Medical Care
A number of serious problems are closely linked to alcohol intoxication. In fact, according to the NIAAA, intoxication is present in 30% of homicides, 22% of suicides, and 33% of car crashes. Any patient who presents an imminent safety risk to themselves or another person should be considered a candidate for hospitalization. This may require the assistance of family members or medical consultation with a psychiatrist.
Many physicians believe no effective treatment is available for alcoholism; therefore, these physicians do not refer their patients for treatment. However, more than 13 studies representing more than 4000 patients demonstrate that brief interventions make a difference. Most of the patients in these studies drank heavily but did not yet have a problem with alcohol.
One study performed in Norway demonstrated that brief advice given early can affect gamma glutamyl transferase levels and reported alcohol consumption. Early warning makes a difference to persons who drink heavily. In a study of 200 workers with alcoholism, recalling a physician's warning about drinking at the beginning of the study was associated with a better prognosis 2 years later. Unfortunately, less than 25% had received warnings from their physicians, again illustrating the problem of missed diagnosis.
Alcoholism can also be categorized into 2 types: early-onset (biological predisposition to the disease) or late-onset (brought on by environmental or psychosocial triggers). Understanding and studying the difference between early- and late-onset alcoholism facilitate the selection of the appropriate therapy. Drugs that affect the rewarding behavior of neural activities, such as ondansetron, naltrexone, topiramate, and baclofen, have been shown to alter drinking behavior. [46]
A 2022 study, the largest clinical trial of its kind, found that two doses of psilocybin pills, along with psychotherapy, helped individuals with alcohol use disorder reduce drinking for at least eight months after their first treatments. Trial participants included 93 men and women ages 25 to 65 who were averaging seven alcoholic drinks at a time before the study. More than 80% of those who were given the psychedelic treatment had drastically reduced their drinking eight months after the study started, compared to just over 50% in the antihistamine control group. [47]
The first step in treatment is brief intervention. The physician states unequivocally that the patient has a problem with alcohol and emphasizes that this determination stems from the consequences of alcohol in that patient's life, not from the quantity of alcohol consumed. Emphasizing the effects on family, friends, and occupation, as well as any physical manifestations, is important. Pointing out that loss of control and compulsive use indicate alcohol dependence also is important.
Present the diagnosis. Use explicit evidence; emphasize the consequences endured by the patient as a result of alcohol abuse. Be empathic and nonjudgmental. Avoid arguments about the diagnosis. Avoid use of the word alcoholic.
Indicate the responsibility for change is with the patient. Listen to the patient's goals and point out discrepancies between his or her goals and actions.
Determine the patient's readiness for change. Motivating a reluctant patient is one of the great challenges in treatment. To enhance the prospects of successful treatment, the clinician needs to have a basic concept of the stages of change. The 5 stages of change (Prochaska,) provide fundamental guidance for enhancing motivation. The Substance Abuse and Mental Health Services Administration, the Center for Substance Abuse Treatment presents this concept in detail through a Treatment Improvement Protocol titled "Enhancing Motivation for Change in Substance Abuse Treatment." The 5 stages of change are precontemplation, contemplation, preparation, action, and maintenance. Specific strategies aligned with each of the 5 stages help a clinician motivate and prepare the patient for change. The 5 stages of change represent a cycle, permitting and explaining behavior that moves in both progressive and regressive directions.
In the precontemplation phase, the individual does not express any interest in the need for change. Many individuals with substance use problems are firmly entrenched in this stage. The options in dealing with patients in this stage are limited and include pointing out the discrepancy between patient action and patient goals, suggesting that the patient bring a family member to the next appointment, and suggesting a 2-week abstinence trial.
Contemplation represents the first evidence of dynamic behavior. The individual expresses a tentative belief in the possibility that alcohol use might be harmful. The hallmark of this stage is ambivalence and skepticism. Skepticism is not the same as denial but instead allows some degree of personal reflection. The patient is receptive to new information, or just as likely reassured that current behavior is acceptable, in the absence of information. Thus, the clinician should influence the ambivalence characteristic of contemplation in a direction favoring change. This can include pointing out that the patient's actions are not congruent with their goals, giving pamphlets concerning alcohol abuse, and suggesting an abstinence trial.
When the clinician successfully alters the balance in favor of a healthy choice, the patient enters the preparation stage. The preparation stage is a thoughtful phase focused on making plans.
The action stage of change represents full recognition of a problem along with observable evidence of steps taken to reduce alcohol use. The clinician should reinforce and praise the decision to change. Emphasizing that the biggest error at this stage is to underestimate the amount of help needed to quit drinking is critical. The patient should be given a list of options for treatment including AA and pharmacotherapy.
Maintenance is the final and most mature stage of change. During the maintenance stage, motivational efforts are directed toward promoting hard won gains and preventing slips. Relapse prevention efforts are sustained by the patient's appreciation of specific environmental and biobehavioral triggers, which contribute to recurrence. See Follow-up.
As mentioned previously, the stages of change represent a cycle permitting both forward and backward movement.
The physician must state firmly, but empathically, that alcohol is a problem for the patient and that the patient determines the solution. Patients come for treatment through several means, often from a mixture of both coercion and concern. The clinician needs to understand the extent of resistance to effectively work with the patient. A good strategy is to learn about patients' goals and indicate discrepancies between their goals and their choices. Pointing out discrepancies is more effective initially than statements such as, "You have to quit," or, "You have to go to AA."
The patient's response determines the physician's next step. If the patient denies the problem, recommending joining AA will not work. Involving the family and/or suggesting a trial of abstinence is useful, and, importantly, the physician should follow up with the patient in a few weeks. The patient might be angry initially and storm out of the office, but then the patient might recall the physician's warning months or years later and stop drinking. For patients who recognize a problem and will consider referral, the cheapest (free) and most accessible option is AA.
