Physical Exam and Laboratory Testing

Because alcohol dependence can harm many organ systems and certain conditions may preclude pharmacotherapy with a particular maintenance medication, a physical exam and laboratory testing should be performed before any treatment is initiated.

Medical complications of excessive alcohol consumption are common and numerous, and this TIP cannot discuss them all. However, common medical conditions such as hypertension and gastritis and common psychiatric conditions such as depression can be incited or exacerbated by AUDs. Various patient complaints can be related to alcohol consumption, including dyspepsia, sleep problems, sexual difficulties, depressed mood, and irritability. AUDs also contribute to progression of morbidity for many diseases. For instance, according to a recent review of the literature (Conigliaro, Justice, Gordon, & Bryant, 2006), excessive alcohol consumption increases the morbidity associated with HIV and viral hepatidies and can complicate medical treatment for these conditions. In addition, existing conditions, such as hepatic or renal disease or pain syndromes, either acute or chronic, may contraindicate treatment with particular maintenance medications.

Psychiatric Assessment

Psychiatric conditions (such as major depression, generalized anxiety disorder, posttraumatic stress disorder, schizophrenia, and personality disorders) frequently co-occur with excessive alcohol consumption (Kranzler & Rosenthal, 2003). Some psychiatric symptoms resolve with abstinence, and others lessen. Nonetheless, the prescribing professional should assess the patient for these disorders and for suicidal ideation or intent (or refer the patient for assessment). Untreated psychiatric conditions can seriously interfere with a patient's ability to comply with pharmacotherapy and psychosocial treatment for alcohol dependence and can cause the patient preventable suffering. More information on co-occurring psychiatric disorders can be found in TIP 42, Substance Abuse Treatment for Persons With Co-Occurring Disorders (CSAT, 2005).

Substance Use Assessment

After healthcare providers have ascertained that a patient has an AUD, they should obtain an adequate history of the patient's substance use and of prior treatments for AUDs. Providers should determine whether the patient has experienced alcohol withdrawal syndrome because this syndrome can indicate a need for more specialized care than primary care providers can typically provide. More information about alcohol withdrawal and detoxification is in TIP 45, Detoxification and Substance Abuse Treatment (CSAT, 2006a). Excerpts of the Quick Guide for Clinicians based on TIP 45 are in Appendix C.

During the assessment, providers should assess the quantity and frequency of alcohol consumption, patterns of alcohol consumption (e.g., persistent, occasional, binge use), episodes of use, duration of use, and consequences of alcohol consumption. The NIAAA clinician's guide suggests a stepwise approach that consists of assessment of any use, quantity/frequency of use, and harm associated with alcohol consumption (NIAAA, 2006). NIAAA's A Pocket Guide for Alcohol Screening and Brief Intervention, a condensed version of the clinician's guide, is in Appendix B. Exhibit 6-2 lists key questions to quickly assess quantity and frequency of alcohol use, based on a “standard drink” in the United States that contains 14 grams of pure alcohol (about 0.6 fluid ounces or 1.2 tablespoons). More detailed information about what constitutes a standard drink is in Appendix B.

The history also should include use of substances other than alcohol, especially opioids, as well as the patient's history of use, misuse, or abuse of prescription medications. Misuse of opioid medications may complicate or contraindicate treatment with naltrexone. Abuse of sedatives and tranquilizers may complicate detoxification and treatment.

A complete assessment includes a patient's current involvement in or history of professional treatment or mutual-help group involvement, including the following:

• Detoxification episodes
• Pharmacotherapy interventions
• Specialty substance abuse treatment episodes (including when, where, modality, duration, and outcome)
• Individual therapy
• 12-Step (e.g., Alcoholics Anonymous) or other mutual- or self-help program involvement.

This information can assist the provider in treatment planning and advocating for psychosocial treatment as an adjunct to pharmacologic treatment for alcohol dependence.

Social History

Understanding a patient's social situation identifies problems that may interfere with treatment and that necessitate referral for ancillary services. Asking a patient basic questions about his or her work, legal, living, and family situations can yield information that is critical to treatment planning:

• What is the patient's family situation? Who should be included in treatment planning? Who can monitor a patient's medication compliance?
• Is the patient on probation at work? Could this be a means of motivating medication compliance?
• What is the patient's living situation? Are extra measures required to ensure medication compliance? Are psychosocial treatment modalities (residential vs. outpatient) recommended?

Assessing Motivation for Change

Before offering treatment for alcohol dependence, providers should assess patients' readiness to change drinking behavior. Through this assessment, patients and providers develop mutually agreeable intervention and treatment plans. Exhibit 6-3 provides questions that determine patients' readiness for change.

Regardless of patients' readiness to change, they should, at a minimum, be willing to be in a supportive relationship with their healthcare provider. If the relationship is strained by dishonesty or mistrust, initial willingness to take medication and ongoing compliance with a medication regimen may suffer. In addition, patients should be willing to consider adjunctive options including specialty treatment, other independent psychosocial treatment providers, or forms of community support. A review of the literature suggests that although psychosocial interventions increase rates of abstinence and decrease alcohol consumption, a significant proportion of patients relapse to drinking within 1 year (Mason, 2005a). Healthcare providers, however, can play a significant role in motivational enhancement and relapse prevention. More information about stages of change and motivational enhancement is in TIP 35, Enhancing Motivation for Change in Substance Abuse Treatment (CSAT, 1999b).

