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Problem Drinking

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Title: Problem Drinking


1
Problem Drinking
A comparison of different screening tests
and why the family physician should take time to
screen for substance abuse
  • Charles Popkin
  • Centreville, Mississippi
  • Preceptors Drs. Dick Rich Field

2
Definitions of Problem Drinking
  • Alcohol Dependence (alcoholism)- involves
    impaired control over drinking, manifested by
    physiological addiction to alcohol and/or serious
    disturbances of health, work, social and/or
    recreational activities or other areas of
    functioning related to alcohol use (DSM IV 1994)
  • Alcohol Abuse (harmful drinking)- involves
    serious disturbances of health, work, social
    and/or recreational activities or other areas of
    functioning related to alcohol use, without
    satisfying criteria for alcohol dependence (DSM
    IV 1994).
  • Hazardous Use- incorporates binge or heavy
    chronic drinking, places asymptomatic drinkers at
    risk for future health problems (USPTF 1996)

3
Relevance to the Population
  • Preceptor Community Centreville, Mississippi
  • Alcohol and the Centreville ER
  • Domestic disputes
  • 4 wheeler accidents
  • MVAs
  • Epilepsy patient who drank heavily and forgot to
    take meds
  • Chronic alcoholic presenting with weakness,
    ataxia and parasthesias

4
Relevance to Family Practice
  • Discussions about alcohol use can be
    uncomfortable, and to be most effective they
    often require.
  • A long term, trusting relationship with the
    patient
  • Knowledge of patients family and social history
    which might reveal strong risk factors for the
    patient to abuse alcohol
  • Many opportunities to build on discussions with
    consecutive office visits
  • Since substance use disorders are often chronic
    conditions that progress slowly over time, family
    physicians are in an ideal position to screen for
    alcohol and monitor each patient's status
  • The family physician is well suited to
  • fulfill these requirements!

5
Method to gather info
  • OVID- used Cochrane DSR, ACP Journal Club and
    DARE databases
  • Keyword searches Alcoholism, screening, and
    interventions
  • PubMed-used Medline 1966-2003 database
  • Keyword search CAGE RAPS4 (questionnaires)
    and Alcohol
  • USPTF website- searched HSTAT database
  • Keyword search- alcohol and screening- Result
    was Treatment Improvement Protocol 24
  • Two meetings with Dr. Don Gallant, Professor
    Emeritus Department of Psychiatry, Tulane
    University School of Medicine. National Expert on
    Alcohol addiction
  • Two meetings of Alcoholics Anonymous outside
    McComb, Mississippi

6
Problems Addressed
  • Determine why it is important for family practice
    physicians to screen patients for alcoholism
  • Determine the best method to screen patients for
    problem drinking
  • Determine how patients perceive discussions about
    problem drinking with their primary care
    physician

7
Alcohols Impact by the Numbers
  • Alcohol-related disorders occur in up to 26
    percent of general medical clinic patients, a
    prevalence rate similar to those for such other
    chronic diseases as hypertension and diabetes
    (Fleming and Barry, 1992).
  • There were 26,552 deaths in the United
    States from Chronic Liver Disease and Cirrhosis,
    the 12th leading cause of death in the United
    States (National Vital Statistics Report, 2000)
  • 32 million Americans (15.8 percent of the
    population) had engaged in binge or heavy
    drinking (five or more drinks on the same
    occasion at least once in the previous month)
    (Substance Abuse and Mental Health Services
    Administration, 1996)

8
Prevalence of Problem Drinking in Primary Care


Manwell, L. Fleming, M.F. Barry, K. and
Johnson, K. Tobacco, alcohol, and drug use in a
primary care sample 90 day prevalence and
associated factors. Journal of Addictive
Diseases, in press.
9
Alcohols Economic Impact
  • Every man, woman, and child in America pays
    nearly 1,000 annually to cover the costs of
    unnecessary health care, extra law enforcement,
    motor vehicle crashes, crime, and lost
    productivity due to substance abuse (Institute
    for Health Policy, 1993).
  • A true estimate of the total economic impact of
    alcohol is difficult to gauge. The costs to
    abusers, their families, and society at large,
    are indisputably enormous and encompass health
    care costs, premature mortality, workers'
    compensation claims, reduced productivity, crime,
    suicide, domestic violence, and child abuse.

