Alcohol Use Disorders in Primary Care Stephen Maisto, Ph.D. Jennifer S. Funderburk, Ph.D. Center for Integrated Healthcare Syracuse University.

Alcohol Use Disorders Alcohol Use Disorders in Primary Carein Primary Care

Stephen Maisto, Ph.D.Stephen Maisto, Ph.D.Jennifer S. Funderburk, Ph.D.Jennifer S. Funderburk, Ph.D.

Center for Integrated HealthcareCenter for Integrated HealthcareSyracuse UniversitySyracuse University

Alcohol Use and Primary CareAlcohol Use and Primary Care

Heavy/problem alcohol use is a major public Heavy/problem alcohol use is a major public health problemhealth problem““Cost of illness” estimate: $166.5 billion in 1995 Cost of illness” estimate: $166.5 billion in 1995 (Schneider Institute for Health Policy, 2001)(Schneider Institute for Health Policy, 2001)

Primary care as a major entry point in the Primary care as a major entry point in the healthcare system for individuals with behavioral healthcare system for individuals with behavioral problemsproblemsOpportunity for early intervention and Opportunity for early intervention and identification of harmful alcohol use identification of harmful alcohol use Harmful alcohol use are priorities within the VAHarmful alcohol use are priorities within the VA

Objectives for this WorkshopObjectives for this Workshop

Discuss:Discuss:

–Empirically supported screening Empirically supported screening measures useful to screen for measures useful to screen for alcohol misuse in primary carealcohol misuse in primary care

–Brief interventions that can be used Brief interventions that can be used in the primary care environment for in the primary care environment for high risk drinkinghigh risk drinking

After this workshop, After this workshop, you should feel comfortableyou should feel comfortable

Conducting further assessment of alcohol Conducting further assessment of alcohol misuse with patientsmisuse with patientsIdentifying the specific courses of action to Identifying the specific courses of action to take with a patient reporting either take with a patient reporting either hazardous drinking, alcohol abuse, or hazardous drinking, alcohol abuse, or alcohol dependencealcohol dependenceUnderstanding how to effectively deliver Understanding how to effectively deliver the World Health Organization’s Simple the World Health Organization’s Simple Advice brief alcohol interventionAdvice brief alcohol intervention

ProcessProcess

Screening Screening AssessmentAssessment Intervention Intervention

Alcohol ScreeningAlcohol Screening

Definition:Definition:

The use of empirically-based procedures for The use of empirically-based procedures for identifying individuals with alcohol-related identifying individuals with alcohol-related problems or consequences, or those who problems or consequences, or those who are at risk for such difficulties.are at risk for such difficulties.

NIAAA RecommendationsNIAAA Recommendations

Single Question:Single Question:– How many times in the past year have you How many times in the past year have you

had:had:MEN: 5 or more drinks in a day?MEN: 5 or more drinks in a day?

WOMEN: 4 or more drinks in a day?WOMEN: 4 or more drinks in a day?

AUDITAUDIT– 10-item self-report questionnaire10-item self-report questionnaire

WITHIN VA: AUDIT-CWITHIN VA: AUDIT-C

1)1) How often do you have a drink containing How often do you have a drink containing alcohol?alcohol?

Never (0), Monthly or less (1), 2-4 times a month (2), 2-3 times a Never (0), Monthly or less (1), 2-4 times a month (2), 2-3 times a week (3), 4 or more times a week (4)week (3), 4 or more times a week (4)

2)2) How many drinks containing alcohol do you How many drinks containing alcohol do you have on a typical day when you are have on a typical day when you are drinking?drinking?1 or 2 (0), 3 or 4 (1), 5 or 6 (2), 7, 8, or 9 (3), 10 or more (4)1 or 2 (0), 3 or 4 (1), 5 or 6 (2), 7, 8, or 9 (3), 10 or more (4)

3) 3) How often do you have six or more drinks How often do you have six or more drinks on one occasion?on one occasion?Never (0), less than monthly (1), Monthly (2), Weekly (3), Daily or Never (0), less than monthly (1), Monthly (2), Weekly (3), Daily or almost daily (4)almost daily (4)

