CE: Managing alcohol problems, Part 2

1. NIAAA screening guide 

The NIAAA has produced an outstanding resource called Helping Patients Who Drink Too Much: A Clinician's Guide, 2005 Edition. The NIAAA approach uses a single question about the number of heavy drinking days experienced in the past year. A positive screen is one or more heavy drinking days (5 drinks in a day for men and 4 drinks in a day for women). An electronic version of the guide is available at http://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/guide.pdf.

2. Audit 

The Alcohol Use Disorders Identification Test (AUDIT)4 incorporates questions about drinking quantity and frequency as well as questions about binge-drinking behaviors, consequences of drinking, and symptoms of alcohol dependence. Developed by the World Health Organization, the 10-question AUDIT is particularly useful in identifying people who are in the early stages of problem drinking but who may not be dependent on alcohol.5 The test may be self-administered or conducted by a health professional and takes only about 5 minutes to complete. Scores of 8 or higher for men up to age 60 and 4 or higher for women, adolescents, and men over age 60 are considered positive screens.2 The NIAAA offers English and Spanish versions of the AUDIT in its online resource Helping Patients Who Drink Too Much, A Clinician's Guide, 2005.

3. Cage 

The four-question CAGE6 screening tool can identify a range of alcohol problems.5 This questionnaire takes its name from the key questions it asks of clients, namely, whether the person has ever:

Research suggests that the CAGE is most useful when it is used as part of a general health history—and not preceded by questions about the quantity or frequency of a client's drinking—to identify clients who are alcohol dependent.7 Two “yes” responses are considered a positive test and indicate that further assessment is warranted.7

4. Craft 

The CRAFFT,8 which covers alcohol and other drugs, was developed specifically for adolescents. Like the CAGE questionnaire, the CRAFFT instrument is named for the first letters of keywords (car, relax, alone, friends, forget, and trouble) in its 6 brief questions. Notably, this is the only screening instrument that contains a question on drinking and driving, more specifically, riding with an intoxicated driver.8 (Alcohol-related car crashes are the leading cause of death among US teens.8) Two or more positive answers strongly indicate the presence of substance abuse and that adolescent clients should be further assessed.8

5. Mast 

The Michigan Alcoholism Screening Test (MAST)9 is a 25-item questionnaire that focuses on the consequences of problem drinking and on the subject's own perceptions of his or her alcohol problems. It has been shown to be particularly effective in identifying advanced alcohol problems such as dependence and has been used successfully with varied populations.5 The test may be self-administered or given by a case manager or other health professional. Clients answer “yes” or “no” questions about such topics as the quantity and frequency of their drinking, the health and employment consequences associated with their drinking, the impact of drinking on social relationships, and their help-seeking behaviors (eg, seeking help from physicians or Alcoholics Anonymous).9 The MAST takes about 10 minutes to complete, but shorter versions of the test are also in use, including include a 13-item Short MAST (SMAST)10 and a 10-item Brief MAST (B-MAST).11

Outpatient 

Outpatient programs can be a particularly effective treatment option for clients who have strong social support systems and who are employed (outpatient programs help minimize time away from work while the client undergoes treatment). Outpatient treatment emphasizes motivating people to change their behaviors and lifestyles to avoid or reduce the risks and negative consequences associated with alcohol misuse.

Depending on the severity of the client's alcohol problem, outpatient treatment may entail attending individual or group counseling sessions once or twice a week for several months. In fact, research has shown that for outpatient treatment, participation for fewer than 90 days is of limited or no effectiveness, and treatments lasting significantly longer often are indicated.15 More-severe alcohol problems may necessitate use of intensive outpatient programs, which participants may attend during the day or evening. These programs incorporate several hours of treatment each week for several months. The participant continues living at home and working while receiving counseling, social skills training, and case management services.

Inpatient 

Inpatient alcohol treatment programs address addiction to alcohol. Candidates for inpatient treatment often have alcohol problems severe enough to require intensive intervention, or detoxification, and that co-occur with serious medical or psychological conditions. Detoxification stabilizes the physiological and emotional symptoms caused by the sudden termination of heavy drinking. Inpatient programs, which may last anywhere from a few days to a year or more, often are recommended for individuals who lack social support systems or who have not been successful in outpatient programs. Inpatient treatment involves round-the-clock care and monitoring in a residential setting, such as a rehabilitation center specializing in substance use treatment, or in an acute care setting, such as a hospital. A medically supervised, multidisciplinary staff provides services (including substance use education; individual, group or family therapy; and life skills training) that address patients' medical, emotional, and/or behavioral problems. Participants also may be prescribed medications to help with withdrawal symptoms, prevent relapse, or prevent cravings for drugs.

Medications 

In some cases, clients may be prescribed medications to help with alcohol withdrawal symptoms, prevent relapse, or prevent cravings. Medications are used after detoxification and in conjunction with other interventions. Drugs used to treat alcohol dependence include acamprosate, disulfiram, and naltrexone.

Although its exact mechanism remains unclear, acamprosate is thought to curb the urge for alcohol by working directly on certain neurotransmitters in the brain whose balance has been disrupted because of regular, heavy drinking. Disulfiram discourages clients from drinking by causing nausea, vomiting, and other unpleasant physical reactions when alcohol is used. Naltrexone reduces a person's craving for alcohol and helps prevent a return to heavy drinking. Case managers and clients should be aware of the side effects of these drugs and their potential interactions with other medications. Clients should not consume alcohol while taking these medications.