Chemical Dependency: Alcoholism
Center for Continuing Dental Education

Helping Patients with Alcohol Problems

It is estimated that at least 20% of adults who visit a physician have had an alcohol problem at one time in their lives.

In a survey of patients admitted to an inpatient service, 12 to 30 percent screened positively for alcoholism. Yet, several recent studies indicate that physicians in various health care settings often do not recognize and treat alcoholism. These findings underscore the need for effective and accurate procedures that will enable all healthcare clinicians, including dental professionals, to screen for alcoholism.

Alcohol screening identifies individuals in a patient population who have begun to develop or who are at risk for developing alcoholism. Although all healthcare professionals customarily take a patient's medical history, routine use of a standard alcoholism-detection instrument is valuable because these instruments provide a structured, disciplined, and consistent means to detect individuals at risk. Two types of alcoholism-screening instruments are available. The first type includes self-report questionnaires and structured interviews; the second type includes clinical laboratory tests which can detect pathophysiology associated with excessive alcohol consumption.

The CAGE questionnaire, developed by Dr. John Ewing, is a self-report screening instrument that appears to be suited to a busy healthcare setting when there is limited time for patient interviews. The CAGE, which can be self-administered or conducted by a clinician, poses four overt yes-no questions and requires approximately 1 minute to complete. For routine health screening, the test may identify individuals with alcohol problems that might have been missed otherwise. (To help remember these questions, note that the first letter of a key word in each of the four questions spells "CAGE.")

Have you ever felt you should Cut down on your drinking?

Have people Annoyed you by criticizing your drinking?

Have you ever felt bad or Guilty about your drinking?

Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover (Eye opener)?

One "yes" response suggests a possible alcohol problem. If someone responded "yes" to more than one question, it is highly likely that a problem exists. In either case, it is important that that they see their physician or other health care provider right away to discuss their responses to these questions. He or she can help them determine whether they have a drinking problem and, if so, recommend the best course of action.

Even if a person answered "no" to all of the above questions, if they are encountering drinking-related problems with their job, relationships, health, or with the law, they should still seek professional help. The effects of alcohol abuse can be extremely serious--even fatal--both to them and to others.

As dental professionals, you are in an excellent position to identify and manage patients at risk for alcohol-related problems. As stated in earlier, nearly 14 million Americans, or 1 in every 13 adults - abuse alcohol or are alcoholic.

Following* is a step-by-step approach to identifying and managing these problems which offers practical advice on making alcohol screening, assessment, and brief intervention procedures a routine part of your clinical practice. There are important reasons for doing so. Untreated alcoholism results in a variety of social, economic, and medical/dental consequences. Alcohol use can complicate treatment for medical/dental problems, interfere with prescribed medications, or lead to adverse side effects. Most importantly, left untreated, alcohol abuse and alcoholism often result in severe or fatal outcomes. Your patients look to you for advice about the risks and benefits associated with drinking. Research, in fact, demonstrates that simply discussing your concerns about alcohol use can be effective in changing many patients' drinking behavior before problems become chronic.

What Your Patients Should Know About Alcohol Use:

Most adults who drink alcohol, drink in moderation and are at low risk for developing problems related to their drinking. However, all drinkers, including low-risk drinkers, should be aware of the health risks associated with alcohol consumption. Provide your patients with information and advice about the risks of drinking.

Recommendations to Patients for Low-Risk Drinking:

Advise those patients who currently drink to drink in moderation. Moderate drinking is defined as follows:

Men - no more than two drinks per day

Women - no more than one drink per day

Over 65 - no more than one drink per day

Note: A standard drink is 12 grams of pure alcohol, which is equal to one 12-ounce bottle of beer or wine cooler, one 5-ounce glass of wine, or 1.5 ounces of distilled spirits.

*Adapted from "The Physician's Guide to Helping Patients with Alcohol Problems," National Institute on Alcohol Abuse and Alcoholism.

Adolescent Drinking

Alcohol is the most widely used drug by young persons between the ages of 12 and 17 years. Routine screening, however, is relatively rare in pediatric practices. Because life problems for adolescents and adults differ, many screening instruments are inappropriate for younger individuals. The Adolescent Drinking Index is a self-report instrument developed specifically to screen adolescents. The inventory's 24 questions focus on drinking-related loss of control as well as social, psychological, and physical symptoms of alcohol problems.

