Identification of the Alcoholic and Intervention

Physicians even in affluent areas should recognize that 20% of patients have alcoholism. Therefore, it is important to pay attention to the alcohol-related symptoms and signs as well as laboratory tests that are likely to be abnormal in the context of regular consumption of 6 to 8 or more drinks per day. The two blood tests with between 70% and 80% sensitivity and specificity are -glutamyl transferase (GGT) (>30 U) and carbohydrate-deficient transferrin (CDT) (>20 U/L); the combination of the two is likely to be more accurate than either alone. Physicians should consider these tests when screening patients for high levels of alcohol intake. These serologic markers of heavy drinking can also be useful in monitoring abstinence as they are likely to return toward normal within several weeks of the cessation of drinking; thus, increases in values of as little as 10% are likely to indicate a resumption of heavy alcohol intake. Other blood tests that can be useful in identifying individuals consuming six or more standard drinks per day include high normal MCVs (>91 m3) and serum uric acid (>416 mol/L, or 7 mg/dL). Physical signs and symptoms that can be useful in identifying alcoholism include mild and fluctuating hypertension (e.g., 140/95), repeated infections such as pneumonia, and otherwise unexplained cardiac arrhythmias. Other disorders suggestive of dependence include cancer of the head and neck, esophagus, or stomach as well as cirrhosis, unexplained hepatitis, pancreatitis, bilateral parotid gland swelling, and peripheral neuropathy.

The clinical diagnosis of alcohol abuse or dependence ultimately rests on the documentation of a pattern of difficulties associated with alcohol use; the definition is not based on the quantity and frequency of alcohol consumption.

Thus, in screening it is important to probe for life problems and then attempt to tie in use of alcohol or another substance. Information regarding marital or job problems, legal difficulties, histories of accidents, medical problems, evidence of tolerance, etc., is important. While all physicians should be able to take the time needed to gather such information, some standardized questionnaires can be helpful, including the 10-item Alcohol Use Disorder Screening Test (AUDIT). However, these are only screening tools, and a careful face-to-face interview is still required for a meaningful diagnosis. Shorter questionnaires have limited usefulness.

After alcoholism is identified, the diagnosis must be shared with the patient as part of an intervention. The presenting complaint can be used as an entre'e to the alcohol problem. For instance, the patient complaining of insomnia or hypertension could be told that these are clinically important symptoms and that physical findings and laboratory tests indicate that alcohol appears to have contributed to the complaints and is increasing the risk for further medical and psychological problems. The physician should share information about the course of alcoholism and explore possible avenues of addressing the problem. This process has been codified under the names of brief interventions and motivational interviewing. The former has been shown to be effective in decreasing alcohol use and problems when instituted as two 15-min sessions 1 month apart, along with a telephone follow-up reminder. Motivational interviewing uses the clinician's level of concern and understanding of the need for patients to progress through their own stages of enhanced understanding of their problems to optimize their ability to alter their drinking behaviors.