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2.
ALCOHOL DEPENDENCE
Steven Asch, M.D., M.P.H.
We relied on four main sources to construct quality indicators for
alcohol abuse among adult women.
Three are the reports of federally
sponsored task forces (United States Preventive Services Task Force
[USPSTF], 1989; Committee of the Institute of Medicine [IOM], 1990;
National Institutes of Health [NIH], 1993) and one is a review article
(Fleming, 1993).
When these core references cited studies to support
individual indicators, we have referenced the original source.
When the
core references were unclear in their support for a particular
indicator, we performed a narrow MEDLINE search of English-language
articles addressing that topic from January 1966 to 1995.
IMPORTANCE
Alcohol is consumed by over half of all American adults, and about
10 percent of users meet criteria for dependence (see below).
It has
been estimated that alcohol accounts for 69,000 deaths annually,
including those resulting from alcohol-related motor vehicle deaths,
homicides, and suicides, as well as the clinical sequelae of chronic use
like cirrhosis, pancreatitis, gastrointestinal bleeding, and
cardiomyopathy (USPSTF, 1989).
Annual societal costs exceed $115
billion in medical treatment, lost productivity, and property damage
(Kamerow et al., 1986).
The lifetime prevalence rate of alcohol
dependence among all individuals in the U.S. aged 18 years and older has
been estimated at 13 percent (Regier et al., 1988).
The one-month
prevalence rate of alcohol dependence in women between the ages of 25
and 44 is about 1 percent, somewhat higher than in older women and
considerably lower than among men (Regier et al., 1988), although the
gap between men and women is probably smaller than reported because
alcohol abuse by women tends to be hidden (Halliday and Bush, 1987, in
Barnes et al., 1987; Cyr and Moulton, 1990).
In addition, evidence has
accumulated that women are more susceptible to cirrhotic, traumatic and
cardiomyopathic complications of heavy alcohol use (Bigby and Cyr, 1995,
- 38 -
in Carlson et al., 1995; Gearhart et al., 1991; Urbano-Marquez et al.,
1995), perhaps as a result of lower levels of gastric alcohol
dehydrogenase (Frezza et al., 1990); however, similar to men, light to
moderate alcohol use by women may actually decrease overall mortality
(Fuchs et al., 1995).
Table 2.1
Standardized One-Month Prevalence Rates of Alcohol
Dependence By Sex and Age
One-Month Prevalence
(percent)
Age
Women
Men
18-24
2.3
6.0
25-44
1.1
6.2
45-64
0.3
4.0
65+
0.3
1.8
All ages
0.9
5.0
Source: Regier et al., 1988
NOTE: The rates are standardized to the age,
sex, and race distribution of the 1980
noninstitutionalized population.
EFFICACY AND/OR EFFECTIVENESS OF INTERVENTIONS
Screening
Common definitions of alcohol dependence require several basic
elements (American Psychiatric Association [APA], 1994):
(1) regular or binge use,
(2) tolerance of the psychoactive effects,
(3) physical dependence, and/or
(4) interference with social function.
The APA defines alcohol abuse as a social disorder distinct from
dependence in that the patient continues to drink despite the knowledge
of recurrent social, occupational, psychological, physical or legal
problems.
Routine measures of biochemical markers like gamma-glutamyl
- 39 -
transferase (GGT) are probably less sensitive and certainly less
specific than clinical history in detecting dependence and abuse
(Hoeksema and de Bock, 1993; USPSTF, 1989).
Screening questionnaires
have reasonable sensitivity and specificity in detecting dependence (see
below), but can be unwieldy to apply en bloc to an unselected
population.
For that reason, many authors recommend instead that
primary care providers at least ask patients about the first basic
element, regular or binge use.
Regular or binge use of alcohol is
usually defined as more than 2 drinks/day, 11 drinks/week, or 5 drinks
in any one day in the last month.
(A drink is generally defined in
ethanol equivalents with 1 ounce representing 1-2 drinks.)
Though
estimates of the sensitivity of patients’ responses to such questions
are lower than the estimated sensitivity of questionnaires (perhaps 50
percent), it can serve as a screen for further evaluation (Fleming,
1993; Cyr and Wartman, 1988; NIH, 1993).
