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US Public Health Service. Office of Disease Prevention and Health Promotion. Clinician's Handbook of Preventive Services. 2nd edition. Washington (DC): Department of Health and Human Services (US); 1999.

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

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Clinician's Handbook of Preventive Services. 2nd edition.

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53Alcohol and Other Drug Abuse

Substance abuse, defined as the harmful or hazardous use of alcohol, tobacco, or other legal and illegal drugs, is a leading cause of death and disability in United States. Alcohol and drug abuse are physically damaging and are associated with other leading causes of death, including accidents, suicide, homicide, and HIV infection.

Alcohol abuse is estimated to cost society approximately $85.8 billion annually -- nearly twice as much as the abuse of all other drugs combined. Alcohol abuse alone is associated with a dramatic proportion of traffic fatalities (41%), drownings and murders (67%), deaths in fires (70% to 80%), and suicides (35%). Consumption of alcohol during pregnancy can lead to development of fetal alcohol syndrome (FAS), which can produce a variety of deleterious effects ranging from physical anomalies to mental impairment to more subtle cognitive and behavioral dysfunctions. According to the Centers for Disease Control and Prevention an estimated 1 in 3,000 births are affected by FAS each year (Selected References).

Abuse of drugs other than alcohol is estimated to cost society approximately $47 billion per year. Illicit drug use contributes to both social and medical problems. An estimated 5.5 million Americans are affected by drug abuse or dependence, half of whom are within the criminal justice system. Injection drug use and use of crack are major contributors to the spread of HIV. Drug use is also integrally related to problems such as accidents, homicide, and suicide. Estimates of the extent of prescription drug misuse vary, but there is little doubt that misuse of legal medications is responsible for a significant portion of the morbidity and mortality associated with substance abuse. One authority indicates that a 60% to 70% of patients treated in emergency rooms for drug-related episodes are misusing prescription drugs.

According to the National Institute on Drug Abuse, the overall prevalence of drug use does not differ between Caucasian, African American, and Hispanic populations although patterns of use may differ. Primary care providers often fail to recognize alcohol and drug abuse problems in their patients. Some studies report detection rates as low as 30%. Minimal interventions by primary care clinicians, such as advice to modify current use patterns and warnings about adverse health consequences, can have beneficial effects, especially for patients in the early stages of addiction. More intensive interventions, such as referral to outpatient or inpatient/residential treatment facilities, can be life-saving for patients in more advanced stages of alcohol and other drug dependence.

See chapter 18 for information on counseling children and adolescents on alcohol and other drug abuse. See chapter 24 for information on counseling children and adolescents about tobacco use prevention and chapter 60 for information about counseling adults on smoking cessation.

Recommendations of Major Authorities

  • American College of Obstetricians and Gynecologists --
  • Women should be asked about their use of alcohol and other drugs.
  • American College of Physicians --
  • The physician's role in recognizing and treating chemical dependence requires knowledge of the symptoms of chronic and excessive drug use and increased sensitivity to and awareness of behavior associated with such problem use. The physician's role in preventing chemical dependency includes patient education and counseling about the appropriate use of substances upon which dependence is likely. Thoughtful and knowledgeable prescribing practices that minimize the likelihood of producing or maintaining iatrogenic chemical dependence are essential.
  • American Medical Association --
  • All physicians with clinical responsibility for diagnosis of and referral for alcoholism and drug abuse problems should be able to recognize alcohol or drug-caused dysfunction and should be aware of the medical complications, symptoms, and syndromes with which alcoholism or drug abuse commonly presents. All complete health examinations should include an in-depth history of alcohol and other drug use. The physician should evaluate patient requirements and community resources so that an adequate level of care may be prescribed, with patients' needs matched to appropriate resources and with referrals made to a resource that provides appropriate medical care.
  • Canadian Task Force on the Periodic Health Examination --
  • Routine active case-finding of problem drinking is highly recommended on the basis of the high prevalence of this problem among patients in medical practices, its association with adverse consequences before the stage of dependency is reached, and its amenability to a counseling intervention by clinicians. Detection of biomarkers is not recommended, although this may be useful to confirm suspicions raised by use of patient administered questionnaires (eg, Alcohol Use Disorders Identification Test [AUDIT], the Michigan Alcoholism Screening Test [MAST] and the Drug Abuse Screening Test [DAST]).
  • US Preventive Services Task Force --
  • Screening to detect problem drinking is recommended for all adult and adolescent patients. Screening should involve a careful history of alcohol use and/or the use of standardized screening questionnaires. Routine measurement of biochemical markers is not recommended in asymptomatic persons. Pregnant women should be advised to limit or cease drinking during pregnancy. Although there is insufficient evidence to prove or disprove harm from light drinking in pregnancy, recommendations that women abstain from alcohol during pregnancy may be made on other grounds. All persons who use alcohol should be counseled about the dangers of operating a motor vehicle or performing other potentially dangerous activities after drinking alcohol.

