The NIAAA (National Institute on Alcohol Abuse and Alcoholism) has recently posted a practical guide for professionals interested in improving their skills in evaluating and treating patients with alcohol problems. The guide is free, is posted on the NIAAA website, and a CME activity based on the guide is available through Medscape (http://www.medscape.com/viewprogram/ 6771). You can also print out a concise pocket guide, though be prepared to reach for a magnifying glass if you want to actually read it. Here are some useful tips for treating alcoholism, adapted both from the NIAAA and other sources.
1. Ask about quantity of drinking. While DSM-4 does not specify a minimum quantity of drinking required to meet the diagnosis of alcohol abuse or dependence, the NIAAA guide suggests that you ask about specific threshold amounts. Patients who exceed the thresholds are at much higher risk of developing drinking problems, according to epidemiological studies. Males should drink no more than 4 standard drinks per day and no more than 14 drinks per week; women should drink no more than 3 drinks per day and no more than 7 per week. The pocket guide includes a useful chart clearly defining the sizes of “standard drinks.” For example, a standard drink of table wine is 5 ounces, and there are 5 such drinks in a typical wine bottle.
2. Assess whether there is a DSM-4 alcohol use disorder. For alcohol abuse, you are looking for evidence that drinking has caused any kind of significant problem, such as physical harm, relationship or work trouble, or legal issues. For alcohol dependence, you can use my mnemonic “Tempted With Cognac” to assess for the presence of Tolerance (needing to drink more to achieve the same high), Withdrawal symptoms, or loss of Control over drinking (continued drinking despite problems). The NIAAA booklet has a handy checklist to guide you through the official criteria.
3. Make an anti-drinking statement. If you diagnose an alcohol use disorder, or if the patient is drinking beyond the thresholds, you should state your concerns in no uncertain terms: “You’re drinking more than is medically safe…you need to cut down.” Ask about motivation: “Are you ready to commit to cutting down your drinking?” The booklet cites evidence that brief physician advice helps patients cut down. In one trial, patients assigned to brief physician advice drank significantly less than patients in the control group, even when followed for 4 years (Fleming MF et al., Alcohol Clin Exp Res 2002;26:36-43).
4. Come up with a decrease drinking plan. These suggestions are based on a harm reduction model, rather than an abstinence model such as that of AA.
• Encourage patients to keep track of their drinking on a 3 X 5 index card they can keep in their pocket.
• Come up with specific and realistic goals, such as a 10% to 20% reduction in drinks per week.
• Encourage patients to schedule a day or two every week as a no drink day. Encourage them to eat before drinking, which will reduce alcohol absorption.
• Help them identify triggers to drinking and strategies to avoid them. If the trigger is coming home after work, potential strategies include: go to the gym first; keep no alcohol in the house; drink a smoothie or other nonalcoholic treat right away.
TCPR VERDICT: Basic advice, but crucial for success