Alcohol Abuse
Alcohol Abuse: Screening and Diagnosis
Background
- Over 60% of American adults drink alcohol
- Moderate alcohol consumption can reduce the risk of heart disease
- 10% of Americans abuse alcohol
- Abuse leads to significant individual and social consequences
- 40% of all traffic fatalities are alcohol-related
- 3 of every 10 people in the US will at some point be involved in an alcohol-related crash
- Up to one-third of ER trauma cases are alcohol-related
- Two-thirds of drownings are alcohol-related
- One-half of cirrhosis-related deaths are due to alcohol abuse
- Alcohol use also related to cancers of mouth, esophagus, pharynx, larynx, breast
- Associated with comorbid conditions including anxiety, antisocial personality, affective disorders
- Women who abuse alcohol have a higher incidence of comorbid conditions, including binge-eating, panic disorders, and depression
- Women are more likely than men to deny having drinking problems
- Alcohol and nicotine dependence are frequently comorbid conditions
- 80% of alcoholics smoke; 30% of smokers drink alcohol
- See also tobacco abuse
- Alcohol is most common drug used by high school students
- Over 10% of eighth graders consume 5 or more drinks at one sitting
- 90% of teenagers admit to consuming alcohol by the time they are seniors in high school
- 10-20% use cocaine; 40-50% use marijuana
- Alcohol use involved in over 50% of crimes committed by college students
- Estimated cost to US related to alcohol abuse in 1998 = $185 billion
- Standard drink is 12 g alcohol, which is 12 oz beer, 5 oz wine, 1.5 oz 80-proof distilled liquor
- Significant impairment can be seen at blood alcohol levels of 50 mg/dL
- Alcohol withdrawal is not a necessary component of addiction
Definitions of Alcohol Abuse
- DSM-IV
- Alcohol abuse: maladaptive pattern associated with one or more of the following
- Failure to fulfill work, school, or social obligations
- Recurrent substance use in physically hazardous situations
- Recurrent legal problems related to substance use
- Continued use despite alcohol-related social or interpersonal problems
- Alcohol dependence: maladaptive pattern associated with three or more of the following
- Tolerance
- Withdrawal
- Substance taken in larger quantity than intended
- Persistent desire to cut down or control use
- Time is spent obtaining, using, or recovering from the substance
- Social, occupational, or recreational tasks sacrificed
- Use continues despite physical and psychological problems
- National Institute on Alcohol Abuse and Alcoholism (NIAAA)
- Moderate drinking: average number of drinks consumed daily that places an adult at low risk for alcohol problems
- Men: < 3 drinks per day
- Women: < 2 drinks per day
- Heavy drinking: number of drinks that place the person at risk for adverse consequences
- Men: > 14 drinks per week, or 4 drinks per occasion
- Women: > 7 drinks per week, or 3 drinks per occasion
Pathophysiology
- Biochemical
- Multiple systems affected
- Antagonist to NMDA receptors
- Agonist to GABA receptors
- Affects serotonin and dopamine systems
- May affect CRF
- Genetic
- First-degree relatives of an alcoholic have a 3-4 times greater prevalence than general population
- Two-fold higher in identical twins
- Risk remains in children who are adopted by non-alcoholic parents
- Decreased inherent response level to alcohol is genetically influenced
- Need for higher levels of alcohol to cause an effect
- May be related to increased dopamine release in response to alcohol
- Psychosocial
- Learned responses to stressor situations can contribute to the development of alcohol dependency
Physical & Laboratory Findings
- Physical exam findings consistent with alcohol abuse
- HTN, tremors, obstructive lung disease, unexplained tachycardia, hepatosplenomegaly and peripheral neuropathy, trauma, telangiectasias
- A normal exam does not rule out alcohol abuse
- Laboratory findings consistent with alcohol abuse
- Macrocytosis
- Elevated LFTs (AST/ALT ratio greater than 2 is specific for alcohol-related liver disease)
- CDT can identify chronic alcohol use
- Normal labs do not rule out alcohol abuse
Screening & Diagnosis
- Screening and behavioral counseling recommended (Go to USPSTF)
- Physicians do not routinely screen for alcohol abuse
- Frequently fail to make appropriate referrals
- Screening and behavioral counseling by clinicians is recommended in adults (Go to USPSTF)
- Adolescents and adults
- Screen all using history or screening instrument
- College students (NIAAA): screen all on National Alcohol Screening Day
- Pregnant women (AAP/ACOG): counsel all on effects of alcohol on pregnancy
- Key elements in screening process
- Determine whether
- Patient has no control over his/her use of alcohol
- Tolerance or addiction is present
- Adverse consequences of excessive drinking have occurred
- Simple process for primary care physicians
- Ask all patients about past and current alcohol use and family history of alcohol-related problems
- Obtain detailed history of frequency and quantity of alcohol use
- Use a standard screening questionnaire
- Ask specific question based on answers to above (ie, other substances used, evidence of medical or psychiatric disease, violence or other behavioral disorders)
- Screening questionnaires (Go to Evidence-Based Inquiry)
- CAGE-AID questionnaire (Open Calc)
- Modified version of CAGE used for alcohol abuse (AID = adapted to include drugs)
- C = Have you ever tried to cut down on your alcohol or drug use?
