The Busy Physician's Five Minute Guide to the Management of Alcohol and Other Drug Problems

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Dimensions of the Problem

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.

Routine Screening

The CAGE questionnaire has been well documented to easily and effectively identify patients with alcohol abuse and dependence. The questions include:

Have you ever...
thought about	Cutting Down?
felt	Annoyed when others criticize drinking?
felt	Guilty about drinking?
used alcohol as an	Eye Opener?

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" or "occasionally."

Diagnostic Criteria

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:

• Tolerance.
  Needing more to feel the effects or less effect with the same amount.
• Withdrawal symptoms.
• Higher consumption or more drug use, and/or over a longer period, than intended.
• Desire or unsuccessful efforts to cut down.
• Considerable time spent in getting alcohol or drugs, drinking, or recovering from effects.
• Important social, work, or recreational activities given up because of use.
• Continued use despite knowledge of problems caused by or aggravated by use.

Abuse is marked by the following:

• Repeated failure to meet important responsibilities due to use.
• Recurrent use in situations when this likely to be physically dangerous.
• Legal problems arising from use.
• Continued to use despite recurrent problems aggravated by the substance use.
  And, never having met the criteria for dependence.

Therapeutic Interventions

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 treatment.

How to Make a Referral

• Use medical authority. Make it clear that alcohol and drug problems are a medical concern and outside resources are necessary to treat them; that it is a condition potentially too serious to disregard; that dependence is an illness; that the patient is not to blame for having an illness; and that successful treatment is possible.
• Provide support. Inform the patient about the resources for help; explain that you will continue to be available.
• Provide basic information. Make it explicit that alcohol and other substance are drugs and their use can lead to medial problems; that they can interfere with ability to accurately perceive what is going one; that use may have serious consequences on the patient's life, e.g. physical and emotional health, academic work, social activities, and family life.
• Inform family.
• Be active.
• Do not simply provide an agency name and phone number. Have your office set up a specific appointment.

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.

Follow-up. Schedule follow-up visits to monitor the patient's status and involvement in the treatment regimen, e.g., self-help groups or counseling.

If All Else Fails

There may be some occasions when all efforts to move the patient into alcohol treatment fail.
In these instances . . .

• Provide necessary medical care for the patient, whether related or unrelated to the alcohol use.
• Explain the underlying primary problem to the patient and family, and remains ready to arrange appropriate care and treatment.
• Encourage family members to enter formal treatment and use self-help groups (Al-Anon and Alateen) to minimize their distress and the problems of living with an alcohol-dependent person.
• Take steps to avoid enabling the dependent patient to continue drinking or using, e.g., not providing psychotropic medications for "nerves" or insomnia nor not authorizing sick leave.
• Be alert to the next crisis.

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.

revised: July 2002