Alcohol and Substance Abuse
in the Elderly
Goals, Objectives, Standards



Employ the scope of alcohol use to
benefit the care of the elderly.
Use NIAAA Clinician’s Guide 2005 ed
Identify and treat alcohol syndromes in
daily practice
Personal Well-Being Domains
Personal Relationships
Legal
Health
WELL-BEING
Financial
Work
Drug Abuse in the Elderly



Little EBM, old statistical data
‘Aging Out’ probably not true
Cocaine abuse is as high as 2%
Drug Abuse in the Elderly




Co-morbid Tobacco, Alcohol, Other
Drug
Co-morbid depression, anxiety,
psychiatric disease, personality disorder
Most over 50 users are new users
Personal Loss and Isolation
Scope

7%

Many undetected
Cost



$148 billion 1992 to $185 billion 1998, ~ 25%
Average annual increase 3.8%
Component with highest growth rate



productivity losses of persons incarcerated for
alcohol-related crimes.
Number and rate of offenses fell
Incarceration census rose 6% (chronic inmates)
Presentations







Delirium, Dementia,
Depression, Anxiety, Sleep Disorders
Difficult Behaviors
Exacerbation of Chronic Disease
Unexpected Response to Treatment
Lab Abnormalities
Protean Manifestations
Co-morbidities


Drug abuse
Smoking




80-90%
Relapse
Gambling
Eating disorder, Sleep Disorder
Psychiatric problems 7-75%

Relapse, suicide
Screening Tools

AUDIT







Primary Care
Serious Drinking
Low Racial Bias
Free
Well Normalized
Consistency of self-report vs clinician administered
Out-performs CAGE, MAST
Screening Biomarkers


No real good tests
AUDIT has better sensitivity and
specificity
Biomarker Names to Know





OLD MARKERS
GGT
ALT
AST
CDT

Carbohydrate deficient
transferrin






EMERGING MARKERS
Urine hexoaminidase
Serum hexoaminidase
Sialic Acid
Acetaldehyde adducts
5–HTOL/5–HIAA




Hydroxytryptophol
5–hydroxyindole–3–acetic
acid
Ethyl glucuronide
Transdermal devices
Diagnosis: DSM-IV rationale

Maladaptive EtOH use with 3 of these:









Tolerance
Withdrawal
Impaired control
Neglect of activities
Time spent drinking
Drinking despite problems
Compulsive use
Duration Criterion
Dependence Sub-typing
Diagnostic Criteria










DSM Alcohol Abuse
A. A maladaptive pattern of alcohol use leading to clinically significant
impairment or distress, as manifested by one or more of the following, occurring
within a 12–month period:
(1) Recurrent drinking resulting in a failure to fulfill major role obligations at
work, school, or home
(2) Recurrent drinking in situations in which it is physically hazardous
(3) Recurrent alcohol–related legal problems
(4) Continued alcohol use despite having persistent or recurrent social or
interpersonal problems caused or exacerbated by the effects of alcohol
B. The symptoms have never met the criteria for alcohol dependence.
ICD–10 Harmful Use of Alcohol
A. A pattern of alcohol use that is causing damage to health. The damage may
be physical or mental. The diagnosis requires that actual damage should have
been caused to the mental or physical health of the user.
B. No concurrent diagnosis of alcohol dependence.
NIAAA Clinician’s Guide
http://www.niaaa.nih.gov/

Treatment: Acute

Benzodiazepines




Beta-blockers
Hypovitaminoses



Oxazepam (mixed liver, renal)
Temazepam (no liver, no CYP450)
Wernickes: Thiamine 100 mg IV x 1, 50-100 daily
Hypoglycemia
Electrolyte disorders
Treatment: Chronic







AA
Ongoing Psychiatric/Psychologic Care
Disulfuram
Naltrexone
Acamprosate
SSRI
Lithium
Disulfiram




A substantial literature has been generated on the
use of disulfiram in alcoholism, but the number of
controlled clinical trials is limited.
Controlled clinical trials of disulfiram reveal mixed
findings. There is little evidence that disulfiram
enhances abstinence, but there is evidence that
disulfiram reduces drinking days. When measured,
compliance is a strong predictor of outcome.
Studies of disulfiram implants are methodologically
weak and generally without good evidence of
bioavailability.
Studies of supervised disulfiram administration are
provocative but limited
Naltrexone