Clinical laboratory procedures, the second type of screening test, frequently are used to corroborate results of physicians' interviews and of self-administered questionnaires. Biochemical markers of heavy alcohol consumption can provide objective evidence of problem drinking, especially in patients who deny any drinking problem. However, the sensitivities and specificity's of these biological laboratory markers can be modified by nonalcoholic liver injury, by drug use, and by metabolic disorders or individual metabolic differences.

It is important to note that self-report interviews and questionnaires have greater sensitivity and specificity than routine blood tests for biochemical markers. Laboratory tests may be used most successfully in conjunction with self-report instruments to enhance objectivity.

Advise patients to abstain from alcohol under certain conditions:

when pregnant or considering pregnancy
when taking a medication that interacts with alcohol
if alcohol dependent
if a contraindicated medical condition is present (e.g., ulcer, liver disease)

If a patient is at risk for coronary heart disease, discuss the potential benefits and risks of alcohol use:

Light to moderate drinking is associated with lower rates of coronary heart disease in certain populations . Infrequent or nondrinkers are not advised to begin a regimen of light to moderate drinking to reduce the risk of coronary heart disease because vulnerability to alcohol-related problems cannot always be predicted. Similar protective effects can likely be achieved through proper diet and exercise.

 

 

Screening & Brief Intervention Procedures

Recommended screening and brief intervention procedures include four steps:

Step I. ASK about alcohol use.
Step II. ASSESS for alcohol-related problems.
Step III. ADVISE appropriate action (i.e., set a drinking goal, abstain, or obtain alcohol treatment).
Step IV. MONITOR patient progress.

Step I. ASK about alcohol use:

Ask all patients:
Do you drink alcohol, including beer, wine, or distilled spirits?

Ask current drinkers about alcohol consumption:
On average, how many days per week do you drink alcohol?
On a typical day when you drink, how many drinks do you have?
What is the maximum number of drinks you had on any given occasion during the last month?

Ask current drinkers the CAGE questions:
Have you ever felt that you should Cut down on your drinking?
Have people Annoyed you by criticizing your drinking?
Have you ever felt bad or Guilty about your drinking?
Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (Eye opener)?

 

If there is a positive response to any of these questions:

ASK: Has this occurred during the past year?

A patient may be at risk for alcohol-related problems IF:

alcohol consumption is:

Men:
> 14 drinks per week or
> 4 drinks per occasion

Women:
> 7 drinks per week or
> 3 drinks per occasion

OR

one or more positive responses to the CAGE that have occurred in the past year

When is screening for alcohol problems appropriate?
as part of a routine oral health examination
before prescribing a medication that interacts with alcohol
in response to presenting problems that may be alcohol-related

Remember to conduct your screening in private and do not show signs of disapproval or judgment. In some cases, the patient's family members may alert you to the alcoholic condition of your patient. It is important to note that your patient needs to admit that alcoholism is a very serious disease and that they are willing to be helped to conquer this disease.

Step II. Assess for Alcohol-Related Problems

Patients who screen positive should be assessed to determine the nature and extent of their alcohol-related problems. Use the assessment procedures described below to determine problem severity, as follows:

1. At increased risk for developing alcohol-related problems,
2. Currently experiencing alcohol-related problems, or
3. May be alcohol dependent

1. At increased risk for developing alcohol-related problems

Indicators

drinking above recommended low-risk consumption levels or in high-risk situations
personal or family history of alcohol-related problems

 Assessment procedures

Ask about typical drinking patterns:

How long have you been drinking this amount?
How many times in a week (or month) do you have four or more drinks on one occasion?
What is the most you have consumed on one occasion during the past year?
Ask about personal and family history: Have you or anyone in your immediate family ever had a drinking problem?

2. Currently Experiencing Alcohol-Related Problems

Indicators

one or two positive responses to the CAGE that have occurred in the past year
evidence of alcohol-related medical or behavioral problems

 Assessment procedures

Review your patient's medical history for evidence of alcohol-related medical problems, such

blackouts
chronic abdominal pain
depression
liver dysfunction
hypertension
sexual dysfunction
trauma
sleep disorders

 Ask about interpersonal or work-related problems:

Has your drinking ever caused you problems, such as problems with your family, problems with your work (or school) performance, or accidents/injuries?