- A = Do you get annoyed when people comment about your drinking or drug use?
- G = Do you feel guilty about things you have done while drinking or using drugs?
- E = Do you need an eye-opener to get started in the morning?
- AUDIT-C (Open Calc)
- Three questions quantifying amount of alcohol consumed
- 4 points or more identify 86% of patients with active alcohol abuse (specificity = 72%)
- How often did you have a drink containing alcohol in the past year? (never = 0 points, monthly = 1, 2-4 times per mth = 2, 2-3 times per week = 3, 4 or more times per week = 4)
- How many drinks did you have on a typical day when you were drinking in the past year? (0-2 drinks = 0, 3-4 drinks = 1, 5-6 drinks = 2, 7-9 drinks = 3, > 10 drinks = 4)
- How often did you have 6 or more drinks on one occasion in the past year? (never = 0, less than monthly = 1, monthly = 2, weekly = 3, daily = 4)
- Other questionnaires
- TWEAK (Open Calc)
- Full AUDIT (Open Calc)
- T-ACE
- Specifically for identification of risk of drinking during pregnancy
- Alcohol, Smoking and Substance Involvement Screening Test (ASSIST)
- An 8-item, self-administered conjoint screen developed by the World Health Organization
- Stratifies patients according to the severity of drug use and specific drugs of abuse, and detects current and lifetime drug use
- Car, Relax, Alone, Forget, Friends, Trouble (CRAFFT) (Open Calc)
- A 6-item, yes-or-no, self-administered questionnaire
- Developed for use among adolescents and young adults (aged 12–26 years) in primary care settings
- Single Question Screen (SQS)
- A 1-item, yes-or-no instrument asking the question: “How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?
- Severity of Alcohol Dependence Questionnaire (SADQ)
- Self-administered
- 20-item questionnaire
- Developed by the Addiction Research Unit at the Maudesley Hospital to measure severity of dependence on alcohol
- Brief Michigan Alcoholism Test (Open Calc)
Nursing Considerations
- Obtain detailed history of current frequency and quantity of alcohol use
- Use a standard screening questionnaire
- Assess patient's past and family history of alcohol-related problems
- Know signs/symptoms of alcohol abuse including
- Drinking alone or in secret
- Being unable to limit amount of alcohol drank
- Not remembering conversations or commitments, sometimes referred to as "blacking out"
- Making a ritual of having drinks before, with or after dinner and becoming annoyed when this ritual is disturbed or questioned
- Losing interest in activities and hobbies that used to bring pleasure
- Feeling a need or compulsion to drink
- Irritability when usual drinking time nears, especially if alcohol isn't available
- Keeping alcohol in unlikely places at home, work or in car
- Gulping drinks, ordering doubles, becoming intoxicated intentionally to feel good or drinking to feel "normal"
- Having legal problems or problems with relationships, employment or finances
- Building a tolerance to alcohol so you need an increasing number of drinks to feel alcohol's effects
- Experiencing physical withdrawal symptoms if patient does not drink such as
- Assist with making arrangements for behavioral counseling
Evidence-Based Practice
- What screening tools effectively identify drug use?
References
- Isaacson JH, Butler R, Zacharek M, Tzelepis A. Screening with the Alcohol use Disorders Identification Test (AUDIT) in an inner-city population. Journal of general internal medicine. 1994;9(10):550-553.
- Cherpitel CJ. Screening for alcohol problems in the U.S. general population: a comparison of the CAGE and TWEAK by gender, ethnicity, and services utilization. Journal of studies on alcohol. 1999;60(5):705-711.
- Cook RL, Chung T, Kelly TM, Clark DB. Alcohol screening in young persons attending a sexually transmitted disease clinic. Comparison of AUDIT, CRAFFT, and CAGE instruments. Journal of general internal medicine. 2005;20(1):1-6.
- Bohn MJ, Babor TF, Kranzler HR. The Alcohol Use Disorders Identification Test (AUDIT): validation of a screening instrument for use in medical settings. Journal of studies on alcohol. 1995;56(4):423-432.
- Screening For Alcohol Use and Alcohol Related Problems. NIH, National Institute on Alcohol Abuse and Alcoholism. Website http://pubs.niaaa.nih.gov/publications/aa65/AA65.htm.
- The Assist screening test and feedback card. World Health Organization. WHO website http://www.who.int/substance_abuse/activities/assist_test/en/
Contributor(s)
- Hernandez, James, DO
- Ausi, Michael, MD, MPH
Updated/Reviewed: February 2024