Trials of naltrexone in the treatment of
alcoholism are recent and of generally good
quality.
There is good evidence that naltrexone
reduces relapse and number of drinking days
in alcohol-dependent subjects.
There is some evidence that naltrexone
reduces craving and enhances abstinence in
alcohol-dependent subjects.
There is good evidence that naltrexone has a
favorable harms profile.
Acamprosate




Trials of acamprosate in alcohol dependence
are large but limited to European populations.
There is good evidence that acamprosate
enhances abstinence and reduces drinking
days in alcohol-dependent subjects.
There is minimal evidence on the effects of
acamprosate on craving or rates of severe
relapse in alcohol-dependent subjects.
There is good evidence that acamprosate is
reasonably well tolerated and without serious
harms.
Serotonergic Agents



There are several controlled clinical trials of
serotonergic agents in primary alcoholics
without co-morbid mood or anxiety disorders.
There is minimal evidence on the efficacy of
serotonergic agents for treatment of the core
symptoms of alcohol dependence.
There is some evidence on the efficacy of
serotonergic agents for the treatment of
alcohol-dependent symptoms in patients with
co-morbid mood or anxiety disorders,
although the data are limited.
Lithium



There are limited studies on the effects of
lithium in primary alcoholics without comorbid mood disorders.
There is evidence that lithium is not
efficacious in the treatment of the core
symptoms of alcohol dependence.
There is minimal evidence for efficacy of
lithium for the treatment of alcoholdependent symptoms in patients with comorbid depression.
Legal Issues




Under-reporting = failure to diagnose
Under-reporting = failure to treat
Driving issues
Confidentiality
ICD-9 codes




303.90
305.00
303.00
291.81
other and unspecified alcohol dependence
alcohol abuse , unspecified
acute alcohol intoxication, unspecified
alcohol withdrawal
Summary


