Internists may be used to screening for alcohol disorders, but treating them has not traditionally been part of primary care practice, according to Richard Saitz, MD, MPH, FACP.
“When I talk to my colleagues, they all recognize that this is an important issue, and they care about it, so it's not for lack of understanding ... but what they often say, though, is that ‘It's not my responsibility to treat this disease,’” he said.
That may change, however, because of new legislation and classifications. The Affordable Care Act (ACA) now mandates that insurance plans cover alcohol treatment as an essential health care benefit, and the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which was published in 2013, now emphasizes the importance of looking for early signs of at-risk drinking.
Many facilities are working to integrate care for alcohol use disorders into primary care offices, said Dr. Saitz, a professor at Boston University Schools of Medicine and Public Health and a member of its Clinical Addiction Research & Education (CARE) Unit. “But the fact that we're working hard on that now tells you that it's not quite there,” he said. “So I don't think that the docs are doing something wrong; it's that systems are set up to really go against having internists treat this disorder.”
A new approach
The term “alcohol use disorder,” which first appeared in DSM-5, is the consolidation of 2 former diagnoses: alcohol abuse and alcohol dependence, Dr. Saitz said.
While alcohol use disorder is currently the most accurate scientific term that describes the disease state, there's also alcohol use that puts people at risk, he said. An analogy would be ischemic heart disease and hypercholesterolemia, where the former is the disease and the latter is the risk factor, said Dr. Saitz. Terms like “alcoholism” and “alcohol abuse” can be less than helpful in clinical care, he said. For example, he noted that some studies have shown that clinicians will take care of patients differently if they're called an alcohol abuser or someone with alcohol abuse instead of someone who has an alcohol use disorder.
“The terms that we use that can be stigmatizing can actually impact quality of care. So now there's really no reason to ever use the word ‘abuse’ in conjunction with describing somebody who has an alcohol use disorder or somebody who's drinking at-risk amounts of alcohol,” he said.
Douglas M. Burgess, MD, an assistant professor of psychiatry at the University of Missouri in Kansas City, noted that avoiding stigmatizing terms can also help from the patients' perspective. “That can only be a positive in terms of engaging people in treatment and working through a lot of the resistance that you typically experience when people are first coming into treatment,” he said.
Screening and diagnosis
In 2013, the U.S. Preventive Services Task Force recommended screening adults 18 or older for alcohol misuse and providing brief behavioral counseling interventions to reduce alcohol misuse in those engaged in risky or hazardous drinking.
“You should screen everybody because depending on where you're working, of people who come in for an appointment, probably about a quarter of them are going to be drinking in at least a harmful or hazardous fashion, and you want to know that,” said Keith Humphreys, PhD, professor of psychiatry at Stanford University in California.
In particular, internists should screen for consumption to identify the entire spectrum of unhealthy alcohol use, from at-risk drinking to alcohol use disorder, said Dr. Saitz. This is a shift from a frequently used screening tool, the CAGE questionnaire, that focuses instead on consequences of drinking and therefore identifies the more severe end of the spectrum of unhealthy alcohol use, he said. There are 2 screening options that assess consumption, and both are recommended by federal agencies like the National Institute on Alcohol Abuse and Alcoholism (NIAAA), he said. The first is a single item: How many times in the past year have you had 5 or more drinks in a day (4 or more for women and those over 65)? This approach works if a clinician asks the patient out loud or even on a previsit health screen, Dr. Saitz said. An answer greater than 0 is a positive test for unhealthy alcohol use.
The other screening method that's widely recommended but not nearly as widely used is the AUDIT-C (the 3 consumption items from a longer questionnaire called the Alcohol Use Disorders Identification Test), Dr. Saitz said. This tool is well validated for detecting the full spectrum of unhealthy alcohol use, but the disadvantages are that it's 3 questions instead of 1 and that it must be scored because each question has 5 response options with associated points, he noted.
“It's not complicated, but you can't really memorize the 3 questions and the 5 response options for each and how to add it up,” he said. (One solution, Dr. Humphreys suggested, is to have patients fill out the AUDIT-C themselves on a laptop or tablet while waiting to be seen.)
AUDIT-C scores range from 0 to 12, and a score of 3 for women or 4 for men is considered positive. A score of 7 or more suggests a more severe alcohol use disorder, Dr. Saitz said. “With the single item, you don't really get that ... [although] the higher number that they give, the more consistent that is with a more severe disorder,” he said.