10
Why do we need to screen?
  • Screening is the application of a simple test to
    determine if a patient has a certain condition.
    For screening to be meaningful in the primary
    care setting, the particular problem
  • Must be prevalent within the general population
  • Must diminish the duration or the quality of life
  • Must have an effective treatment available that
    reduces morbidity and mortality when given during
    the asymptomatic stage of the disease
  • Must be detectable via cost-effective screening
    earlier than without screening and must avoid
    large numbers of false positives or false
    negatives
  • Must be detectable and treatable early enough to
    halt or delay disease progression and thereby
    improve outcome (U.S. Preventive Services Task
    Force, 1996 National Institute on Alcohol Abuse
    and Alcoholism, 1993)
  • Screening for Problem Drinking meets all the
    above criteria!

11
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12
Why do we need to screen? -ctd
  • Problem drinking is too prevalent and costly to
    be ignored. Take the time to screen!

13
Appropriate Screening Methods in the Family
Practice Setting
  • There are four screening tests that are advocated
    for use in the primary care/ER setting. They are
    the CAGE, the AUDIT, the RAPS4 and the FAST
    questionnaires.
  • Each one has its individual strengths and
    weaknesses

14
Identifying those at risk
  • CAGE questionnaire is an good predictor of
    current and lifetime alcohol dependence, with
    high sensitivity and specificity
  • CAGE consists of 4 questions?
  • 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 get rid of a
    hangover (Eye-opener)
  • Cut-off or a positive test is gt 2
    answers of yes
  • Fiellin DA, Carrington RM, OConnor PG, Screening
    for alcohol problems in primary care a
  • systematic review. Archives of Internal Medicine
    20001601977-1989. OVID DARE 2003
  • Babor, T.F. Kranzler, H.R. and Lauerman, R.J.
    Early detection of harmful alcohol consumption
  • Comparison of clinical, laboratory, and
    self-report screening procedures. Addictive
    Behaviors
  • 14(2)139-157, 1989.
  • .

15
(No Transcript)
16
Evidenced Based Medicine
  • DARE Cochrane review of Alcohol screening tests
    from a meta-analysis of 27 trials advocated using
    the CAGE questionnaire for identifying current
    and lifetime alcohol abuse and dependence
  • Sensitivity and Specificity of the CAGE were
    between 43-94 and 70-97 respectively
  • The concise nature of the CAGE questionnaire
    followed with questions addressing quantity and
    frequency of alcohol consumption is pragmatic and
    recommended for primary care physicians
  • Fiellin DA, Carrington RM, OConnor PG,
    Screening for alcohol problems in primary care
    a systematic review. Archives of Internal
    Medicine 20001601977-1989. OVID DARE 2003

17
AUDIT for screening
  • More involved then the CAGE questionnaire, it
    consists of ten questions that address frequency
    and quantity of drinking, symptoms of dependence,
    and problems related to alcohol use.
  • Designed for early identification of hazardous
    drinking that may lead to alcohol dependence down
    the line.
  • Individual answers are scored 0 to 4, with the
    range of the test 0 to 40. Cut-off or a positive
    test is gt 8 points
  • Not the screening test of choice for primary care
    physicians crunched for time.
  • Fiellin DA, Carrington RM, OConnor PG,
    Screening for alcohol problems in primary care a
    systematic review. Archives of Internal Medicine
    20001601977-1989. OVID DARE 2003
  • Saunders, J.B. Aasland, O.G. Babor, T.F.
    Development of the Alcohol Use Disorders
    Identification Test (AUDIT) WHO collaborative
    project on early detection of persons with
    harmful alcohol consumption-II. Addiction
    88791-804, 1993.

18
Evidence Based Medicine on AUDIT
  • DARE Cochrane review of Alcohol screening tests
    from a meta-analysis of 27 trials advocated using
    the AUDIT questionnaire for identifying hazardous
    or harmful drinking
  • Sensitivity and Specificity of the AUDIT were
    between 57-97 and 78-96 respectively
  • The AUDIT is not as specific or sensitive as the
    CAGE in identifying current or lifetime alcohol
    abuse or dependence, but does have a role with
    the primary care physician with extra time
    concerned about catching hazardous drinking
    before it escalates to abuse/dependence.
  • Fiellin DA, Carrington RM, OConnor PG, Screening
    for alcohol problems in primary care a
  • systematic review. Archives of Internal Medicine
    20001601977-1989. OVID DARE 2003