There is less alcohol related EMB for
elderly
Use NIAAA Clinician’s Guide 2005 ed for
evaluation and treatment
The Guide’s Table of Contents
To order free copies of the
Introduction……………………………….…1
Clinician’s
Guide,
contact
Using the
NIAAA
What’s
the Same, What’s New.......................2
NIAAA…
Clinician’s Guide
Before You Begin……………………………3
By mail
(Updated
2005
Edition)
How
to Help
Patients
Who
Drink Too Much:
NIAAA
Publications
Distribution
ACenter
Clinical Approach
A note to Instructors: This
P.O.
Box
10686
Step
1: Ask
About
Alcohol Use……………4
slideshow
is
intended
towith
be used
For additional training
the as
Rockville,
MDGuide,
20849-0686
Step
2: Assess
for
Alcohol
Usetext
Disorders.…5
Clinician’s
visit
Medscape.com
for
a companion
to
the full
version
online
CME/CE
Step 3:free
and
Assist credit courses.
of theAdvise
Clinician’s
Guide. For best
Coming
in
early
2008:
NIAAA introduces
ByAt-Risk
phone
results,Drinking…..…………..…………6
distribute copies of the
301-443-3860
FreeUseInteractive
Training
Alcohol
Disorders…..……..……...…7
Guide for students to follow along
Video Case
Scenarios
Stepusing
4: At Followup:
Continue
Support
in conjunction
with
the
slide
at Medscape.com -Online
At-Risk Drinking………………………….6
presentation.
Check for availability at
www.niaaa.nih.gov/guide
Alcohol Use Disorders……………............7
www.niaaa.nih.gov/guide
Appendix (Support Materials, FAQs, etc.)……...10-33
HELPING PATIENTS WHO DRINK TOO MUCH
Introduction (cont’d)
The
Guide
wasis
written
How
Much
Is
“Too
“Toofor
Much”?
Much”?
primary care and mental health
IndividualIt
Drinking
becomes
responses
tootomuch
alcohol
vary
it…
–
clinicians.
is produced
by
thewhen
National
on
Alcohol
Drinking
CausesInstitute
at
orlower
elevates
levels
the may
risk for
be problematic
alcoholAbuse
andproblems,
Alcoholism
depending
related
on many factors;
or (NIAAA),
for example…
a component
the National of other health
Complicates
 Patient’sofage
management
Institutes
of Healthconditions
(NIH), with
problems
 Co-existing
guidance
from
physicians,
 Medication
use risksnurses,
There
are
increased
for alcohol-related
advanced
problemspractice
for… nurses,
physician
assistants,
and clinical
Note: The
U.S. Surgeon
General urges
 Men who drink more than 4 standard drinks in a day
researchers.
abstinence
from
drinking
for women
(or more than
14 per
week) and
who
are who
or may
 Women
drinkbecome
more thanpregnant.
3 standard drinks in a
day (or more than 7 per week)
HELPING PATIENTS WHO DRINK TOO MUCH
Introduction (cont’d)
Why Screen for Heavy Drinking?
At-risk drinking and alcohol problems are common
 About 3drinking
in 10 adults drink
at levels
elevate health risks.
 Heavy
often
goesthat
undetected
 Among heavy drinkers, 1 in 4 has alcohol abuse or dependence.
 Patients
with
alcohol
dependence
received
the recommended
quality of
All heavy
drinkers
have
a greater risk
of hypertension,
gastrointestinal
 Patients
are disorders,
likely
tomajor
more
care
only about
10 percent
ofbe
thedepression,
time. receptive,
bleeding,
sleep
hemorrhagicopen,
stroke, cirrhosis
of the
liver, and
cancers.
and
ready
to several
change
than you expect
Most patients don’t object to being screened for alcohol use by
 You
are in a prime position to make a difference
clinicians and are open to hearing advice afterward.
Most interventions
primary care patients
who screen
positive
for heavy
drinking
Brief
can promote
significant,
lasting
reductions
in or
alcohol
uselevels
disorders
showdrinkers
some motivational
to change; and
drinking
in at-risk
who are notreadiness
alcohol dependent.
Those who have the most severe symptoms are often the most ready to
change.
HELPING PATIENTS WHO DRINK TOO MUCH
What’s the Same, What’s New in This Update
Same approach to screening and
intervention
The approach presented in the original
2005 Guide remains unchanged.
Updated and new supporting materials
 Updated medications section (pages 13-16)
 Medication management support (pages 17-22)
 Specialized alcohol counseling resource (page 31)
 Online resources at www.niaaa.nih.gov/guide
(listed on page 27)
 New patient education handouts: see pages 26-27
and online at www.niaaa.nih.gov/guide
BEFORE YOU BEGIN…
Before You Begin…
Decide on a Screening Method
The Clinician’s Guide provides two
screening methods—decide which
you prefer:
• Option 1. A single question about heavy
drinking days* to use during a clinical
interview
• Option 2. The AUDIT – a written selfreport instrument (about 5 minutes to
complete)
* The single question can be used at any time or in
conjunction with the AUDIT.
CLINICIAN SUPPORT MATERIALS – AUDIT
Before
BeforeYou
YouBegin…
Begin…
Think
indications
for the
Set upabout
yourclinical
practice
to simplify
The AUDIT
screening.
Key opportunities include…
process.
is part
found
on
As
of routine
examination