The AA 12-step approach involves psychosocial techniques used in changing behavior (eg, rewards, social support networks, role models). Each new person is assigned an AA sponsor (a person recovering from alcoholism who supervises and supports the recovery of the new member). The sponsor should be older and should be of the same sex as the patient (opposite sex if the patient is homosexual).
Patients do not need a strong religious background to be successful in AA; they only need the belief in a power higher than themselves. Urge patients to use aspects of the program that can help them stay sober and ignore aspects that are not helpful.
Patients who have tried AA may have had a bad past experience. Patients should try at least 5-10 different meetings before giving up on the AA approach because each meeting is different. For example, women often do better at meetings for women only because the issues for female patients with alcoholism are different from the issues for male patients with alcoholism. A meeting in the suburbs might not be appropriate for someone from the inner city and vice versa.
The physician should have AA literature in the office (dates and places of meetings), have the AA phone number available, and know about other treatment services in the community, including referrals for medical consultants or specialists in chemical dependency. No randomized trials of AA have been performed, but a US Veterans Administration study suggested that patients who attended meetings did much better than those who refused to go.
AA can be reached via their Web site (Alcoholics Anonymous) or by mail (AA General Service; PO Box 459; Grand Central Station; New York, NY 10163). Physicians can order pamphlets and other patient education material from these sources.
Additional sources of help include the Substance Abuse Treatment FACILITY LOCATOR, Self-Help Group Sourcebook Online, and SMART Recovery. The acronym SMART is for Self-Management and Recovery Training.
Treatment of alcoholism involves the following:
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Brief physician advice makes a difference.
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While a trial period of controlled drinking with careful follow-up might be appropriate for a diagnosis of alcohol abuse, this approach increases a physician's professional liability. Complete abstinence is the only treatment for alcohol dependence. Emphasize that the most common error is underestimating the amount of help that will be needed to stop drinking. The differential diagnosis between alcohol abuse and dependence can be a difficult judgment call.
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Hospitalize patients if they have a history of delirium tremens or if they have significant comorbidity. Consider inpatient treatment if the patient has poor social support, significant psychiatric problems, or a history of relapse after treatment.
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Strongly recommend AA.
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Encourage hospitalized patients to call AA from the hospital. AA will send someone to talk to them if the patient makes the contact. Patients need to attend meetings regularly (daily at first) and for a sufficient length of time (usually 2 y or more) because recovery is a difficult and lengthy process.
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In the beginning of treatment, and perhaps ongoing, patients should remove alcohol from their homes and avoid bars and other establishments where strong pressures to drink may influence successful abstinence.
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If the patient has an antisocial personality (ie, severe problems with family, peers, school, and police before age 15 y and before the onset of alcohol problems), recovery is less likely. If the patient has primary depression, anxiety disorder, or another potentially contributory disorder (the other disorder must antedate the problems with alcohol or it must be a significant problem during long periods of sobriety), treat this primary problem aggressively.
Strongly encourage family members of patients with alcoholism to contact Al-Anon and Alateen via its Web site (Al-Anon/Alateen) or mailing address (Al-Anon Family Group Headquarters; PO Box 182; Madison Square Garden Station; New York, NY 10159-0182).
Consultations
Consultation with a psychiatrist might be indicated in cases in which questions of suicide, violence, or comorbid psychiatric disorders might be present.
Diet
Persons with alcoholism often have a poor diet. Folate deficiency is common. Advise patients to eat plenty of fruits and vegetables and consider a multivitamin supplement. Supplemental enteral nutrition improves survival in persons with advanced liver disease.
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Deaths while intoxicated. Data from the National Institute on Alcohol Abuse and Alcoholism (NIAAA).
Tables
Questions |
0 Points |
1 Point |
2 Points |
3 Points |
4 Points |
1. How often do you have a drink containing alcohol? |
Never |
Monthly or less |
2-4 times a month |
2-3 times a week |
4 or more times a week |
2. 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 |
7-9 |
10 or more |
3. How often do you have 6 or more drinks on 1 occasion? |
Never |
Less than monthly |
Monthly |
Weekly |
Daily or almost daily |
4. How often during the past 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 |
5. How often during the past year have you failed to do what was normally expected of you because of drinking? |
Never |
Less than monthly |
Monthly |
Weekly |
Daily or almost daily |
6. How often during the past 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 |
7. How often during the past year have you had a feeling of guilt or remorse after drinking? |
Never |
Less than monthly |
Monthly |
Weekly |
Daily or almost daily |
8. How often during the past 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 |
9. Have you or has someone else been injured as a result of your drinking? |
No |
|
Yes, but not in the past year |
|
Yes, during the past year |
10. Has a relative, friend, or a doctor or other health care worker been concerned about your drinking or suggested you cut down? |
No |
|
Yes, but not in the past year |
|
Yes, during the past year |
Biomarker |
Sensitivity (%) |
Specificity (%) |
AST |
15-69 |
47-68 |
ALT |
18-58 |
50-57 |
GGT |
34-85 |
11-95 |
MCV |
34-89 |
26-95 |
CDT |
39-94 |
82-100 |
CDT + GGT |
90 † |
98 |
Alcohol |
0-100 |
0-100 |
EtG |
76-91 |
77-92 |
*Values vary considerably according to gender, age, drinking pattern, prevalence of alcohol abuse/dependence, and prevalence of comorbidity, among other factors. [40, 6, 41, 43, 44] † The sensitivity comes from one study in Finland, which uses a special formula. This study needs to be replicated. [45] |
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