AUDIT-CAUDIT-C

Annual Clinical Reminder within VA primary care clinics; a Annual Clinical Reminder within VA primary care clinics; a part of the pay for performance for PCPspart of the pay for performance for PCPsDeveloped to effectively screen for excessive drinking or Developed to effectively screen for excessive drinking or alcohol use disorders in the past yearalcohol use disorders in the past year3-items3-itemsScores range from 0 to 12Scores range from 0 to 12Designed to be given in paper formatDesigned to be given in paper formatThose individuals that would benefit from reducing or Those individuals that would benefit from reducing or ceasing drinking score:ceasing drinking score:– Men Men ≥ 4≥ 4– Women ≥ 3Women ≥ 3

Cross-national standardization Cross-national standardization (see Bradley et al., 2007)(see Bradley et al., 2007)

Common Concerns About Common Concerns About AUDIT-C AUDIT-C

Cut-offs for the AUDIT-C seem too sensitiveCut-offs for the AUDIT-C seem too sensitive– Goal of a screening measure: Goal of a screening measure:

Maximize sensitivity and specificityMaximize sensitivity and specificityNot meant to diagnose, rather identify those Not meant to diagnose, rather identify those individuals needing further assessmentindividuals needing further assessment

– Bradley et al. (2007) conducted a cross-Bradley et al. (2007) conducted a cross-sectional validation study—1,319 patientssectional validation study—1,319 patients

Found: Current cut-offs maximized sensitivity (.86) Found: Current cut-offs maximized sensitivity (.86) and specificity (.89) for detecting alcohol misuse, if and specificity (.89) for detecting alcohol misuse, if you increased the cut-off for males to 5 reduced you increased the cut-off for males to 5 reduced sensitivity to .72sensitivity to .72

ProcessProcess


FURTHER ASSESSMENTFURTHER ASSESSMENT

Goals:Goals:– Assess for symptoms of:Assess for symptoms of:

Alcohol DependenceAlcohol Dependence

Alcohol AbuseAlcohol Abuse

Hazardous Alcohol UseHazardous Alcohol Use

DefinitionsDefinitions

Alcohol DependenceAlcohol Dependence: alcohol consumption that : alcohol consumption that may result in a physical dependence on alcohol may result in a physical dependence on alcohol and results in clinical distress/impairmentand results in clinical distress/impairmentHarmful Use/Alcohol AbuseHarmful Use/Alcohol Abuse: “alcohol : “alcohol consumption that results in consequences to consumption that results in consequences to physical and mental health” physical and mental health” (World Health Organization, 2001)(World Health Organization, 2001)

Hazardous DrinkingHazardous Drinking: “pattern of alcohol : “pattern of alcohol consumption that increases the risk of harmful consumption that increases the risk of harmful consequences for the user or others” consequences for the user or others” (World Health (World Health Organization, 2001)Organization, 2001)

AssessmentAssessment

Can use DSM-IV checklist providedCan use DSM-IV checklist provided

You can start by asking:You can start by asking:– What are your drinking habits like?What are your drinking habits like?– How much have you been drinking?How much have you been drinking?– What have you been drinking?What have you been drinking?– Has there ever been a time when you had 5 Has there ever been a time when you had 5

or more drinks on one occasion in the last or more drinks on one occasion in the last year?year?

Further Assessment for Further Assessment for Alcohol DependenceAlcohol Dependence

Focuses on DSM-IV criteriaFocuses on DSM-IV criteria– Has the patient in the past 12 months:Has the patient in the past 12 months:

had to drink more to get the same effecthad to drink more to get the same effectexperienced withdrawal symptoms when cutting down experienced withdrawal symptoms when cutting down or trying to quit? (i.e., sweating, nausea, tremors, or trying to quit? (i.e., sweating, nausea, tremors, insomnia when cutting down or trying to quit drinking)insomnia when cutting down or trying to quit drinking)repeatedly drank more than they were planning to?repeatedly drank more than they were planning to?repeatedly failed at cutting down or quitting drinking or repeatedly failed at cutting down or quitting drinking or persistently wanted to stop drinking?persistently wanted to stop drinking?spent the majority of time drinking or recovering from spent the majority of time drinking or recovering from drinking?drinking?given up other important activities to go drinking?given up other important activities to go drinking?continued drinking despite physical or psychological continued drinking despite physical or psychological

problems (e.g., blackouts, anxiety)?problems (e.g., blackouts, anxiety)?