Types of Psychosocial Therapies

As with pharmacotherapy, there is no psychosocial “magic bullet.” However, a number of modalities of psychosocial therapy have been studied and validated for treatment of alcohol use disorders (reviewed by McCaul & Petry, 2003). Medical management (MM) is often practiced by primary care physicians in patients with diabetes and hypertension treatment. NIAAA developed an MM treatment as part of its COMBINE study (NIAAA, 2004). MM was designed specifically to accompany pharmacotherapy for AUDs and be delivered by medically trained clinicians in a medical setting. MM provides the structure and materials to enable clinicians to do the following:

• Provide patients with strategies for taking their medications and staying in treatment
• Provide educational materials about alcohol dependence and pharmacotherapy
• Support patients' efforts to change drinking habits
• Make direct recommendations for changing drinking behaviors.

An MM manual is available through NIAAA at http://www.niaaa.nih.gov.

Providers in psychiatric practice may provide psychosocial therapies on site. In the context of the primary care setting, however, delivering particular psychosocial therapies (e.g., group therapy) may be difficult because of time constraints, patient population, and lack of training. Brief interventions, motivational enhancement therapy, and MM treatment are more conducive to primary care settings (Anton et al., 2005, 2006). Sources of information about these interventions are listed in Exhibit 6-6. If these types of in-office interventions are not effective with a patient, or if the provider does not have the resources to offer them, providers may need to refer the patient for more intensive or specialized services.

Referring Patients for Specialty Treatment

Primary care practitioners may need to refer patients for psychosocial therapies, including to specialty substance abuse treatment programs. Many specialty substance abuse treatment programs provide comprehensive treatment services, either directly or through referrals, that address multiple factors affecting recovery. Such programs address not only immediate withdrawal and craving but management of long-term abstinence through the following:

• Pharmacotherapy
• Case monitoring
• Individual, group, and family/couples counseling and therapy
• Other psychosocial services (e.g., vocational counseling)
• Referral to mutual-help groups.

The underlying basis for a specialty program is that optimal outcomes are achieved through a range of complementary services and that, as abstinence lengthens, other issues related to alcohol use become clearer and more amenable to treatment.

A practitioner who is planning to treat patients with alcohol dependence should become familiar with a range of local treatment resources. Developing relationships with treatment staff will facilitate smooth referrals and followup. In addition, understanding something about a program's treatment duration, modality, philosophy, and continuing-care options helps the practitioner better match a patient to appropriate treatment; practitioners can prepare the patient for what to expect, enhancing compliance with the referral. Practitioners can find programs in their areas or throughout the United States by using the interactive Substance Abuse Treatment Facility Locator on the Substance Abuse and Mental Health Services Administration (SAMHSA) Web site at http://dasis3.samhsa.gov.

Mutual- or Self-Help Programs

Mutual- or self-help group support can be critical to long-term recovery. The oldest, best-known, and most accessible mutual-help program is Alcoholics Anonymous (AA) (http://www.aa.org). Patients may resist attending AA meetings and may fear that disclosure of medication use may be unwelcome. Although some AA members may have negative attitudes toward medications, the organization itself supports appropriate medication use (AA, 1984). Providers should encourage patients to try different group meetings if they meet with negativity. Lists of local meetings can be obtained from http://www.aa.org and given to patients. Dual Recovery Anonymous (http://www.draonline.org) is a 12-Step program for patients with co-occurring psychiatric disorders. Other mutual- or self-help groups include Self Management and Recovery Training (http://www.smartrecovery.org) and Women for Sobriety, Inc. (http://www.womenforsobriety.org). Although groups other than AA are not available in every community, they do offer a number of online resources. For patients' family members, there are Al-Anon and Alateen meetings (http://www.al-anon.alateen.org).

Providers should have a working knowledge of the most common groups so that they can suggest these groups to their patients and discuss patients' participation.

Setting Goals: Abstinence or Reduction?

Each patient-provider interaction should assess and clarify outcome goals for the patient. A patient initially may seek to reduce alcohol consumption. Another patient may be motivated for total abstinence. Investigations into prescribing of pharmacotherapy employ both alcohol use reduction outcomes and abstinence outcomes to assess the efficacy of medications to treat alcohol dependence. Clinical outcomes to assess progress include the length of time to first drink, time to heavy drinking, cumulative abstinence days, and drinks per drinking episode. Each provider and patient should set an initial goal and be willing to refine that goal as treatment progresses.

If a patient with an AUD is unwilling to be completely abstinent, he or she may be willing to cut down on alcohol use. Practitioners can work with this while noting that abstinence is the safer strategy and has a greater chance of long-term success.

