Primary care management of alcohol use disorder and at-risk drinking

Screen all patients, at least yearly, for unhealthy drinking with a simple validated single-item screening test. Screen patients who present with medical or psychosocial problems that might be related to alcohol use

Primary care physicians should use a validated screening test to screen for unhealthy drinking. They should consider using the validated single-item screening test recommended by the National Institute on Alcohol Abuse and Alcoholism: How many times in the past year have you had 4 or more drinks for women or 5 or more drinks for men on one occasion?^8,10,11 If the answer is once or more, the screening result is positive. This single-item screening test has a sensitivity of 82% and a specificity of 79% for detecting unhealthy drinking.⁸ It has a higher sensitivity (87%) for detecting AUD but a lower specificity (67%). It is a very simple screening test and will enable physicians to detect most cases of at-risk drinking and AUD in their patients.

Another commonly used screening test is the Alcohol Use Disorders Identification Test (AUDIT). The longer 10-question AUDIT-10 (www.integration.samhsa.gov/AUDIT_screener_for_alcohol.pdf) has a sensitivity and a specificity of 92% and 94%, respectively, for the detection of AUD. The shorter 3-question AUDIT-C (www.integration.samhsa.gov/images/res/tool_auditc.pdf) has a sensitivity of 86% and a specificity of 72%. These are excellent screening tests; however, they do take more time to complete. The CAGE questionnaire will identify most patients with AUD but will miss many with at-risk drinking.¹²

Physicians should also screen all patients who present with health problems that might be related to alcohol use (Table 1). If clinical suspicion of AUD is high, physicians should consider screening with the AUDIT-10 instead of the single-item screening test for increased sensitivity and specificity. However, physicians should not rely on case identification alone. Studies show that unless providers employ universal screening with a validated test, many patients with at-risk drinking and milder AUD are missed and others are falsely labeled as having a disorder.^13–15

Determine if patients with positive screening test results have at-risk drinking or AUD

Physicians should ask specific questions about the duration of problematic alcohol use, the number of drinks, and the frequency of drinking. They should ask about cravings and attempts to cut back or quit. They should determine if alcohol has had an effect on the social, physical, or mental health of the patient. Physicians should inquire about withdrawal and tolerance. Patients often mistake withdrawal for anxiety. They might also be reluctant to acknowledge withdrawal because of its strong association with “alcoholism.” Therefore, the physician should avoid the term withdrawal, but can ask instead: “What time of day is your first drink? How are you feeling before the first drink? Do you find that your hands shake a bit when you reach for a coffee cup or other object? Is the shaking relieved by the first drink?” Physicians can determine tolerance by asking how many drinks it takes to feel “high” or to have an effect on mood.¹⁶

At-risk drinkers are typically not drinking much above the LRDG. Their alcohol use has minimal harmful effects on their lives. Those with mild AUD are often drinking more heavily but usually not daily. They typically drink fewer than 40 drinks per week and do not have serious withdrawal symptoms. Alcohol has some harmful effects on their lives. Those with moderate AUD are usually drinking daily and might have some withdrawal symptoms. They might be drinking daily or drinking intermittently but heavily (binge drinking). Those with severe AUD are typically drinking daily and consuming more than 40 drinks per week. They often have severe withdrawal symptoms and substantial life consequences.

Physicians should refer to the DSM-V criteria to make a diagnosis of mild, moderate, or severe AUD (Box 1).

Physicians should, clearly but sensitively, share the diagnosis with their patients. They should acknowledge that reducing or quitting can be very difficult. It is very important that physicians mention that they can provide effective treatments to encourage patients to follow up (Box 2). The approach is similar to that of any newly diagnosed, serious medical condition.

Do a further assessment for patients with AUD

Alcohol withdrawal: All patients with more severe AUD should be asked about past and current withdrawal symptoms that are relieved by drinking. Unless withdrawal symptoms are very mild, alcohol withdrawal should not be managed with a prescription for at-home treatment of alcohol withdrawal; this is unsafe.