There is insufficient evidence to recommend for or against routine screening for drug abuse with standardized questionnaires or biologic assays. Including questions about drug use and drug-related problems when taking a history from all adolescents and adult patients may be recommended on other grounds including the prevalence of drug use and the serious consequences of drug abuse and dependence. All pregnant women should be advised of the potential adverse effects of drug use on the development of the fetus. Clinicians should be alert to the signs and symptoms of drug abuse in patients and refer drug abusing patients to specialized treatment facilities where available.

Basics of Identification for Abuse of Alcohol and Other Drugs

1. Conduct an Alcohol/Drug History

Identifying patients with substance abuse problems is critical. Begin history-taking with questions about relatively nonthreatening subjects -- such as the number of cups of caffeinated beverages the patient drinks per day -- before moving on to questions about the types, amounts, duration, and patterns of use of legal and illegal substances. When asking questions about frequency and use, be aware that there may be a tendency among patients to under-report use. However, such questions may be helpful in identifying individuals who drink large quantities (eg, binge drinkers). Questions about the negative consequences of abuse can also be helpful in assessing the magnitude of the problem. Areas that may be addressed include: driving history, employment history, educational progress, legal problems, family life, social activities, and enrollment in treatment programs. Asking about family history of substance abuse will help assess the patient's genetic vulnerability. If the patient has made previous attempts to stop or moderate use of alcohol or drugs, ask about the methods, barriers encountered, and degree of success. Table 53.1 and Figure 53.1 outline the screening algorithm recommended by the National Institute on Alcohol Abuse and Alcoholism. Table 53.2 provides sample questions for taking clinical histories about drug use.

Table 53.1. Screening Procedures for Alcohol-Related Problems.

Table

Table 53.1. Screening Procedures for Alcohol-Related Problems.

Figure 53.1. Steps for Alcohol Screening and Brief Intervention.

Figure

Figure 53.1. Steps for Alcohol Screening and Brief Intervention. From: National Institute on Alcohol Abuse and Alcoholism. The Physician's Guide to Helping Patients With Alcohol Problems. Bethesda, Md. Department of Health (more...)

Table 53.2. Examples of Questions for Taking Clinical Histories About Drug Use.

Table

Table 53.2. Examples of Questions for Taking Clinical Histories About Drug Use.

2. Use Brief Screening Questionnaires

Brief, self-administered screening questionnaires can help identify patients in need of more detailed evaluation. Examples of such tools include: the Alcohol Use Disorders Identification Test (AUDIT), the Michigan Alcoholism Screening Test (MAST), and the Drug Abuse Screening Test (DAST). See Provider Resources.

3. Ask about physical symptoms

Ask the patient about physical symptoms of substance abuse. Examples include frequent headaches or other chronic tension states, absence from work based on vague physical complaints, insomnia, unexplained mood changes, gastrointestinal disorders, uncontrolled hypertension, impotence and other sexual disorders, and neuropathies.

4. Physical Examination

The physical examination is a relatively insensitive and nonspecific method of detecting alcohol or drug abuse. Some signs of alcohol abuse include weight gain or loss, labile or refractory hypertension, abnormal skin vascularization, conjunctival injection, tongue or hand tremor, epigastric tenderness, and hepatomegaly. Cocaine users may have damaged nasal mucosa and weight loss. Injection drug users may have hypodermic marks. Signs of previous or current trauma are other clues to substance abuse problems.

