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The Busy Physician's Five Minute Guide to the Management of Alcohol and Other Drug Problems
Alcohol is among the most widely "self-prescribed" drug; approximately 75% of all adults and adolescents use alcohol. Moderate alcohol use may to contraindicated in light of an individual's health status be it pregnancy or presence of hypertension. A safe dose or safe pattern of use is not constant across individuals, nor constant for a single individual through his or her lifetime. In addition to complicating other conditions, alcohol use may become a primary problem -- be it alcohol abuse or dependence.
A minimum of 25% of al hospitalized patients have a significant alcohol problem, regardless of admitting diagnosis or presenting problem. An estimated 20% or patients in a primary care or family practice have a significant alcohol problem. Identifying these patients is important to treat them medically and to treat the substance abuse.
Other drug use is also a national problem with multiple
presentations, whether over-the-counter drug use in the elderly, the
recent emergence of "chasing the dragon" (smoking heroin) which
rapidly leads to dependence, or the role of intra-venous drug use in
the transmission of HIV/AIDs.
The CAGE questionnaire has been well documented to easily and
effectively identify patients with alcohol abuse and dependence. The
In scoring the CAGE, each positive response equals 1 point. Two or
3 points is highly suggestive of alcohol dependence, and requires
further evaluation, especially if cutting down is included.
Four points is diagnostic.
The Medical Record
Alcohol or drug use should be described in the medical record so
that changes in use can be detected over time. Notes in the chart
should include sufficient objective detail to provide meaningful data
to other clinicians. Avoid one word descriptions such as "socially"
The diagnosis of psychoactive substance use and dependence is made primarily on the basis of medical and social history. The earliest symptoms are always behavioral. Unlike other chronic diseases, there are no pathognomonic physical signs or symptoms to signal a transition from health to disease.
The hallmark sign is the presence of negative consequences that
have resulted from use. No constellation of problems is uniquely
associated with dependence; the significant problem is the multiple
difficulties attributed to substance use. For example, it is highly
probable the individual who has four or more problems associated with
alcohol use will also meet formal diagnostic criteria.
DSM-IV Diagnostic Criteria
Dependence is present when any three of the following seven items have been present for 12 months:
If uncertain as to the presence, or the extent or nature of an alcohol or drug problem, refer for further evaluation. Proceed as with any other potentially serious medical problem. Explain the need for further evaluation or consultation. Provide reassurance and hope, noting that you are making a referral for further evaluation to someone you and the patient can trust.
If an alcohol-related incident has occurred, but there is neither abuse nor dependence, specific risk reduction &emdash; health maintenance efforts should be initiated. This effort entails that either a physician specialist or a substance abuse clinician review with the patient and his or her drinking practices, health status, life-style, and activities associated with drinking, to identify high risk factors, and adopt a plan to reduce risks.
For other drug use that is not socially sanctioned and entails a
substantial risk for abuse or dependence, a referral is warranted. If
alcohol or drug abuse or dependence is present, refer the patient for
How to Make a Referral
How to Select a Treatment Program
Seek a specialized substance abuse treatment program. Treatment is
generally multi-modal -- involving group, individual, and family
therapies plus patient education -- which requires a treatment team.
Collaborating in Care
Provide support. Request a report from any treatment
agency, including specific treatment recommendations. Be prepared to
reinforce the need for compliance with patient and family. Lend your
medical authority to alcohol and drug abuse treatment efforts.
If All Else Fails
There may be some occasions when all efforts to move the patient
into alcohol treatment fail.
Adapted from Kinney J. The busy physician's guide to
alcohol problems. Chicago: American Medical Association, 1988.
Distributed nationally by the AMA in collaboration with the National
Institute on Alcohol Abuse and Alcoholism.