After identifying a positive test, an internist should determine if the patient has any of the 11 consequences—such as trouble at work, tolerance, or interpersonal problems—that are the criteria for alcohol use disorder in DSM-5, Dr. Saitz said. The presence of 2 to 3 of these symptoms suggests a mild disorder, whereas 4 to 5 or 6 or more constitute moderate and severe disorders, respectively.
Unhealthy alcohol use
Unhealthy alcohol use poses risks for many health issues, such as acute consequences like injuries and exposure to unsafe sex (and therefore transmission of sexually transmitted infections) and social consequences that can lead to mental health conditions, such as depression and anxiety, Dr. Saitz said. Lower amounts of alcohol are also associated with breast cancer, he said.
More severe disorders can cause loss of brain cells in the frontal cortex and hippocampus, increased incidence of cancer and lung disease, and alcoholic hepatitis, said George Koob, PhD, director of NIAAA. “Severe drinkers are very vulnerable to toxic effects of alcohol on virtually all organs in the body, from the brain to the liver to the pancreas to the heart to the lungs,” he said.
An internist should gauge how much patients are drinking and what they think about the problem, whether they feel it's important to cut back or quit, and how confident they are that they'd succeed in making a change, Dr. Saitz said. “It makes no sense for me to recommend to a patient something that they're not going to do ... because this is something that only they can change,” he said.
The next step is to provide feedback and advise at-risk drinkers or those with mild disorders to cut down, although it's their decision, Dr. Saitz said. Appropriate amounts would be no more than 4 drinks per occasion or 14 per week for men and no more than 3 drinks per occasion and 7 per week for women and those older than 65. Follow up with a routine assessment—perhaps repeating a screening tool for consumption—to monitor changes in drinking habits, he said.
This kind of education is a preventive service because the impact of drinking less is being at a lesser risk of injuries and other negative consequences, Dr. Burgess said. “Those brief interventions can have huge impacts. ... I think there's really a huge role for primary care to address the group of people who have either mild to moderate substance use disorders, assessing for it, and asking about it.”
For patients with a moderate to severe alcohol use disorder, the best medical advice to give in brief counseling is for them to not drink at all, Dr. Saitz said. “For any recommendation, I would then follow by saying, ‘What do you think about that?’” he said. If a patient says she's not ready to quit but that she may be able to cut down, work with her and follow up in a week or 2 to see if she's successful, he said.
“It's certainly true that some people who have had an alcohol use disorder will be able to drink low amounts—not most people—and I can't tell you which ones those are. We can't predict it, so that's why we usually recommend abstinence,” Dr. Saitz said.
More severe disorders
For someone who's already in practice and established, it can be difficult to take on yet another responsibility, such as alcohol treatment, but it's possible, Dr. Saitz said. “You have to start by learning about the medications, by learning about what the efficacious counseling pieces are, by knowing all the resources that are available in your community so you can make effective referrals,” he said.
Although the lifetime prevalence of alcohol use disorders has increased over the past decade, fewer than 20% of affected individuals seek and receive treatment, according to a JAMA Psychiatry study published in August. But primary care physicians have an arsenal of treatment options, experts said.
The more complicated patients who require medications or referral to specialized help don't respond to brief interventions, haven't responded to initial steps of addressing their alcohol use, and have a significant comorbid mental health diagnosis, said Dr. Burgess, medical director for outpatient psychiatric care at Truman Medical Centers in Kansas City, Mo. Patients who are ready to do something about an alcohol use disorder may require detoxification, which can almost always be done as an outpatient if they've never had seizures or delirium tremens before, Dr. Saitz noted. Detox can be done with short-term benzodiazepines as an outpatient or inpatient if needed, but it is not treatment, he said.
Dr. Burgess, however, has a different view on the issue. Most of the time, Dr. Burgess said, those with significant medical comorbidities should not undergo alcohol detox as an outpatient because they are at high risk for impulsive decisions, which could include mixing alcohol and benzodiazepines. These patients, he said, often require inpatient detox, at least for the initial part of treatment. “Perhaps I am overly conservative, but there are few situations where I would feel comfortable prescribing benzodiazepines to an individual who was actively drinking to the point that I thought they required medication to ease their withdrawal symptoms,” he said.