Decide
who
will
conduct
the
page
11…
Before prescribing medication
screening
or administer
In the
emergency
department the
or
…and
a Spanish
AUDIT
urgent care center
translation
is found
Inpatients
who are… progress notes
Use preformatted
on page 12.
 (see
Pregnant
or trying
to conceive page
Online
Materials,
 Likely to drink heavily (e.g. smokers,
27)
For
a complete
Spanish reminders
 Use
computer
adolescents,
young adults)
translation
of
the
visitthat might be alcohol
 Having healthGuide,
problems
 Keep copies of the Pocket Guide
www.niaaa.nih.gov\guide
induced
and
referral information
 Experiencing chronic illness not responding to
treatment
HOW TO HELP PATIENTS: A CLINICAL APPROACH
STEP 1:
Ask About
Alcohol Use
Prescreen: Do you
sometimes drink
beer, wine, or other
alcoholic beverages?
If NO… the screening
is complete.
If YES…
HOW TO HELP PATIENTS: A CLINICAL APPROACH
If YES…
Ask the screening question about
heavy drinking days:
How many times in the past
year have you had…
5 or more drinks in a day? (for men) ?
4 or more drinks in a day? (for women)
Tip: It may be useful to show
patients the Standard Drinks
chart on page 24.
WHAT’S A STANDARD DRINK?
What’s a Standard Drink?
• In the U.S., a standard drink is any drink
that contains about 14 grams of pure
alcohol (about 0.6 fluid ounces or 1.2
tablespoons).
HOW TO HELP PATIENTS: A CLINICAL APPROACH
STEP 1 (continued):
Is the Screening
Positive?
Positive Screening =
 1 or more heavy
drinking days, or…
For patients given the
AUDIT, start here:
Positive Screening =
 AUDIT score of
≥ 8 for men
≥ 4 for women
HOW TO HELP PATIENTS: A CLINICAL APPROACH
STEP 1: Is the Screening Positive?
If NO then…
 Advise staying within these limits:
Maximum Drinking Limits
For healthy men up to age 65—
• no more than 4 drinks in a day AND
• no more than 14 drinks in a week
For healthy women (and healthy men
over age 65)—
• no more than 3 drinks in a day AND
• no more than 7 drinks in a week
HOW TO HELP PATIENTS: A CLINICAL APPROACH
STEP 1: Is the Screening Positive?
If NO then…
 Recommend lower limits or abstinence
as medically indicated for patients who• take medications that interact with
alcohol
• have health conditions exacerbated
by alcohol
• are pregnant (advise abstinence)
 Express openness to talking about
alcohol use and any concern it may raise
 Rescreen annually
HOW TO HELP PATIENTS: A CLINICAL APPROACH
STEP 1: Is the Screening Positive?
If YES then…
 Your patient is an at-risk drinker.
For a more complete picture of the
drinking pattern, determine the
weekly average:
• On average, how many days a
week do you have an alcoholic drink?
x
• On a typical drinking day, how
many drinks do you have?
Weekly Average
HOW TO HELP PATIENTS: A CLINICAL APPROACH
STEP 1: Is the Screening Positive?
If YES then…
Record the following:
 heavy drinking days
in the past year and
 the weekly average
Tip: Download preformatted
Progress Notes and
templates from NIAAA at
www.niaaa.nih.gov/guide
-see materials listed on page 27
GO TO
STEP 2
HOW TO HELP PATIENTS: A CLINICAL APPROACH
STEP 2:
Assess for Alcohol Use
Disorders (AUDs)
Determine if there is—