Further Assessment for Further Assessment for Alcohol AbuseAlcohol Abuse

Focuses on DSM-IV criteria:Focuses on DSM-IV criteria:– In the past 12 months, has the patient’s In the past 12 months, has the patient’s

drinking repeatedly (more than once) caused drinking repeatedly (more than once) caused or been associated with:or been associated with:

Failures in Responsibility (e.g., going to work, Failures in Responsibility (e.g., going to work, doing chores around the house)? doing chores around the house)?

Bodily Risk? (e.g. driving while intoxicated)Bodily Risk? (e.g. driving while intoxicated)

Problems with the Law? Problems with the Law?

Problems with Family and / or Friends? Problems with Family and / or Friends?

What is a Standard Drink?What is a Standard Drink?

5 oz. wine12 oz. beer 1.5 oz of

spirits

Assessment for Hazardous UseAssessment for Hazardous UseFocuses on clarifying quantity and frequency Focuses on clarifying quantity and frequency of drinking:of drinking:– ON ANY DAYON ANY DAY: Drinking more than 4 standard : Drinking more than 4 standard

drinks (men ≤ 65) or 3 standard drinks (women drinks (men ≤ 65) or 3 standard drinks (women and men > 65)and men > 65)

– IN ANY TYPICAL WEEKIN ANY TYPICAL WEEK: Drinking more than 14 : Drinking more than 14 standard drinks (men ≤ 65) or 7 standard drinks standard drinks (men ≤ 65) or 7 standard drinks (women and men > 65)(women and men > 65)

– Drinking more than Drinking more than an average of 2 standard an average of 2 standard drinks per daydrinks per day (men ≤ 65) or (men ≤ 65) or drinking more than drinking more than an average of 1 standard drink per day an average of 1 standard drink per day (women (women and men > 65) and men > 65) Defined by NIAAA, 2005Defined by NIAAA, 2005

ProcessProcess


Institute of Medicine (1990)Institute of Medicine (1990)

LightNone

ModerateSubstantial

Heavy

None

MildModerate

Substantial

Severe

Alcohol Consumption

Alcohol Problems

Intervention OptionsIntervention OptionsStepped Care ApproachStepped Care Approach

Patient reports symptoms meeting DSM-IV diagnosis

of Alcohol Dependence

Discuss a referral to a Substance

Treatment Service

Set the patient up with an appointment,

describe the process, answer any questions

Provide a brief alcohol intervention

Consider talking with the PCP and patient about the

possibility of starting Naltrexone

Patient is receptive to an appointment

Patient is unreceptive to an appointment

These guidelines are based on our review of clinical and research literature, including NIAAA (2007) guidelines.

Basic Information: NaltrexoneBasic Information: Naltrexone

FDA-approved medication for alcohol FDA-approved medication for alcohol dependencedependence

Has been associated with fewer drinking Has been associated with fewer drinking days, reduced rates of relapse, briefer days, reduced rates of relapse, briefer relapse, and reduced drinking during relapse, and reduced drinking during relapse periodsrelapse periods

It is thought to work by reducing an It is thought to work by reducing an individual’s cravingindividual’s craving

Intervention OptionsIntervention Options

Patient reports symptoms meeting DSM-IV diagnosis

of Alcohol Abuse

Discuss a referral to a Substance

Treatment Service

Set the patient up with an appointment,

describe the process, answer any questions


Patient is receptive to an appointment

Patient is unreceptive to an appointment or

provide in addition to appointment

These guidelines are based on our review of clinical and research literature, including NIAAA (2007).

Intervention OptionsIntervention Options

Patient reports hazardous/harmful drinking


These guidelines are based on our review of clinical and research literature.