Viable treatments involve manualized therapies, such as cognitive behavioral therapy (CBT) and motivational enhancement therapy, which require referral to someone trained in psychosocial counseling, Dr. Saitz said. Internists and primary care physicians may do some brief motivational counseling repeatedly over time, but not full-fledged therapies, he said.
Behavioral treatments can be very effective, Dr. Koob said. “Cognitive behavioral therapy is particularly effective in treating alcohol use disorder because it can strengthen coping responses, have people avoid stress, and figure out ways to avoid stress in uncomfortable situations,” he said.
It may be difficult to find CBT or motivational enhancement therapy in your community, Dr. Saitz said. “You may find that the addiction treatment program ... won't do the full range of treatments, and the full range of treatments should include manualized therapies and medication treatments. The more common experiential educational counseling, which is available widely in the U.S., has actually not been shown to be effective,” he said.
The overall effectiveness of pharmacotherapy for alcohol use disorder is modest, perhaps because some people respond and some people don't, Dr. Saitz said. “We may be better in the future at [genetically] predicting who those people are, which we look forward to,” he said. There are 3 FDA-approved medications for alcohol use disorders: naltrexone, acamprosate, and disulfiram.
When primary care physicians prescribe medications for moderate to severe alcohol use, the most likely drug is naltrexone, an opioid antagonist, Dr. Saitz said. Naltrexone works by blocking some of the pleasurable effects of alcohol so that there's less incentive for patients to drink, he said, noting that it also blocks externally taken opioids, so these drugs will not work if one needs opioids for pain.
Naltrexone comes in a daily pill or a monthly injectable medication. The latter presents barriers in primary care because a physician must have it in her office to administer it or arrange for the patient to obtain it from a pharmacy before coming to the office, Dr. Saitz said. “The injectable is doable, but it has a few extra steps. On the other hand, that's once a month, whereas the problem with the pills is adherence to a treatment that people aren't so excited to take in the first place,” he said. Naltrexone also may work when taken occasionally before a situation that may involve drinking, although fewer data are available on the efficacy of this type of use, Dr. Saitz said.
Acamprosate, a taurine derivative, appears most useful in people who want to maintain abstinence and are having trouble dealing with the associated low-level irritability and crankiness, Dr. Koob said, noting that it has an effect size similar to that of naltrexone. This medication increases rates of abstinence, Dr. Saitz said, although a challenge to adherence is that it is dosed 3 times daily.
The oldest medication, disulfiram, an aldehyde dehydrogenase inhibitor, works if patients take it, but maintaining adherence is difficult because it makes patients ill when they drink, Dr. Koob said.
Although not FDA-approved for alcohol use disorder, the antiepileptic agent topiramate, which is used to treat seizures, migraines, and pain, appears to reduce alcohol consumption, Dr. Saitz said. “There may be other reasons why an internist might be prescribing topiramate, so having it as a side effect to reduce alcohol consumption might be good,” he said. Dr. Koob noted, however, that he doesn't believe there will be widespread use of the drug for alcohol use disorders because of its severe cognitive debilitating effects. Gabapentin, a drug approved for use for a variety of disorders, such as chronic pain, has shown effectiveness in an initial clinical trial, and an NIAAA clinical trial to evaluate its safety and effectiveness for this indication is under way, Dr. Koob said.
In addition, selective serotonin reuptake inhibitors (SSRIs) taken for depression can reduce alcohol consumption, Dr. Saitz said, and buspirone has also been shown to reduce alcohol consumption in people with anxiety. Dr. Koob cautioned, “Antidepressants do not work on alcohol use disorders unless the person has a major depressive episode, so we have to be very careful there too.” Finally, in a clinical trial, varenicline, an FDA-approved medication for smoking cessation, reduced drinking in both smokers and nonsmokers.
Although alcohol treatment must be covered under the ACA, the Department of Health and Human Services is still working to determine what such treatment should entail. But no matter what is decided, there are not enough addiction specialists to cover all the people who need these treatments, Dr. Humphreys said.
“The only way those [FDA-approved] medications will become a big feature of American health care—as big as they might potentially be and the good they can do—is if primary care docs, internists ... started prescribing them more for people with drinking problems,” he said.