a maladaptive pattern
of alcohol use

causing clinically
significant impairment
or distress
HOW TO HELP PATIENTS: A CLINICAL APPROACH
STEP 2:
Assess for Alcohol Use
Disorders (AUDs) cont’d
It is important to assess
the severity and extent of
all alcohol-related
symptoms to inform your
decisions about
management.
The Clinician’s Guide
presents a list of
symptoms adapted from
the DSM-IV, Revised.
HOW TO HELP PATIENTS: A CLINICAL APPROACH
STEP 2:
Assess for Alcohol Use
Disorders (AUDs) cont’d
Sample Assessment
Questions are available
online at
www.niaaa.nih.gov/guide
HOW TO HELP PATIENTS: A CLINICAL APPROACH
STEP 2: Assess for AUDs (cont’d)
Determine whether, in the past 12 months,
your patient’s drinking has repeatedly
caused or contributed to…
 risk of bodily harm
 relationship trouble
 role failure
 run-ins with the law
If YES to one or more
your patient has Alcohol Abuse
In either case, proceed to assess for Dependence symptoms.
HOW TO HELP PATIENTS: A CLINICAL APPROACH
STEP 2: Assess for AUDs (cont’d)
Determine whether, in the past 12 months,
your patient has…
 not been able to stick to drinking limits
(repeatedly gone over them)
 not been able to cut down or stop (repeated failed
attempts)
 shown tolerance (needed to drink a lot more to get
the same effect)
 shown signs of withdrawal (tremors, sweating,
nausea, insomnia when trying to quit or cut down)
 kept drinking despite problems (recurrent
physical or psychological problems)
 spent a lot of time drinking (or anticipating or
recovering from drinking)
 spent less time on other matters (activities that
had been important or pleasurable)
If Yes to three or
more your patient has
Alcohol
Dependence
HOW TO HELP PATIENTS: A CLINICAL APPROACH
STEP 2: Assess for AUDs (cont’d)
Does the patient meet the criteria for
alcohol abuse or dependence?
If NO: patient is
still at risk. Go to
Steps 3 & 4 for
At-Risk Drinking
(Page 6)
Page 6
If YES:
Go to Steps 3 & 4
for Alcohol Use
Disorders
(Page 7)
HOW TO HELP PATIENTS: A CLINICAL APPROACH
Example 1:
A patient with
AT-RISK DRINKING
(no abuse or dependence)
Page 6 3:
STEP
Advise and Assist
(Brief Intervention)
HOW TO HELP PATIENTS: A CLINICAL APPROACH
AT-RISK DRINKING
(no abuse or dependence)
STEP 3: Advise and Assist
 State your conclusion and
recommendation clearly
“You are drinking more
than is medically safe.”
image credit: Comstock
HOW TO HELP PATIENTS: A CLINICAL APPROACH
AT-RISK DRINKING
(no abuse or dependence)
STEP 3: Advise and Assist
 State your conclusion and
recommendation clearly
Consider using the chart on page
25 to show increased risk.
“I strongly recommend
that you cut down (or
quit), and I’m willing to
help.”
image credit: Comstock
HOW TO HELP PATIENTS: A CLINICAL APPROACH
AT-RISK DRINKING
(no abuse or dependence)
STEP 3: Advise and Assist
 State your conclusion and
recommendation clearly
 Gauge readiness to change
drinking habits
“Are you willing to
consider making changes
in your drinking?”
image credit: Comstock
HOW TO HELP PATIENTS: A CLINICAL APPROACH
AT-RISK DRINKING
(no abuse or dependence)
STEP 3: Advise and Assist
Is the patient ready to commit to
change at this time?
NO
Do not be discouraged.
Ambivalence is common. Your advice has
likely prompted a change in your patient’s
thinking, a positive change in itself. With
continued reinforcement, your patient may
decide to take action.
HOW TO HELP PATIENTS: A CLINICAL APPROACH
AT-RISK DRINKING
(no abuse or dependence)
STEP 3: Advise and Assist
Is the patient ready to commit to
change at this time?
NO
For now…
 Restate your concern about
his or her health.
HOW TO HELP PATIENTS: A CLINICAL APPROACH
AT-RISK DRINKING
(no abuse or dependence)
STEP 3: Advise and Assist
Is the patient ready to commit to
change at this time?
NO
 Encourage reflection:
Ask patients to weigh what they
like about drinking versus their
reasons for cutting down. What
are the major barriers to change?
HOW TO HELP PATIENTS: A CLINICAL APPROACH
AT-RISK DRINKING
(no abuse or dependence)
STEP 3: Advise and Assist
Is the patient ready to commit to
change at this time?
NO
 Reaffirm your willingness
