOSIS AND MANAGEMENT OF ALCOHOL PROBLEMS

Abstract

Approximately 14 million Americans suffer from alcohol abuse and dependence, 14 and drinking remains the most common cause of liver-related mortality in the United States. Forty-four percent of the 26,000 annual deaths from liver cirrhosis are attributed to alcohol use. Even this is likely to be an underestimate because certifying physicians may not be familiar with the decedent's drinking history or may desire to protect the family from the stigma of a family member being an alcoholic. 10 Alcoholic liver disease is also an important cause of morbidity. It has been estimated that between 15% and 30% of heavy drinkers develop advanced liver disease. 19 In 1990, cirrhosis was listed as a diagnosis on approximately 1% of discharges from nonfederal short-stay hospitals for those 15 years and older and was the principal diagnosis for 0.2% of the discharges. Underestimation of alcoholic liver disease on hospital discharge records may exceed that for death certificates. 37 Because of the adverse effects of alcohol on the liver, alcohol-dependent and alcohol-abusing patients commonly are seen in many hepatologists' practices. Although findings on the physical examination and laboratory tests may provide clues, the diagnosis of alcoholism depends on the history provided by patients and their relatives. The two most commonly employed sets of criteria are the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders , ed 4 (DSM-IV) 1 and in the World Health Organization's International Classification of Diseases , 10th rev (ICD-10). 36 Both are based on symptoms of alcohol dependence and abuse rather than specific thresholds of drinking frequency, quantity, or patterns. The term alcoholism has been dropped in favor of two distinct categories— alcohol abuse and alcohol dependence. Alcoholic liver disease can result from either. It also can result from heavy drinking itself, even if the patient does not satisfy criteria for a diagnosis of abuse or dependence. The symptoms of alcohol dependence include tolerance, withdrawal, impaired control, neglect of activities, time spent drinking, and drinking despite problems. A diagnosis of alcohol dependence by the DSM-IV criteria requires that three or more of the following symptoms occur during the previous 12-month period: Tolerance denotes the need for markedly increased amounts of alcohol to achieve the desired effect or intoxication, or a markedly diminished effect with the continued ingestion of the same amount of alcohol. Withdrawal is the occurrence of an acute alcohol withdrawal syndrome . Alcohol (or other drugs in the alcohol–sedative group) may be ingested to relieve or avoid the symptoms associated with the abrupt cessation of drinking. Impaired control is divided into two categories. The first implies one or more unsuccessful efforts to cut down or control one's drinking. The second involves drinking in larger amounts or over longer periods of time than a person initially intended. Neglect of activities refers to the reduction of important social, occupational, or recreational activities because of drinking. Time spent drinking emphasizes the fact that inordinate periods of time are spent in obtaining alcohol, drinking, or recovering from the effects of alcohol. Drinking despite problems refers to the common occurrence in which the individual continues to drink despite knowing that he or she suffers a persistent or recurrent physical or psychological problem caused or exacerbated by drinking alcohol. The ICD-10 contains the additional criterion of a strong desire or sense of compulsion to drink. Alcohol abuse is defined by the DSM-IV as a maladaptive pattern of alcohol use leading to clinically significant impairment as manifested by one or more of the following symptoms during a 12-month period: 1 Recurrent drinking resulting in a failure to fulfill major obligations at work, home, or school 2 Recurrent drinking in situations that are physically hazardous 3 Recurrent alcohol-related legal problems 4 Continued use of alcohol despite having persistent or recurrent social or interpersonal problems caused by or exacerbated by drinking alcohol Additionally, the symptoms have never met the criteria for alcohol dependence. The ICD-10 analogue to alcohol abuse is labeled “harmful use” of alcohol and is defined as a pattern of drinking disruptive to physical or mental health. Although it is important to make a precise diagnosis, it usually is best not to proceed immediately to asking the patient about the symptoms of alcohol dependence or abuse. One usually begins by obtaining a more general drinking history. To obtain valid answers, it has been suggested that the drinking history should be couched in questions about health risk or promotion activities. The questions should be open ended rather than those that are likely to elicit yes or no responses and should be asked in an empathetic manner. Doing a formal diagnostic interview can be time consuming. Fortunately, practical screening tests for alcohol dependence and abuse consisting of only a few questions have been developed. These require only a few minutes to do and may be very helpful in indicating an alcohol problem at an initial visit. Depending on the circumstances, a formal diagnostic interview can await a subsequent visit. A diverse array of these brief screening tests has been developed. 23 The most commonly used are the CAGE, 21 the Michigan Alcoholism Screening Test (MAST), 32 and the Short MAST (SMAST). A new screening test with some potential advantages is the Alcohol Use Disorders Identification Test (AUDIT). 3 The CAGE questionnaire consists of only four items: 1 Have you ever felt you should C ut down on your drinking? 2 Have people A nnoyed you by criticizing your drinking? 3 Have you ever felt bad or G uilty about your drinking? 4 Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover ( E ye opener)? In general, the cut-off for the CAGE is two positive responses, but some authors recommend a cut-off at a single affirmative response. 11 The major advantage of the CAGE is brevity. Having only four items, it is convenient for the busy physician. Further, the acronym for the test makes it easy for practitioners to remember the items that constitute it and to integrate them into a clinical interview. A limitation of the CAGE questionnaire is that it does not ask about quantity and frequency of drinking. Also, because no time frame is given for the items, positive responses must be followed up by questions to establish whether the reported symptom is current or occurred in the past and is no longer present. Because the items of the CAGE seem to presuppose a fairly long history of drinking, the measure may be less useful with younger patients. CAGE scores appear to be more related to a formal diagnosis of alcohol dependence rather than the amount and frequency of alcohol consumption. 