19
RAPS4
  • Developed due to concern that the CAGE was not
    validated for women and minorities (general
    population) (Cherpitrel, Comparison of screening
    instruments for alcohol problems, 1997)
  • RAPS4 consists of 4 questions
  • During the past year have your felt guilty about
    drinking? (Remorse)
  • During the past year has a friend ever told you
    things you said or did but do not remember?
    (Amnesia)
  • During the past year have you failed to do what
    was normally expected of you? (Perform)
  • Do you sometimes take a drink in the morning when
    you first get up? (Starter)
  • Cut-off or a positive test is gt 2 answers of
    yes

20
Evidence Based Medicine
  • RAPS4 was shown to be more sensitive for problem
    drinking for both males and females in the ER
    setting than the CAGE.
  • Important to note that patients were seen in ER
    and not the clinic of a primary care physician.
  • RAPS4s sensitivity can increase even more with
    the addition of two questions concerning quantity
    and frequency (QF)
  • Cherpitrel C, Screening for alcohol problems in
    the US General Population Comparison of the CAGE
    RAPS4 and RAPS4 and RAPSQ4 by gender, ethnicity
    and service utilization. Alcoholism Clinical and
    Experimental Research 200226(11)1686-1691.

21
For those in a hurry..
  • The FAST questionnaire was created by researchers
    in the UK because of concern that the other tests
    were too time consuming.
  • The FAST is administered in two stages, the first
    of which consists of only 1 question!
  • Stage I
  • How often do you have more than 8 drinks on one
    occasion (6 if patient is a woman)?
  • -If the patient answers never, the test is over
    and the patient is not likely to be misusing
    alcohol
  • -If the patient answers less than monthly,
    monthly, weekly or daily, proceed to Stage II of
    the FAST screening test.
  • Hodgson R, Alwyn T, John B. The FAST Alcohol
    Screening Test. Alcohol Alcohol. 2002
    Jan-Feb37(1)61-6.

22
Stage II of the FAST
  • How often during the last year have you been
    unable to remember what happened the night before
    because of drinking?
  • How often have you failed to do what was expected
    of you because of drinking?
  • In the last year has a family member, friend or
    doctor told you to cut down on your drinking?
  • The answers to these questions are never,
    monthly, less than monthly, weekly or daily.
    Scored from 0 (never) to 4 (daily)
  • A score of above 3 is positive and indicates a
    high probability of problem drinking!

23
Healthy People 2010 Goals
  • 26-1 Reduce deaths and injuries caused by alcohol
    related motor vehicle
  • 26-2 Reduce cirrhosis deaths
  • 26-5 Reduce alcohol-related hospital emergency
    department visits
  • 26-7 Reduce intentional injuries resulting from
    alcohol related violence
  • 26-8 Reduce the cost of lost productivity in the
    workplace due to alcohol use

24
Patients at the Alcoholics Anonymous in McComb,
Mississippi
  • By taking a couple of minutes, a primary care
    physician can help identify problem drinking and
    take the first step towards helping a patient.
  • This potential to help, however, is largely
    untapped Saitz and colleagues found that of a
    sample of patients seeking substance abuse
    treatment, 45 percent reported that their primary
    care physician was unaware of their substance
    abuse!
  • Saitz, R. Mulvey, K.P. Plough, A. and Samet,
    J.H. Physician unawareness of serious substance
    abuse. American Journal of Alcohol Abuse, in
    press.
  • At the AA meetings in McComb, I asked 14 members
    if their primary care physician was aware of
    their alcohol/substance abuse problem, only 3
    indicated their primary care physician was aware
    of their alcohol problem before they went for
    treatment.

25
Quality of EBM
  • Cochrane review supports the use of formal
    screening tests such as the AUDIT and CAGE to
    increase recognition of alcohol problems in
    primary care.
  • Paper supporting the use of RAPS4 was not a RCT
    and the patients tested were from an ER setting,
    not primary care clinics/offices.
  • FAST screening test supporting literature
    requires future research comparing its efficacy
    against other accepted screening tools, but holds
    promise for those physicians on a tight schedule.
  • Data regarding primary physician knowledge of
    patients substance abuse problems is in press,
    to appear in the American Journal of Alcohol
    Abuse. The evidence is not strong and additional
    work is required to demonstrate this finding,
    although an informal survey of McComb AA members
    does support this position.