to help when he or she is
ready.
HOW TO HELP PATIENTS: A CLINICAL APPROACH
AT-RISK DRINKING
(no abuse or dependence)
STEP 3: Advise and Assist
Is the patient ready to commit to
change at this time?
YES
 Help set a goal to cut down to
within maximum limits (see Step 1)
or abstain for a period of time.
HOW TO HELP PATIENTS: A CLINICAL APPROACH
AT-RISK DRINKING
(no abuse or dependence)
STEP 3: Advise and Assist
Is the patient ready to commit to
change at this time?
YES
 Agree on a plan, including—
• what specific steps the patient will take
(e.g., not go to a bar after work,
measure all drinks at home, alternate
alcoholic and non-alcoholic beverages)
HOW TO HELP PATIENTS: A CLINICAL APPROACH
AT-RISK DRINKING
(no abuse or dependence)
STEP 3: Advise and Assist
Is the patient ready to commit to
change at this time?
YES
Agree on a plan (cont’d) including—
• how drinking will be tracked - diary, etc.
• how to manage high-risk situations
• who might be willing to help, such as a
spouse or non-drinking friends
HOW TO HELP PATIENTS: A CLINICAL APPROACH
AT-RISK DRINKING
(no abuse or dependence)
STEP 3: Advise and Assist
Is the patient ready to commit to
change at this time?
YES
 Provide educational
materials—See page 26 for
“Strategies for Cutting Down”
and online materials on page 27
HOW TO HELP PATIENTS: A CLINICAL APPROACH
AT-RISK DRINKING
(no abuse or dependence)
STEP 4: At Followup:
Continue Support
REMINDER: At each visit—
• document alcohol use, and
• review goals
Obtain the drinking quantity
and frequency at followup visits
Tip: Download Progress Notes from
www.niaaa.nih.gov/guide -see materials listed on Page 27
HOW TO HELP PATIENTS: A CLINICAL APPROACH
AT-RISK DRINKING
(no abuse or dependence)
STEP 4: Followup
Was the patient able to meet and
sustain the drinking goal?
NO
 Acknowledge change is difficult.
 Support any positive change. Address barriers.
 Renegotiate the goal and plan (e.g.,
consider abstinence)
 Consider engaging significant others.
 Reassess the diagnosis. (Go to Step 2.)
HOW TO HELP PATIENTS: A CLINICAL APPROACH
AT-RISK DRINKING
(no abuse or dependence)
STEP 4: Followup
Was the patient able to meet and
sustain the drinking goal?
YES
 Reinforce and support continued
adherence to recommendations.
 Renegotiate drinking goals as indicated.
 Encourage patient to return if unable to
maintain adherence.
 Rescreen at least annually.
This completes
Example 1,
a patient with
At-Risk
Drinking.
However, if the patient
assessment completed
in Step 2 indicates an
Alcohol Use Disorder:
GO TO
Steps 3 and 4
(page 7)
HOW TO HELP PATIENTS: A CLINICAL APPROACH
Example 2 -For patients who meet
the criteria for
Alcohol Use Disorders
(abuse or dependence)
STEP 3:
Advise and Assist
(Brief Intervention)
HOW TO HELP PATIENTS: A CLINICAL APPROACH
ALCOHOL USE DISORDERS
(abuse or dependence)
STEP 3: Advise and Assist
 State your conclusion and
recommendation clearly.
• Relate to the patient’s concerns
and medical findings, if present.
“I believe that you have an alcohol
use disorder. I strongly recommend
that you quit drinking and I’m
willing to help.”
image credit: Comstock
HOW TO HELP PATIENTS: A CLINICAL APPROACH
ALCOHOL USE DISORDERS
(abuse or dependence)
STEP 3: Advise and Assist
 Negotiate a drinking goal:
• Abstaining is the safest course for
most patients with AUDs.
• Patients who have milder forms of
alcohol abuse or dependence and
are unwilling to abstain may be
successful at cutting down. (See
Step 3 for At-Risk Drinking, page 6.)
HOW TO HELP PATIENTS: A CLINICAL APPROACH
ALCOHOL USE DISORDERS
(abuse or dependence)
STEP 3: Advise and Assist
 Consider referring for additional
evaluation by an addiction
specialist, especially for
dependence. (See tips on finding
treatment resources, page 23.)
 Consider recommending a mutual
help group.
HOW TO HELP PATIENTS: A CLINICAL APPROACH
ALCOHOL USE DISORDERS
(abuse or dependence)
STEP 3: Advise and Assist
For patients who have alcohol
dependence, consider…
• the
need for medically
managed withdrawal
(detoxification) and treat
accordingly (see page 31)
HOW TO HELP PATIENTS: A CLINICAL APPROACH