Initial Evaluation
If patients show evidence of regular or binge use, there are many
questionnaires that can assist in determining if the patient meets the
other criteria for alcohol dependence.
The lengthy Michigan Alcoholism
Screening Test (MAST) has a reported sensitivity between 84 and 100
percent and a reported specificity of between 87 and 95 percent.
The
much shorter and more popular CAGE has only 4 items and an estimated
sensitivity and specificity of 49-89 percent and 79-95 percent,
respectively.
Other questionnaires include the Self-Administered
Alcoholism Screening Test (SAAST) (Swenson and Morse, 1975), Alcohol Use
Disorder Identification Test (AUDIT) (Babor and Grant, 1989), the Short
MAST (SMAST) (Selzer et al., 1975), and Health Screening Survey (HSS)
(Fleming and Barry, 1991).
If the patient reports regular or binge
drinking, we propose that the chart should indicate some assessment of
the three other criteria for alcohol dependence or the administration of
one of the above-mentioned questionnaires.
Treatment
Treatment of alcohol dependence is usually divided into three
phases:
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1) detoxification,
2) active treatment and rehabilitation, and
3) relapse prevention.
The Institute of Medicine (IOM) reviewed more than 60 controlled
trials evaluating specific treatments for one of these three phases,
including inpatient and outpatient rehabilitation, mutual help groups,
supportive psychotherapy, disulfuram, benzodiazapines, and aversion
therapy.
While various treatment modalities have clinical trial support
when compared with no treatment, the IOM concluded that there was
insufficient evidence to recommend any one modality over another.
The
Secretary’s Eighth Special Report to Congress on Alcohol and Health
(NIH, 1993) came to a similar conclusion, though the authors emphasized
the need to tailor the treatment to the individual patient.
In
particular, they note one randomized controlled trial of 200 women
assigned to a single gender vs. a mixed gender treatment group (Dahlgren
and Willander, 1989).
In this trial, the women assigned to the single
gender group remained in treatment longer and had higher rates of
program completion.
However, the authors were reluctant to base
recommendations on this single trial because treatment conditions varied
in more aspects than gender segregation.
We propose simply that the
medical record should indicate referral for one of the above treatment
modalities for alcohol dependent patients.
Regular or binge drinkers who do not meet criteria for dependence
can still benefit from medical intervention.
Two recent randomized
trials have shown that primary care providers can reduce alcohol use
among regular or binge drinkers.
A British study of 47 medical
practices and 909 patients who reported they drank more than 35 drinks
per week found that a brief intervention decreased alcohol use, episodes
of binge drinking, and GGT levels (Wallace et al., 1988).
The
intervention in this study consisted of physician advice, a self-help
booklet, a weekly diary of alcohol use, and a written contract in the
form of a prescription.
A U.S. study of 72 women and 54 men who
reported drinking between 21 and 70 drinks per week found that a brief
intervention reduced alcohol use in men but not in women (Scott and
- 41 -
Anderson, 1990).
The intervention in this trial consisted of a 10-
minute brief advice session with the patient’s primary care provider.
Two other randomized trials have also found brief advice to be equally
effective in reducing alcohol use as inpatient treatment (Edwards et
al., 1977; Drummond et al., 1990).
Given the low cost of such an
intervention, many experts have recommended its widespread adoption
(NIH, 1993; Fleming and Barry, 1991).
Follow-up
The core references agree that the third phase of treatment,
relapse prevention, is the most difficult and least well evaluated.
Most of the predictors of relapse (psychosocial stressors, mood state,
concomitant psychiatric diagnoses) are difficult to modify.
Two
randomized trials comparing aftercare protocols have only shown that
those patients who adhere to the assigned protocol relapse less often,
regardless of the type of protocol used (Gilbert, 1988; McLatchie and
Lomp, 1988; NIH, 1993).
These trials compared different aftercare
protocols head-to-head and found no difference in relapse rates by
protocol, but did find that those who did not drop out relapsed less
often.
The outcome could be a result of self-selection of compliant or
motivated patients.
Observational trials of perhaps the best known
aftercare program of all, Alcoholics Anonymous (AA), can be interpreted
in the same way.
Patients who subscribe to the 12-step AA philosophy or
who maintain affiliation relapse less often (Gilbert, 1991; Cross,
1990), but the results could be due to patient self-selection.