5. Laboratory Tests

Laboratory tests, such as measurement of liver enzymes and erythrocyte mean corpuscular volume, are helpful in evaluating physiological damage but are not good screening tools for detecting alcohol abuse. Determination of the gamma-glutamyl transferase (GGT) level is the most sensitive biochemical test for alcohol abuse, but this test has a sensitivity of only 25% to 36%. Screening of urine for drugs can help confirm drug use, but such screening provides no information about the quantity or frequency of use. An estimated 5% to 30% of positive drug screens are false positives, depending on the drug, the method of analysis, and the population being tested. In general, these tests should not be used as screening tools in the primary care setting, and certainly they should not be used without patient consent.

Basics of Counseling for Abuse of Alcohol and Other Drugs

1. Establish a Therapeutic Relationship

Express genuine concern and maintain an honest, nonjudgmental approach with substance-abuse patients. Avoid arguing with, confronting, or labeling the patient. Attempt to maintain a partnership with the patient, functioning as an expert consultant. Trust is essential; assure the patient that any information disclosed will be kept confidential to the maximum extent possible.

2. Make the Medical Office or Clinic Off-Limits for Substance Abuse

This policy should apply to use of tobacco, alcohol, and other drugs. Counseling a patient who is under the influence of alcohol or other drugs is not productive and may be counterproductive because of the indirect encouragement of abuse that it gives to the patient. Schedule return appointments for such patients to occur when they are not under the influence.

3. Present Information About Negative Health Consequences

Present such information in a straightforward, nonjudgmental manner. For example, "Your trouble sleeping, the difficulty in controlling your blood pressure, and the recent problems at home with your family make me concerned that alcohol may be the main problem. I would like to discuss this possibility with you more. Warn injection drug users about the risk of HIV infection, hepatitis B infection, and other disorders associated with using contaminated or shared needles. Counseling for injection drug users should also involve proper screening for conditions including infectious hepatitis and HIV (chapters 48 and 59).

4. Emphasize Personal Responsibility and Self-Efficacy

Convey to the patient a sense of optimism and confidence that he or she can control his or her substance use.

5. Convey a Clear Message and Set Goals

Communicate clearly and firmly to the patient a recommendation to stop substance abuse. Assist the patient in setting a date for abstinence or goals for step-wise moderation of substance use. Help the patient to anticipate physiologic and psychologic withdrawal symptoms and to plan for potential relapses or "slips."

6. Involve Family and Other Supports

The assistance and patience of family members can be critical for the success of the patient's efforts at abstinence or moderation. Involve others only with the patient's consent.

7. Establish a Working Relationship with Community Treatment Resources

Many patients may benefit from the structure provided by peer counseling, support groups, in-patient treatment, and other modalities. Become familiar with support and treatment resources available in the community so that appropriate referrals, if needed, can be made.

8. Provide Follow-Up

Monitoring and supporting patient success is essential and desirable, even for patients referred for treatment. Schedule return appointments at regular intervals, particularly during the first weeks of each patient's efforts to stop or moderate use.

Patient Resources

  • Alcohol: What to Do If It's a Problem for You. American Academy of Family Physicians, 8880 Ward Pkwy, Kansas City, MO 64114-2797; (800)944-0000. Internet address: http://www.aafp.org
  • Alcohol and Women. American College of Obstetricians and Gynecologists, 409 12th St, SW, Washington, DC 20024; (800)762-2264. Internet address: http://www.acog.com
  • Drugs and Pregnancy: Often the Two Don't Mix. FDA Office of Consumer Affairs. HFE 88 Room 1675, 5600 Fishers Ln, Rockville, MD 20857; (800)532-4440.
  • Let's Talk Facts about Substance Abuse. American Psychiatric Association, 1400 K St, NW, Washington, DC 20005; (800)368-5777. Internet address: http://www.psych.org
  • National Clearinghouse for Alcohol and Drug Information. For information about the numerous publications that are available in both English and Spanish, call: (800)729-6686.