26
Interpretations and Conclusions
  • Due to the high prevalence of problem drinking in
    the primary care setting (up to 26), the
    significant health risks that result without
    treatment (cirrhosis, hypertension, peripheral
    neuropathy, cardiomyopathy, etc), and its
    tremendous economic impact, alcohol screening is
    recommended in the primary care setting.
  • The literature supports the use of the CAGE and
    AUDIT to screen patients in primary care. CAGE is
    better for identifying current and lifetime
    alcohol abuse/dependence, but the AUDIT for
    hazardous drinking. The use of RAPS4 should be
    limited to the ER setting (like Centreville). It
    has not been proven in the primary care setting.
    The FAST questionnaire requires additional
    studies to prove its efficacy.
  • More important than which test for alcohol
    screening, the physician decides to use, make
    sure you ask about alcohol use! As one physician
    from the USPTF said, With respect to alcohol
    abuse, our charge is straightforward first we
    must ask something, then we must do something.

27
Limitations
  • Time constraints for a in depth discussion
  • Only spoke with 14 members of the McComb AA about
    their relationship with their primary care
    physician.
  • Many of the Cochrane and other RCT/studies
    dealing with alcohol screening tests made
    recommendations based on ER/trauma patients which
    may not be applicable to the primary care/office
    setting

28
Application to Preceptors Practice
  • A brochure was developed on Problem Drinking
    which will help instigate discussion between
    patients and doctors about alcohol use.
  • The brochure will be available in the Field
    Memorial Hospital ER
  • The brochure gives some facts about alcohol
    misuse, contains the RAPS4 screening test and
    provides additional sources for more information
    (including the number to the Summit, Mississippi
    AA chapter)

29
How to use in own practice
  • Being knowledgeable about the alcohol screening
    tests will be an asset to help identify future
    patients at risk for problem drinking in future
    practice
  • Spending time at AA meetings, sessions with Dr.
    Gallant and time in the Centreville ER revealed
    the potential devastation of untreated problem
    drinking in the lives of the patient and the
    effect on their family. By applying these
    screening tests hopefully I will be able to
    prevent a future patients drinking from
    escalating out of control.

30
Relevant literature
  • Babor, T.F. Kranzler, H.R. and Lauerman, R.J.
    Early detection of harmful alcohol consumption
    Comparison of clinical, laboratory, and
    self-report screening procedures. Addictive
    Behaviors14(2)139-157, 1989.
  • Cherpitrel C, Screening for alcohol problems in
    the US General Population Comparison of the CAGE
    RAPS4 and RAPS4 and RAPSQ4 by gender, ethnicity
    and service utilization. Alcoholism Clinical and
    Experimental Research 200226(11)1686-1691.
  • Fiellin DA, Carrington RM, OConnor PG, Screening
    for alcohol problems in primary care a
    systematic review. Archives of Internal Medicine
    20001601977-1989.
  • Fleming M.F. and Barry K.L, Clinical Overview of
    alcohol and drug disorders. In Fleming M.F. and
    Barry K.L. eds of Addictive Disorders.
    ChicagoMosby Textbook, 1992. p3-21.
  • Hodgson R, Alwyn T, John B. The FAST Alcohol
    Screening Test. Alcohol Alcohol. 2002
    Jan-Feb37(1)61-6.
  • Manwell, L. Fleming, M.F. Barry, K. and
    Johnson, K. Tobacco, alcohol, and drug use in a
    primary care sample 90 day prevalence and
    associated factors. Journal of Addictive
    Diseases, in press
  • Saitz, R. Mulvey, K.P. Plough, A. and Samet,
    J.H. Physician unawareness of serious substance
    abuse. American Journal of Alcohol Abuse, in
    press.
  • Saunders, J.B. Aasland, O.G. Babor, T.F.
    Development of the Alcohol Use Disorders
    Identification Test (AUDIT) WHO collaborative
    project on early detection of persons with
    harmful alcohol consumption-II. Addiction
    88791-804, 1993.
  • U.S. Preventive Services Task Force, 1996
  • http//hstat2.nlm.nih.gov/download/553375426949.ht
    ml (HSTAT - National Library of Medicine)
  • http//www.cdc.gov/nchs/fastats/alcohol.htm (CDC
    website on Alcoholism)

31
Thank you
  • Special thank you to all the Doctors and Nurses
    in Centreville, Dr. Streiffer for his help with
    this project and to Dr. Gallant for taking the
    time to meet with me and share his extensive
    knowledge of the subject.
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