ALCOHOL USE DISORDERS
(abuse or dependence)
STEP 3: Advise and Assist
For patients who have alcohol
dependence, consider…
• prescribing
a
medication for
patients who endorse
abstinence as a goal
(see page 13)
HOW TO HELP PATIENTS: A CLINICAL APPROACH
ALCOHOL USE DISORDERS
(abuse or dependence)
STEP 3: Advise and Assist
 Arrange followup
appointments
• including
medication
management support if
needed (see page 17)
HOW TO HELP PATIENTS: A CLINICAL APPROACH
ALCOHOL USE DISORDERS
STEP 4: At Followup:
Continue Support
REMINDER: At each visit—
• document alcohol use, and
• review goals
Obtain the drinking quantity
and frequency at followup visits
Tip: Download progress notes from
www.niaaa.nih.gov/guide -see materials listed on Page 27
HOW TO HELP PATIENTS: A CLINICAL APPROACH
ALCOHOL USE DISORDERS
STEP 4: At Followup
Was the patient able to meet and
sustain the drinking goal?
NO
 Acknowledge that change is difficult.
 Support efforts to cut down or abstain,
while making it clear that your
recommendation is to abstain.
 Relate drinking to problems (medical,
psychological, and social) as appropriate.
HOW TO HELP PATIENTS: A CLINICAL APPROACH
ALCOHOL USE DISORDERS
STEP 4: At Followup
Was the patient able to meet and
sustain the drinking goal?
NO
 If the following measures are not already
being taken, consider
• referring to an addiction specialist or
consulting with one
• recommending a mutual help group
• engaging significant others
• prescribing a medication for alcohol
dependent patients who endorse
abstinence
HOW TO HELP PATIENTS: A CLINICAL APPROACH
ALCOHOL USE DISORDERS
STEP 4: At Followup
Was the patient able to meet and
sustain the drinking goal?
NO
Address coexisting disorders—
medical and psychiatric—as
needed.
HOW TO HELP PATIENTS: A CLINICAL APPROACH
ALCOHOL USE DISORDERS
STEP 4: At Followup
Was the patient able to meet and
sustain the drinking goal?
YES
 Reinforce and support continued
adherence to recommendations.
 Coordinate care with a specialist
if the patient has accepted referral.
HOW TO HELP PATIENTS: A CLINICAL APPROACH
ALCOHOL USE DISORDERS
STEP 4: At Followup
Was the patient able to meet and
sustain the drinking goal?
YES
 Maintain medications for alcohol
dependence for at least 3 months
and as clinically indicated
thereafter.
HOW TO HELP PATIENTS: A CLINICAL APPROACH
ALCOHOL USE DISORDERS
STEP 4: At Followup
Was the patient able to meet and
sustain the drinking goal?
YES
 Treat coexisting nicotine
dependence for 6 to 12 months
after reaching the drinking goal.
HOW TO HELP PATIENTS: A CLINICAL APPROACH
ALCOHOL USE DISORDERS
STEP 4: At Followup
Was the patient able to meet and
sustain the drinking goal?
YES
 Address coexisting disorders—
medical and psychiatric—as
needed.
APPENDIX – CLINICIAN SUPPORT MATERIALS
Following the clinical approach
Clinician
support materials
outlined on pages 6-7, the
(pages
10 to additional
23):
Guide provides
resources
featured
in the The
•Screening
Instrument:
Alcohol Use Disorders
IdentificaAppendix
—
tion Test (AUDIT)…10-12
 Clinician Support
•Prescribing Medications for
Materials………10-23
Alcohol Dependence
 Patient Education
•Supporting Patients Who Take
Materials………24-26
Medications
for Alcohol
Dependence
Online Materials for
Clinicians
and
•Medication
Management
Patients.…………...27
Support
for Alcohol Dependence
Frequently
Asked
-Initial
Session Template
Questions………28-32
- Followup
Session Template
•Referral Resources
APPENDIX – CLINICIAN SUPPORT MATERIALS
Extendedrelease
injectable
Naltrexone
Clinician support materials
(pages 10 to 23):
•Screening Instrument: The
Alcohol Use Disorders
Identification Test (AUDIT)
•Prescribing Medications for
Alcohol Dependence…13-16
•Supporting
This sectionPatients
featuresWho
a Take
Medications
Alcohol
Medicationsfor
Chart
with
Dependence
details about- Naltrexone
– available in
•Medication
Management
2 forms:
oral andDependence
Support
for Alcohol
extended-release
•Initial
Session Template
injectable
•Followup
Session Template
 Acamprosate
 Disulfiram
•Referral
Resources
Oral form
Naltrexone
Acamprosate
Disulfiram
APPENDIX – CLINICIAN SUPPORT MATERIALS