 

3. May Be Alcohol Dependent

Indicators

three or four positive responses to the CAGE that have occurred in the past year
evidence of one or more of the following symptoms:

- Compulsion to drink--preoccupation with drinking
- Impaired control--unable to stop drinking once started
- Relief drinking--drinking to avoid withdrawal symptoms
- Withdrawal--evidence of tremor, nausea, sweats, or mood disturbance
- Increased tolerance--takes more alcohol than before to get "high"

Assessment procedures

Ask the following questions:

Are there times when you are unable to stop drinking once you have started?
Does it take more drinks than before to get "high"?
Do you feel a strong urge to drink?
Do you change your plans so that you can have a drink?
Do you ever drink in the morning to relieve the shakes?

Step III: Advise Appropriate Action

State Your Medical Concern

Be specific about your patient's drinking patterns and related health risks.
ASK: How do you feel about your drinking?

Advise to abstain or cut down

Advise to abstain if:
-- evidence of alcohol dependence
-- history of repeated failed attempts to cut down
-- pregnant or trying to conceive
-- contraindicated medical condition or medication

Advise to cut down if:
-- drinking above recommended low-risk drinking amounts and no evidence of alcohol dependence 

Agree upon a plan of action:

 ASK: Are you ready to try to cut down or abstain?

Talk with patients who are ready to make a change in their drinking about a specific plan of action.

 For patients who are not alcohol dependent:

-- Recommend low-risk consumption limits for your patient based upon the low-risk drinking recommendations and your patient's health history (See Recommendations to patients for low-risk drinking).
-- Ask your patient to set a specific drinking goal:
Are you ready to set a drinking goal? Some patients choose to abstain for a period of time or for good; others prefer to limit the amount they drink. What do you think will work best for you?
-- Provide patient education materials and tell your patient:
It helps to think about your reasons for wanting to cut down and examine what situations trigger unhealthy drinking patterns. These materials will give you some useful tips on how to maintain your drinking goal.

 For patients with evidence of alcohol dependence:

Refer for additional diagnostic evaluation or treatment.
Procedures for patient referral are as follows:
-- Involve your patient in making referral decisions.
-- Discuss available alcohol treatment services.
-- Schedule a referral appointment while the patient is in the office.

 Some Patient Counseling Tips

Use an empathic, nonconfrontational style.
Offer your patient some choices about how to effect change.
Emphasize your patient's responsibility for changing drinking behavior.
Convey confidence in your patient's ability to change drinking behavior.

Step IV: Monitor Patient Progress

Monitor patient progress in the same way you manage other chronic medical problems, such as hypertension or diabetes. Recognize that behavior change is an incremental process that often involves trial and error. Patient management strategies include the following:

Indicate that you (or designated staff) are available to provide ongoing assistance and support.

Support your patient's efforts to cut down or abstain at each subsequent visit by:

-- reviewing progress to date
-- commending your patient for efforts made
-- reinforcing positive change
-- assessing continued motivation

 Consider scheduling a separate followup visit or telephone call, as appropriate, if the patient needs additional support.

Consider referring a selected patient whose counseling needs exceed the services provided in a primary care setting.

 For patients who have been advised to abstain or have been referred for alcohol treatment:
-- Ask to receive periodic updates from the treatment specialist on your patient's treatment plan and prognosis.
-- Monitor symptoms of depression and anxiety (if possible). Such symptoms may occur, but they often decrease or disappear after 2 to 4 weeks of abstinence.

 

 

 

What To Do About Patients Who Are Not Ready To Change Their Drinking Behavior

Do not be discouraged if patients are not ready to take action immediately. Decisions to change behavior often involve fluctuating motivation and feelings of ambivalence. By offering your advice, you have prompted your patients to think more seriously about their drinking behavior. In many cases, continued reinforcement is the key to a patient's decision to take action. Offer the following guidance to patients who are not ready to take action:

Restate your concern for your patient's health.
Reinforce your willingness to help when the patient is ready.
Continue to monitor alcohol use at subsequent office visits.

