–Single-question screening three-question AUDIT-C screening used.
-Patient meets DSM-V criteria for the diagnosis of alcohol use disorder. Patient indeed has a problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by at least 2 of the 11 criteria occurring within a 12-month period.
Treatment
-Brief behavioral counseling (Motivational Interviewing) to reduce alcohol misuse initiated. Multi-contact brief counseling will be cont. at future visits.
-Will consider referring to counseling for CBT and motivational enhancement therapy as needed.
-I recommend Alcoholics Anonymous (AA) or similar mutual help groups.
-I discussed Blood Alcohol Concentration (BAC) limits and DUI rules for the state.
-Discussed the FDA approved medications: Disulfiram, Naltrexone, & Acamprosate.
-Residential treatment facilities (RTFs) discussed. Will consider if the pt fails in maintaining abstinence at a less intensive level of treatment (eg, an intensive outpatient program). RTFs will remove pt from their environments and so remove negative influences and temptations.
-Patient denies intimate partner violence. This screening was done because men and women who misuse illicit drugs/alcohol are at increased risk of being victims and perpetrators of intimate partner violence.
-F/u in 4-6 weeks.
-Will consider referring to psychiatry as needed.
Background
Alcohol use disorder was formerly called Alcohol Abuse and Alcohol Dependence.
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-Oral naltrexone is the most effective medication to prevent alcohol relapse.
-Acamprosate is contraindicated in patients with renal disease.
-Disulfiram not effective in preventing relapse (per recent studies)
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Motivational enhancement therapy = a type of motivational interviewing that includes structured assessment of substance use and consequences, and personalized risk feedback to patients.
Related: ABUSERS: Substance Abuse
You only use medications to treat people who have alcohol dependence. There is little evidence on the effectiveness of medication in the treatment of nondependent alcohol abuse.
“Consider prescribing oral naltrexone (50 mg/d) for patients with alcohol use disorder who wish to maintain abstinence after a brief period of detoxification” J Fam Pract 2015;64(4):238-240
USPSTF explanation of behavioral counseling interventions.
“Behavioral counseling interventions for alcohol misuse vary in their specific components, administration, length, and number of interactions. They may include cognitive-behavioral strategies, such as action plans, drinking diaries, stress management, or problem-solving. Interventions may be delivered by face-to-face sessions, written self-help materials, computer or Web-based programs, or telephone counseling. For the purposes of this recommendation statement, the USPSTF uses the following definitions of intervention intensity: very brief single contact ( 5 minutes), brief single contact (6 to 15 minutes), brief multi-contact (each contact is 6 to 15 minutes), and extended multi-contact ( 1 contact, each 15 minutes). Brief multi-contact behavioral counseling seems to have the best evidence of effectiveness; very brief behavioral counseling has limited effect” USPSTF
“Behavioral counseling interventions are associated with a time commitment ranging from 5 minutes to 2 hours, spread over multiple contacts. There are potential financial costs for parents and caregivers from lost work hours and travel to and from the provider.”
Resources for alcohol use disorder:
http://www.aafp.org/afp/2016/0315/p457.html
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2695521/
http://www.integration.samhsa.gov/images/res/tool_auditc.pdf (AUDIT-C alcohol screening tool)
http://www.hepatitis.va.gov/provider/tools/audit-c.asp
https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/alcohol-misuse-screening-and-behavioral-counseling-interventions-in-primary-care
https://www.uptodate.com/contents/psychosocial-treatment-of-alcohol-use-disorder
JAMA 2014;311(18):1889-1900. Pharmacotherapy for adults with alcohol use disorders in outpatient settings: A systematic review and meta-analysis.
Centers for Disease Control and Prevention. Fact sheets—Alcohol use and your health.
J Fam Pract 2015;64(4):238-240. PURLS: Consider these medications to help patients stay sober.