Provider Resources

  • Drug Abuse Screening Test. Internet address: http://www.nida.nih.gov/Diagnosis-Treatment/DAST10.html
  • Michigan Alcohol Screening Test. Internet address: http://www.silcom.com/~sbadp/treatment/mast.htm
  • The Physician's Guide to Helping Patients With Alcohol Problems. National Institute on Alcohol Abuse and Alcoholism. NIH Publication No. 95-3769. 1995. Internet address: http://silk.nih.gov/silk/niaaa1/publication/physicn.htm

Selected References

  1. American Academy of Family Physicians. Summary of Policy Recommendations for Periodic Health Examination. Kansas City, MO: American Academy of Family Physicians; 1997.
  2. American College of Obstetricians and Gynecologists. Guidelines for Women's Health Care. Washington, DC: American College of Obstetricians and Gynecologists; 1996.
  3. American College of Physicians. Chemical Dependence . Philadelphia, Pa: American College of Physicians; 1984.
  4. American Medical Association, Council on Scientific Affairs. Guidelines for Alcoholism Diagnosis, Treatment and Referral . Chicago, Ill: American Medical Association; 1979.
  5. American Medical Association. Prescribing Controlled Drugs: Source Book . Chicago, Ill: American Medical Association; 1986.
  6. Babor TF. Alcohol and substance abuse in primary care settings. In: Mayfield J, Grady M, eds. Primary Care Research: An Agenda for the 90s. Washington, DC: US Department of Health and Human Services; 1990:113-124.
  7. Babor TF, Ritson EB, Hodgson RJ. Alcohol-related problems in the primary health care setting: a review of early intervention strategies. Br J Addict . 1986; 81:23–46. [PubMed: 3457598]
  8. Baird MA. Early detection of alcoholism. Drug Therapy. October 1990:29-39.
  9. Barnes HN. Presenting the diagnosis: working with denial. In: Barnes HN, Aronson MD, Delbanco TL, eds. Alcoholism: A Guide for the Primary Care Physician. New York, NY: Springer-Verlag; 1987: chap 6.
  10. Batki SL. Drug abuse, psychiatric disorders, and AIDS: dual and triple diagnosis. West J Med . 1990; 152:547–552. [PMC free article: PMC1002409] [PubMed: 2190423]
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  12. Bigby JA. Negotiating treatment and monitoring recovery. In: Barnes HN, Aronson MD, Delbanco TL, eds. Alcoholism: A Guide for the Primary Care Physician. New York, NY: Springer-Verlag; 1987: chap 7.
  13. Brown RL. Identification and office management of alcohol and drug disorders. In: Fleming MF, Barry KL, eds. Addictive Disorders. St Louis, Mo: Mosby Year Book; 1992.
  14. Bush B, Shaw S, Cleary P, Delbanco TL, Aronson MD. Screening for alcohol abuse using the CAGE questionnaire. Am J Med . 1987; 82:231–235. [PubMed: 2880504]
  15. Canadian Task Force on the Periodic Health Examination. Early detection and counseling of problem drinking. In: The Canadian Guide to Clinical Preventive Health Care. Ottawa, Canada: Minister of Supply and Services; 1994: chap 42.
  16. Centers for Disease Control and Prevention. Fetal alcohol syndrome — United States, 1979-1992. MMWR . 1993; 42:339–341. [PubMed: 8479418]
  17. Colvin R. Prescription Drug Abuse: The Hidden Epidemic. Omaha, Neb: Addicts Books; 1995.
  18. Cyr MG, Wartman SA. The effectiveness of routine screening questions in the detection of alcoholism. JAMA . 1988; 259:51–54. [PubMed: 3334771]
  19. Delbanco TL. Patients who drink too much: where are their doctors? JAMA . 1992; 267:702–703. [PubMed: 1731140]
  20. Ewing JA. Detecting alcoholism: the CAGE questionnaire. JAMA . 1984; 252:1905–1907. [PubMed: 6471323]
  21. Gerstein DR, Lewin LS. Treating drug problems. N Engl J Med . 1990; 323:844–848. [PubMed: 2392142]
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  26. National Institute on Alcohol Abuse and Alcoholism. The Physician's Guide to Helping Patients With Alcohol Problems. Bethesda, Md: US Department of Health and Human Services; 1995. NIH Publication No. 95-3769.
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