 For patients who may be alcohol dependent, you may want to consider some additional strategies:

 Encourage your patient to consult an alcohol specialist or Alcoholic's Anonymous (AA). AA is a fellowship of men and women who share their experience, strength and hope with each other that they may solve their common problem and help others to recover from alcoholism.
Ask your patient to discuss your recommendation with family members and schedule a followup visit that includes family members/significant others.

Preventing Alcohol Abuse and Related Problems

Prevention measures aim to reduce alcohol abuse and its consequences. Such measures include policies regulating alcohol-related behavior on the one hand and community and educational interventions seeking to influence drinking behavior on the other. Researchers use scientific methods, such as randomized controlled trials, time-series analysis, and computer simulation, to determine the effectiveness of prevention initiatives. The resulting data may both inform policy and guide community and educational prevention efforts.

Following are just a small sample of policy and educational interventions that have been tried in communities throughout the US with varying degrees of success.

Alcohol Taxes

Studies demonstrate that increased beer prices lead to reductions in the levels and frequency of drinking and heavy drinking among youth. Higher taxes on beer are associated with lower traffic crash fatality rates, especially among young drivers, and with reduced incidence of some types of crime.

Raising the Minimum Legal Drinking Age (MLDA)

MLDA legislation is intended to reduce alcohol use among those under 21, to prevent traffic deaths, and to avoid other negative outcomes. Raising the MLDA has been accompanied by reduced alcohol consumption, traffic crashes, and related fatalities among those under 21. A nationwide study found a significant decline in single-vehicle nighttime (SVN) fatal crashes--those most likely to involve alcohol--among drivers under 21 following increases in the MLDA.

Zero-Tolerance Laws

The National Highway Systems Act provides incentives for all States to adopt "zero-tolerance laws" that set maximum blood alcohol concentration (BAC) limits for drivers under 21 to 0.02 percent or lower. An analysis of the effect of zero-tolerance laws in the first 12 States enacting them found a 20-percent relative reduction in the proportion of SVN fatal crashes among drivers under 21, compared with nearby States that did not pass zero-tolerance laws

Blood Alcohol Concentration Laws

Numerous states have lowered BAC limits from 0.10 to 0.08 percent to reduce alcohol-related fatal motor vehicle crashes. One study found that states with the reduced limit experienced a 16-percent decline in the proportion of fatal crashes involving fatally injured drivers whose BAC's were 0.08 percent or higher, compared with nearby states that did not reduce their BAC limit.

Warning Labels

The mandated warning label on containers of alcoholic beverages aims to inform and remind drinkers that alcohol consumption can result in birth defects, impaired ability to drive a car or operate machinery, and health problems.

Research indicates that public support for warning labels is extremely high but that the label has not had important effects on hazardous behavior. One study of pregnant women found that after the label appeared, alcohol consumption declined among lighter drinkers but not among those who drank more heavily.

Drug Abuse Resistance Education (DARE)

DARE, typically taught to 10- and 11-year-old students in grades five and six by police officers, aims to inform about alcohol and other drugs and to teach social and decisionmaking skills to help students resist their use. Studies have found that DARE essentially has no impact on alcohol use.

Informational Programs

Programs attempting to persuade students not to use alcohol by arousing fear do not work to change behavior. Emphasizing the dangers of alcohol may attract those who tend to be risk-takers. Programs providing information about the pharmacological effects of alcohol may arouse curiosity and lead to drinking.

Server Training

Server training, mandatory in some states, educates alcohol servers to alter their serving practices, particularly with underage customers and those who show obvious signs of intoxication. Server training explains the effects of alcohol, applicable laws, how to refuse service to obviously intoxicated patrons, and how to assist customers in obtaining transportation as an alternative to driving. Some, but not all, studies report more interventions with customers after server training than before. One evaluation of the effects of Oregon's mandatory server-training policy indicates that it had a statistically significant effect on reducing the incidence of single-vehicle nighttime traffic crashes in that state.

The good news is that, using contemporary tools of science, prevention can be rigorously studied. Currently, research evidence shows that some prevention efforts are effective and others have little or no effect. This knowledge will help local communities, the states, and others who have made significant investments in prevention activities develop or refine existing programs to achieve their desired objectives.

Congratulations - you have just completed the third module of this online course.

Return to the Table of Contents to continue and click on Module 4.