STYLE OF COMMUNICATION STYLE OF COMMUNICATION THROUGHOUT ALL THROUGHOUT ALL

DISCUSSIONSDISCUSSIONS

MOTIVATIONAL INTERVIEWINGMOTIVATIONAL INTERVIEWING

DANCE RATHER THAN WRESTLE WITH DANCE RATHER THAN WRESTLE WITH THE PATIENT THE PATIENT

CLINICAL TOOLS:CLINICAL TOOLS:– LISTENLISTEN– ELICIT-PROVIDE-ELICITELICIT-PROVIDE-ELICIT– IDENTIFY THE CHANGE TALKIDENTIFY THE CHANGE TALK– USE REFLECTIVE LISTENING TO USE REFLECTIVE LISTENING TO

RESPOND TO CHANGE TALKRESPOND TO CHANGE TALK

IDENTIFY WHERE THE PATIENT IDENTIFY WHERE THE PATIENT IS ON THE STAGES OF CHANGEIS ON THE STAGES OF CHANGE

““Using the ruler below, indicate how ready Using the ruler below, indicate how ready you are to make a change in your you are to make a change in your drinking.” drinking.”

1 2 3 4 5 6 7 8 9 10 Not Ready Ready Trying

to to to Change Unsure Change Change

Motivational InterviewingMotivational Interviewing

PATIENT CENTEREDNESS:PATIENT CENTEREDNESS:– MATCH YOUR COMMUNICATION ABOUT MATCH YOUR COMMUNICATION ABOUT

INTERVENTION TO THE PATIENT’SINTERVENTION TO THE PATIENT’SSTAGE OF CHANGESTAGE OF CHANGE

Pre-contemplation—focus on education, self-assessment Pre-contemplation—focus on education, self-assessment

Contemplation—Avoid argument, use reflective listening, roll Contemplation—Avoid argument, use reflective listening, roll with resistance, use decisional balance (what are the with resistance, use decisional balance (what are the pros/cons to drinking?)pros/cons to drinking?)

Preparation/Action—Set S.M.A.R.T. (specific, measurable, Preparation/Action—Set S.M.A.R.T. (specific, measurable, attainable, realistic, and timely) goals; be positive about attainable, realistic, and timely) goals; be positive about goals setgoals set

Maintenance—focus on relapse preventionMaintenance—focus on relapse prevention

Brief Interventions for Brief Interventions for High Risk DrinkingHigh Risk Drinking

““time limited, patient-centered counseling strategy time limited, patient-centered counseling strategy that focuses on changing patient behavior and that focuses on changing patient behavior and increasing patient compliance with therapy” increasing patient compliance with therapy” (Fleming et (Fleming et al., 1999)al., 1999)

1, 5-min. session to 3, 1-hour sessions1, 5-min. session to 3, 1-hour sessionsStrong evidence for the efficacy of brief Strong evidence for the efficacy of brief interventions interventions (Bertholet et al., 2005; Bien et al., 1993; Kahan et al., 1995; (Bertholet et al., 2005; Bien et al., 1993; Kahan et al., 1995; Moyer et al., 2002; Wilk et al., 1997; Whitlock et al., 2004)Moyer et al., 2002; Wilk et al., 1997; Whitlock et al., 2004)

– Efficacious for substantial reductions of alcohol use Efficacious for substantial reductions of alcohol use compared to no treatment controlscompared to no treatment controls

Examples: Examples: – Based on review by Whitlock et al., 2004--10-19% more of those Based on review by Whitlock et al., 2004--10-19% more of those

participants receiving the intervention achieved recommended participants receiving the intervention achieved recommended drinking levels in comparison to no treatment controlsdrinking levels in comparison to no treatment controls

– WHO brief alcohol intervention– 21% reduction in alcohol useWHO brief alcohol intervention– 21% reduction in alcohol use

– These reductions are maintained at 12 month follow-upsThese reductions are maintained at 12 month follow-ups

World Health Organization:World Health Organization:Simple AdviceSimple Advice

see handoutssee handoutsProvider reviews with participant:Provider reviews with participant:• The Drinker’s PyramidThe Drinker’s Pyramid• Health risks of drinkingHealth risks of drinking• Low-risk drinking and standard drink definitionsLow-risk drinking and standard drink definitions• Consideration of cutting back or abstainingConsideration of cutting back or abstaining