Patients with a history of severe withdrawal or alcohol withdrawal seizures should be admitted for medical management of withdrawal to a hospital or a medical withdrawal unit (or, in an urgent situation, treated in the emergency department). Patients with substantial medical or psychiatric comorbidities, who lack social supports, or who are pregnant should also be admitted for management of withdrawal.¹⁷

Patients without these risk factors might be able to have elective treatment of withdrawal in the physician’s office.¹⁸ Patients need to be motivated, reliable, and committed to abstinence following withdrawal treatment. They should also have a treatment plan in place. Office detoxification is within the scope of practice for primary care practitioners. Physicians who do not have experience with office detoxification can consult an addiction specialist for assistance with management. A detailed description of office-based management of alcohol withdrawal is available from CFPlus.*

Patients who are able to go at least 3 to 4 days without drinking and only have mild withdrawal symptoms likely do not need medical management for withdrawal. However, as withdrawal can be unpredictable, consider having patients check in with you the day after their quit date either in person or on the telephone. Also, physicians should advise all patients to go to the emergency department if they develop more serious symptoms. For reliable patients, it is reasonable to give a few doses of diazepam to use at home under the supervision of a partner or staff at a nonmedical detoxification centre.

Concurrent substance use and mental health problems: Patients with AUD frequently misuse other substances. Physicians should inquire about each substance of abuse and determine if the patient has at-risk use or a substance use disorder. Patients with AUD also have high rates of mood and anxiety disorders.¹⁷ Physicians should determine if the mood and anxiety symptoms are part of an underlying mood disorder or secondary to the AUD. With an underlying disorder, the anxiety or depression symptoms usually predate the AUD and remain substantial even during periods of abstinence. There is also a strong association between AUD and other mental health problems including schizophrenia, personality disorders, bipolar disorders, posttraumatic stress disorder, and addictions.¹⁹ Primary care physicians might need assistance in making these diagnoses.

Trauma: Primary care physicians should understand and acknowledge the strong causal link between interpersonal childhood trauma (eg, abuse, neglect, family dysfunction) and substance use.⁷ Patients with AUD also have high rates of adulthood interpersonal trauma. Physicians should ensure AUD patients’ environments are physically and emotionally safe.²⁰ They should demonstrate transparency and trustworthiness and provide clear boundaries. Physicians should screen all patients with AUD for trauma with a sensitive, gradual, staged approach (Box 3) and offer to connect patients to trauma-specific services. They should make clear to their patients that they have choice and control over disclosure and over their treatment in general. Physicians should not inquire about details of the trauma, as studies have shown this is unhelpful.²⁰

Child protection services: Physicians should ask all patients if they care for children. Contact child protection services to report (or for advice) if there is a suspicion of child abuse or neglect or if a child is likely to suffer abuse or neglect (eg, the patient has been intoxicated while caring for a child).

Drinking and driving: Physicians should ask all patients with AUD or at-risk drinking about drinking and driving. Physicians should be aware that long-term alcohol use can have cognitive effects and impair driving ability as well. Physicians are required to report patients whose ability to operate a motor vehicle might be impaired by alcohol use (Box 4). The physician should explain to the patient the legal obligation to report, emphasizing that the reporting requirements apply to all medical conditions, not just alcohol misuse. The physician should also inform the patient about the requirements for licence reinstatement. These vary among provinces. Most require the individual to attend a treatment program and provide evidence of abstinence or reduced drinking for 6 months to 1 year, confirmed through self-report and measurement of liver transaminase levels.

Physical examination and laboratory tests: Primary care physicians should conduct a focused physical examination looking for signs of liver dysfunction. They should order a complete blood count and measure liver transaminase levels (aspartate aminotransferase, alanine aminotransferase, and γ-glutamyl transpeptidase) for all patients with AUD. If a patient’s liver transaminase levels or mean corpuscular volume are elevated, physicians should repeat these tests every 2 to 3 months to monitor response to treatment. They should also share the results with their patient. Feedback on γ-glutamyl transpeptidase and mean corpuscular volume results helps motivate patients who have reduced drinking by providing objective confirmation that the liver is healing. Physicians should order more extensive investigations for patients with evidence of liver dysfunction or changes in liver transaminase levels not explained by alcohol use.