A trial
of randomized court mandated attendance of AA meetings vs. no treatment
showed no long-term difference in the likelihood of relapse (Brandsma et
al., 1980).
Given this weak evidence, we cannot recommend any
particular aftercare program.
Instead, we follow Fleming’s
recommendation that providers review all regular or binge drinkers’
alcohol consumption at all subsequent visits (Fleming, 1993).
RECOMMENDED QUALITY INDICATORS FOR ALCOHOL DEPENDENCE
The following criteria apply to women age 18-50.
Diagnosis
Indicator
1.
2.
Screening
New patients should be screened for problem
drinking. This should include an assessment of
at least one of the following:
a. Quantity (e.g., drinks per day)
b. Binge drinking (e.g., more than 5 drinks in
a day in the last month)
Initial Assessment
The record should indicate more detailed
screening for dependence, tolerance of
psychoactive effects, loss of control and
consequences of use (examples include but
are not confined to the following
questionnaires: CAGE, MAST, HSS, AUDIT,
SAAST, and SMAST), if the medical record
indicates any of the following:
a. Patient drinks more than 2 drinks each
day.
b. Patient drinks more than 11 drinks per
week.
c. Patient drinks more than 5 drinks in a
day in the last month.
Quality of
evidence
Literature
Benefits
Comments
II-III
Fleming, 1993
Reduce alcohol-associated
pathology.*
Diagnosis of alcohol dependence requires
regular or binge use. Sensitivity of history
probably about 50 percent. Increased
detection of problem drinkers may lead to
counseling and detoxification and
ultimately cessation of alcohol intake.
II
Fleming, 1993;
Babor and
Grant, 1989;
Swenson and
Morse, 1975;
Selzer et al.,
1975
Reduce alcohol-associated
pathology.*
Diagnosis of alcohol dependence requires
evidence of dependence, loss of control
and consequences. Sensitivity and
specificity of questionnaires are 49-100
percent and 75-95 percent, respectively.
Increased detection of alchohol
dependence may lead to detoxification,
treatment, and cessation.
42
Treatment
Indicator
3.
Patients diagnosed with alcohol dependence
should be referred for further treatment to at
least one of the following:
a. Inpatient rehabilitation program
b. Outpatient rehabilitation program
c. Mutual help group (e.g., AA)
d. Supportive psychotherapy
e. Aversion therapy
Quality of
evidence
I
Literature
Benefits
Comments
NIH, 1993
Reduce alchohol-associated
pathology.*
Multiple clinical trials show effectiveness
of various treatment modalities, though no
one treatment has consistently been
demonstrated to be most effective.
Quality of
evidence
I
Literature
Benefits
Comments
Wallace et al.,
1988; Scott
and Anderson,
1990
Reduce alchohol-associated
pathology.*
III
Fleming, 1993
Reduce alchohol-associated
pathology.*
Two randomized trials have shown
effectiveness of a brief intervention to
reduce alcohol use in regular or binge
drinkers, though one found no effect
among women.
Prevention of relapse is the most difficult
phase of treatment. Experts recommend
frequent reassessment to evaluate
success of intervention.
Follow-up
Indicator
4.
Regular or binge drinkers (as defined above)
should be advised to decrease their drinking.
5.
Providers should reassess the alcohol intake of
patients who report regular or binge drinking at
every visit.
* Alcohol associated pathology includes: cirrhosis, pancreatitis, gastrointestinal bleeding, cardiomyopathy, assault, suicide and motor vehicle accidents. Cirrhosis,
cardiomyopathy and pancreatitis may cause chronic decreases in health-related quality of life due to vomiting, ascites, abdominal pain, bleeding, shortness of breath and
may eventually result in mortality. Gastrointestinal bleeding has a short-term mortality risk as well as a chronic impact on health-related quality of life due to anemia and
other complications. Motor vehicle accidents and assaults may result in chronic disability from injuries and death. The health-related quality of life of persons other than the
patient may also be affected. Liver disease and alcohol-related trauma are more common in women.
Quality of Evidence Codes:
I:
II-1:
II-2:
II-3:
III:
RCT
Nonrandomized controlled trials
Cohort or case analysis
Multiple time series
Opinions or descriptive studies
43
- 44 -
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