Provider encourages veteran to set a goal ofProvider encourages veteran to set a goal ofcutting back or abstainingcutting back or abstaining

Provider provides veteran with encouragementProvider provides veteran with encouragementtoward maintaining his/her goaltoward maintaining his/her goal

Booster sessionsBooster sessions

2 telephone booster sessions2 telephone booster sessions– Recommend 2 weeks and 4 weeks after brief alcohol Recommend 2 weeks and 4 weeks after brief alcohol

interventionintervention– Inquire about goalInquire about goal– Assess for problems maintaining goalAssess for problems maintaining goal

If participant is experiencing problems:If participant is experiencing problems:– Briefly discuss problem solving Briefly discuss problem solving

– Provide encouragementProvide encouragement

““I’m just calling today to check in with you I’m just calling today to check in with you regarding our conversation 2 weeks ago. I regarding our conversation 2 weeks ago. I wanted to see how you have been doing wanted to see how you have been doing regarding the goals that we set around your regarding the goals that we set around your alcohol use.”alcohol use.”

NIAAA RecommendationsNIAAA Recommendations

Advise and AssistAdvise and Assist– State your conclusion and recommendation State your conclusion and recommendation

clearlyclearly– Gauge readiness to changeGauge readiness to change

Precontemplation-Contemplation---restate Precontemplation-Contemplation---restate concern, encourage reflection, willingness to helpconcern, encourage reflection, willingness to help

Contemplation---Action---set a goal, agree on a Contemplation---Action---set a goal, agree on a planplan

Role-PlayRole-Play

Common Tricky Areas & SolutionsCommon Tricky Areas & Solutions

View that different alcoholic beverages are View that different alcoholic beverages are different in their effects (e.g., I drink beer not different in their effects (e.g., I drink beer not alcohol)alcohol)– Avoid argumentation, just review standard drinksAvoid argumentation, just review standard drinks

Identifying that the individual is drinking at a high Identifying that the individual is drinking at a high risk level may trigger strong reactionsrisk level may trigger strong reactions– Avoid creating additional resistance, remember to roll Avoid creating additional resistance, remember to roll

with themwith them– ““From what you’ve said I can see that you do not see From what you’ve said I can see that you do not see

yourself as a high risk drinker. Let’s just look at what yourself as a high risk drinker. Let’s just look at what research shows as some of the things that can happen research shows as some of the things that can happen at your current level of alcohol use.”at your current level of alcohol use.”


Express your concern as a way to break Express your concern as a way to break down resistancedown resistance– ““I’m concerned about your current level of I’m concerned about your current level of

drinking and how it may be increasing….(e.g, drinking and how it may be increasing….(e.g, your depressed mood, sleep problems)your depressed mood, sleep problems)

Support patient’s independenceSupport patient’s independence– ““Obviously, you need to evaluate the situation Obviously, you need to evaluate the situation

yourself and whether or not you should be yourself and whether or not you should be concerned about the potential consequences concerned about the potential consequences of drinking heavily is up to you.of drinking heavily is up to you.


When setting the drinking goal at the end, be When setting the drinking goal at the end, be sensitive to patient’s reactionsensitive to patient’s reaction– Allow patient to take the leadAllow patient to take the lead– ““It’s up to you to decide what to do about your It’s up to you to decide what to do about your

drinking. Because of your reluctance, what do you drinking. Because of your reluctance, what do you think about spending some time thinking about what think about spending some time thinking about what we’ve discussed today.”we’ve discussed today.”

– ““Based on what we’ve talked about today, I would Based on what we’ve talked about today, I would suggest that you reduce from 2 beers a night to 1 suggest that you reduce from 2 beers a night to 1 beer a night. What do you think about that?beer a night. What do you think about that?