Clinician support materials
(pages 10 to 23):
•Screening Instrument: The
Alcohol Use Disorders
Identification Test (AUDIT)
•Prescribing Medications for
Alcohol Dependence
•Supporting Patients Who Take
Medications for Alcohol
Dependence………………17-18
•Medication Management
Support for Alcohol Dependence
-Initial Session Template…….19
-Followup Session Template…20
•Referral Resources………….22
APPENDIX – CLINICIAN SUPPORT MATERIALS
Patient education
materials (pages 23 to 26):
•What’s a Standard
Drink………………24
•U.S. Adult Drinking
Patterns………….…25
•Strategies for
Down………26
Cutting
APPENDIX
Examples of Free Patient Education Materials
Online
for Clinicians
from NIAAA – in English
andMaterials
Spanish
and Patients… page 27
Alcohol: •Visit
A Women's
the NIAAA Web site at
Health Issue
www.niaaa.nih.gov/guide for
these and other materials to
support you in alcohol
screening, brief interventions,
and followup patient care.
•Check the Website for updates
A Family History
of Alcoholism:
Are You at Risk?
•To order materials
-call NIAAA at 301-443-3860
-or write to: NIAAA
Publications Distribution
Center, P.O. Box 10686,
Rockville, MD 20849-0686
Drinking and
Your Pregnancy
FREQUENTLY ASKED QUESTIONS
Should I recommend any
particular behavioral
therapy for patients with
alcohol use disorders?
The Guide provides
answers to important
What can I do to help
Frequently
patients who struggle
to
Are
laboratoryAsked
tests
How
effective
are brief
When shouldregarding…
I recommend
Questions
or should alcohol
available to screenremain
for or abstinentHow
interventions?
abstaining
versus
cutting
• screening
and
brief
relapse?
monitor
alcohol
withdrawal be managed?
interventions
down?
problems?
• drinking levels and advice
• diagnosing and helping
patients with AUDs
POCKET GUIDE
NIAAA also offers a condensed Pocket Guide.
It features the same step-by-step format and
includes the medications chart and other
supporting materials.
ONLINE TRAINING OPPORTUNITIES
NIAAA Introduces…
Free Interactive Web-based Training
Coming in early 2008
Check availability at
www.niaaa.nih.gov/guide
• Four engaging, 10-minute video case
scenarios and a 20-minute tutorial
• Free CME credits through Medscape.com
Online
technology
brings training
to your
desktop
Meet the patients:
• 4 heavy drinkers at
different levels of severity
and readiness to change
• seen in a variety of
settings
Realistic video
scenarios show
the Clinician’s
Guide in action
Experts offer
insights and
ask what you
would do in
each
situation
POCKET GUIDE
To order free copies of the Guide, Pocket
Guide, or the CD, contact NIAAA…
By mail
NIAAA Publications Distribution Center
P.O. Box 10686
Rockville, MD 20849-0686
By phone 301-443-3860
Online www.niaaa.nih.gov/guide
Bibiliography
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http://www.niaaa.nih.gov/
Harwood, H. Updating Estimates of the Economic Costs of Alcohol Abuse in the United
States: Estimates, Update Methods, and Data. Report prepared by The Lewin Group for the
National Institute on Alcohol Abuse and Alcoholism, 2000. Based on estimates, analyses,
and data reported in Harwood, H.; Fountain, D.; and Livermore, G. The Economic Costs of
Alcohol and Drug Abuse in the United States 1992. Report prepared for the National
Institute on Drug Abuse and the National Institute on Alcohol Abuse and Alcoholism,
National Institutes of Health, Department of Health and Human Services. NIH Publication
No. 98-4327. Rockville, MD: National Institutes of Health, 1998.
Annu Proc Assoc Adv Automot Med. 2007;51:449-64
Scand J Clin Lab Invest. 2007 Jun 24;:1-17
AMDA 2003 position papers on alcohol in facilities (2)
Chiatti, R; Fahmy, S, et al. Cocaine Abuse in Older Adults: An Underscreened Cohort. Journal of the
American Geriatric Society. Vol 58, No. 2 pg 391-392 American Geriatrics Society.
Lin, JD; Darno, MP, et al. Determinants of Early Reductions in Drinking in Older At-Risk Dinkers
Participating in the Intervention Arm of a Trial to Reduce At-Risk Drinking in Primary Care. Journal of the
American Geriatric Society. Vol 58, :227-233. American Geriatrics Society.