Certain conditions warrant advising a patient to abstain from rather than reduce drinking. As noted in the NIAAA (2006) clinician's guide, these conditions include when drinkers:

• Are or may become pregnant
• Are taking a contraindicated medication
• Have a medical or psychiatric disorder caused or exacerbated by drinking
• Have an AUD.

For those who drink heavily and who do not have an AUD, the practitioner should use professional judgment to determine whether cutting down or abstaining is more appropriate, based on factors such as (NIAAA, 2006):

• A family history of alcohol problems
• Advanced age
• Injuries related to drinking.

Elements of a Treatment Plan

A comprehensive pharmacotherapy treatment plan for a patient with an AUD should include the following:

• The medication to be used and a rationale for its use
• Initial and maintenance dosages
• A schedule for followup office visits and laboratory testing for monitoring health status and progress
• Criteria for discontinuing the medication
• A referral and followup plan for concurrent specialty substance abuse treatment, psychiatric treatment, and/or family therapy
• A plan for mutual- or self-help group attendance
• Clarification of family or significant other involvement in treatment
• A plan for treating alcohol-related or other concurrent conditions.

Special attention must be paid to developing a medication compliance plan with the patient. This plan may include the following:

• Specific strategies for remembering to take medications
• Using blistercard packs or pill boxes
• Monitoring medication compliance on an appropriate schedule given the patient's history of compliance with maintenance and other medication regimens
• Involving the patient's family members in monitoring compliance.

Monitoring Adherence

Several means exist for a provider to monitor patients' compliance with treatment plans, including the following:

• Tracking patients' record of keeping (or not keeping) appointments for medication monitoring
• Monitoring prescription refills
• Noting whether patients are keeping agreements about payment for treatment
• Requesting periodic status reports from specialty substance abuse treatment programs, psychiatric referrals, and other psychosocial therapy or support.

Monitoring Abstinence or Reduction in Alcohol Consumption

The ways in which providers can monitor patients' drinking behavior include the following:

• Patient self-reports can be useful indicators of treatment success. The provider should discuss with the patient the quantity and frequency of drinking, especially during stressful periods (e.g., holidays, celebrations, major life changes).
• Laboratory tests may include AST, GGT, CDT, EtG, and urine drug screening.

In addition, providers can use periodic Breathalyzer^TM tests (although these detect only for a short period following ingestion) to monitor alcohol intake and provide positive feedback to patients who are successful in maintaining abstinence.

Monitoring Craving

Greatly diminished craving to drink alcohol is an optimum outcome of treatment. To assess craving, a physician can rely largely on the patient's subjective reports, although measures such as the Alcohol Urge Questionnaire (Bohn, Krahn, & Staehler, 1995) may prove useful.

More important than the method of monitoring is consistency in how the patient is asked about craving patterns and trends. Patients should be asked about current craving as well as how they felt over the past week (e.g., as a rating between 1 and 10, with 1 being no craving and 10 the most intense craving the patient has ever experienced). Patients may be asked whether any episodes have caused particular problems for them.

The patterns of craving over time can be useful. Both the provider and the patient can see that the patient's patterns of craving may fluctuate throughout the day and over longer periods; these patterns can assess the appropriateness to continue, adjust, supplement, enhance, or terminate pharmacologic treatment.

Providers should educate the patient about the role of craving in relapse. Learning from and responding optimistically to relapse may increase the patient's motivation to reduce or eliminate alcohol consumption.

Monitoring Health Status and Social Functioning

Ultimately, the goal of treatment is improved quality of life. It is important to monitor patients' progress over time in the following areas:

• Health
  • Normalization of previously elevated blood pressure
  • Improvement of liver function
  • Stabilization of related medical problems that the patient was experiencing before treatment (e.g., control of blood glucose, stabilization of asthma, cardiomyopathy, encephalopathy, gastritis, ascites and edema)
  • Signs of increased concern about health care, such as seeing a physician for the first time in years and/or increased compliance with prescribed medication regimens not related to AUD treatment (e.g., asthma or blood pressure medications)
• Family/social activities
  • Spending more positive time with children and/or spouse
  • Greater involvement/participation with family members
  • Improved intimate relationships
  • Reduced family conflict
  • Engagement in nondrinking leisure and recreational activities
• Work/vocational status
  • Obtaining employment if previously unemployed
  • Improved attendance at work
  • Fewer job-related and financial problems
  • Improved job performance
• Legal status
  • No parole or probation violations (in a patient with legal problems)
  • No new driving-under-the-influence charges
• Mental status
  • Decreased irritability and anxiety
  • Improved mood
  • Improved sleep
  • Getting appropriate treatment for anxiety disorders, suicidal ideation, depression, or schizophrenia rather than self-medicating with alcohol.

Monitoring Other Substances of Abuse

It is important to address other substances of abuse that pose the same level of concern and possible adverse consequences. The abuse of other substances can be evaluated by random urinalysis collection and testing and self-reports from the patient. Use of illicit substances, tobacco use, and abuse of prescription and nonprescription medications should be addressed. The patient's agreement or resistance to continuing treatment may indicate his or her willingness to consider other substance use a problem.