20 Finally, because the first three questions focus on emotional and perceived social reactions to drinking, individuals who are less emotionally perceptive or those living in heavy-drinking social environments may be more inclined to respond negatively to the items. Buchsbaum and colleagues 6 evaluated the CAGE as a screening tool in the Medical College of Virginia's ambulatory medicine clinic. They used the criteria in the previous version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R) as the gold standard for alcohol abuse and dependence. Overall, 36% of their sample (821 patients) met criteria for a history of dependence or abuse. Forty-six percent of the men and 14% of the women met the criteria for dependence, and 17% of the men and 9% of the women met the criteria for abuse. A CAGE score of two or more was reasonably sensitive (71%) and quite specific (91%). They also found that the higher the CAGE score, the greater the probability of alcohol dependence. Nearly as popular as the CAGE is the MAST. The MAST is considerably longer, although a variety of shorter versions (e.g., SMAST) have been constructed, reducing its 25 items to a more manageable number. Again, as with the CAGE, the MAST itself does not ask the questions in relation to time of occurrence. The MAST has also been criticized for its heavy emphasis on late-stage symptoms of alcoholism, such as having delirium tremens or directly seeking alcohol treatment. Finally, the MAST assigns varying points (1–5) for different questions. To our knowledge, this scoring system has not been validated on a sample other than the one originally used to test the MAST. From a psychometric perspective, this is a limitation of the MAST. Another theoretic limitation is that one incident with more than one consequence (e.g., being both injured and arrested in an alcohol-related traffic accident) will yield a MAST score high enough for the presumption of alcoholism. In their review of screening tests for alcohol problems, Maisto 20 found five studies comparing the CAGE and MAST and four comparing the CAGE and SMAST. Sensitivities and specificities for the CAGE ranged from 0.48 to 1.00 and 0.61 to 0.99, respectively. For the MAST, the ranges for sensitivity and specificity were 0.69 to 1.00 and 0.62 to 0.91, respectively. In part, this variability appears to be related to the studies being done in different settings (e.g., general medical clinic or alcohol traffic offense assessment agencies) and sampling different types of patients (e.g., male inpatients or urban prenatal clinic patients). Although not consistent across all studies, the MAST was generally found to be more sensitive than the CAGE. Maisto concluded that the CAGE and SMAST appeared to perform comparably. A newer screening test is the AUDIT. At least at face value, it appears useful for medical settings because it contains questions inquiring about alcohol consumption as well as consequences of drinking. The AUDIT consists of 10 multiple-choice questions and is shown below. Seven of the items deal with the past year. The first three questions of the AUDIT assess quantity, frequency, and peak intensity of drinking. The AUDIT is scored by summing the weights associated with the response selected for each item. The usual cut-off is 8 points. Special efforts were made in constructing the AUDIT to develop an unbiased gender and ethnic screening test. AUDIT scores have also been found to correspond well with reports of significant others about the patient's drinking. In addition, responses on the AUDIT can serve as the basis for treatment (see section on brief interventions). Showing the patient how his or her drinking behavior compares with that of the general population may well motivate change, for example. Feedback on this information might include pointing out health risks associated with drinking in this manner. The Alcohol Use Disorders Identification Test How often do you have a drink containing alcohol? Never Monthly or less Two to four times a month Two to three times a week Four or more times a week How many drinks containing alcohol do you have on a typical day when you are drinking? 1 or 2 3 or 4 5 or 6 7 or 9 10 or more How often do you have six or more drinks on one occasion? Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year have you found that you were not able to stop drinking once you had started? Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year have you failed to do what was normally expected from you because of drinking? Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year have you had a feeling of guilt or remorse after drinking? Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year have you been unable to remember what happened the night before because you had been drinking? Never Less than monthly Monthly Weekly Daily or almost daily Have you or someone else been injured as a result of your drinking? No Yes, but not in the last year Yes, during the last year Has a relative, friend, doctor, or other health worker been concerned about your drinking or suggested that you should cut down? No Yes, but not in the last year Yes, during the last year Israel and his colleagues 15 developed a brief, five-question, trauma questionnaire that they believe is nonintrusive (only the last question refers to alcohol). They believe that their questionnaire is more suitable for medical practice because it gives physicians a clinically valid reason to ask about alcohol use (i.e., as a possible factor involved in trauma). In the past five years: 1 Have you had any fractures or dislocations to your bones or joints? 2 Have you been injured in a road traffic accident? 3 Have you injured your head? 4 Have you been injured in a fight or assault? (Do not count injuries during sports.) 5 Have you been injured while or after consuming alcoholic beverages? In their most recent report they used the following protocol: When the patient arrived at the office, the receptionist gave the patient a form containing the first four (alcohol neutral) questions. If the patient answered yes to one or more of the four questions, the physician asked the patient the fifth question. If the patient answered positively to any two or more of the questions, the physician next asked about alcohol consumption. Patients who drank 56 more drinks in 4 weeks (≥ 2 drinks/day on average) or drank five or more drinks per day four or more times in a 4-week interval were administered the CAGE questionnaire. They reported that their screening system identified approximately 70% of problem drinkers. They further report that this system was acceptable to most of the 42 physicians participating in their study. Although this is an alternative method to consider, it must be noted that this method has not been evaluated by others.