Modifying the Simple Advice Modifying the Simple Advice Intervention for the TelephoneIntervention for the Telephone

Send materials to the patient prior to phone call Send materials to the patient prior to phone call – Include a cover letter indicating to the patient that you will help Include a cover letter indicating to the patient that you will help

them understand these handouts once you talk during the them understand these handouts once you talk during the scheduled appointmentscheduled appointment

Be prepared it will be more difficult because you won’t be Be prepared it will be more difficult because you won’t be able to see the patient’s facial reactionsable to see the patient’s facial reactionsMake sure you review the patient’s medical chart (e.g., Make sure you review the patient’s medical chart (e.g., look at age of patient, previous treatment, psychiatric look at age of patient, previous treatment, psychiatric diagnoses, and medical issues)diagnoses, and medical issues)If you have never met the patient:If you have never met the patient:– It may be more helpful to conduct the intervention within the arena It may be more helpful to conduct the intervention within the arena

of talking to the patient about health behaviors in generalof talking to the patient about health behaviors in general– Send along some (1-2) additional handouts on other health Send along some (1-2) additional handouts on other health

behaviors that might be good to includebehaviors that might be good to include– Begin by assessing health behaviors, including alcohol useBegin by assessing health behaviors, including alcohol use– Discuss how the patient wants to improve his/her health; Discuss how the patient wants to improve his/her health;

summarize goalssummarize goals

DocumentationDocumentation

Progress NoteProgress Note– Clearly describe the assessment conducted, Clearly describe the assessment conducted,

symptoms endorsed, and intervention providedsymptoms endorsed, and intervention provided

Encounter Form—Encounter Form—– Diagnosis: Alcohol Abuse (305.00), Alcohol Diagnosis: Alcohol Abuse (305.00), Alcohol

Dependence (303.9), Screening for Alcoholism Dependence (303.9), Screening for Alcoholism (V79.1)(V79.1)

– Procedure: use your standard code for treatments Procedure: use your standard code for treatments (15, 30 or 45 min blocks) OR use preventive medicine (15, 30 or 45 min blocks) OR use preventive medicine counseling and/or risk factor reduction intervention to counseling and/or risk factor reduction intervention to an individual (15, 30, or 45 minute blocks)an individual (15, 30, or 45 minute blocks)

Role PlaysRole Plays

ConclusionConclusion

CompetenciesCompetenciesAdminister and accurately interpret the Administer and accurately interpret the AUDIT-CAUDIT-C

Conduct further assessment of alcohol Conduct further assessment of alcohol misusemisuse

Deliver the WHO Simple Advice Deliver the WHO Simple Advice interventionintervention

Each competency has areas that cover Each competency has areas that cover specific content that needs to be covered specific content that needs to be covered and the quality of the assessment/ and the quality of the assessment/ interventionintervention

Additional Resources Additional Resources in your packetsin your packets

Self-help bookletSelf-help booklet

Brief Counseling scriptBrief Counseling script

AUDITAUDIT

Helpful ReferencesHelpful References

World Health Organization—Brief Intervention ManualWorld Health Organization—Brief Intervention Manual– http://www.who.int/substance_abuse/publications/http://www.who.int/substance_abuse/publications/

alcohol/en/alcohol/en/NIAAANIAAA– National Institute of Alcohol Abuse and Alcoholism (NIAAA). National Institute of Alcohol Abuse and Alcoholism (NIAAA).

(2007). Helping patients who drink too much: A clinician’s (2007). Helping patients who drink too much: A clinician’s guide. NIH Publication No. 07-3769. guide. NIH Publication No. 07-3769. http://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2http://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/clinicians_guide.htm005/clinicians_guide.htm

Hunter, C.L., Goodie, J.L., Oordt, M.S., & Dobymeyer, A.C. Hunter, C.L., Goodie, J.L., Oordt, M.S., & Dobymeyer, A.C. (2009). Integrated Behavioral Health in Primary Care: (2009). Integrated Behavioral Health in Primary Care: Step-by-step guidance for assessment and intervention. Step-by-step guidance for assessment and intervention. Washington DC: American Psychological Association.Washington DC: American Psychological Association.

Alcohol Use Disorders in Primary Care Stephen Maisto, Ph.D. Jennifer S. Funderburk, Ph.D. Center for Integrated Healthcare Syracuse University.

Documents