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This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the author's clinical recommendations.
A 32-year-old man has a three-month history of difficulty sleeping. On questioning, he mentions that he drinks four to six glasses of wine three to four times per week. How should his case be assessed and managed?
The Clinical Problem
Each year in the United States, 85,000 deaths, along with substantial disability from medical and psychiatric consequences, injuries, and "secondhand" effects (e.g., motor vehicle crashes), are attributed to the use of alcohol. The estimated annual costs that are attributable to alcohol use are $185 billion.1,2 Unhealthy alcohol use covers a spectrum that is associated with varying degrees of risk to health (Table 1 and Figure 1). The prevalence of unhealthy use is 7 to 20 percent or more among outpatients, 30 to 40 percent among patients in emergency departments, and 50 percent among patients with trauma.11,12 Dependence (alcoholism) is best understood as a chronic disease, with peak onset by the age of 18.13
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Strategies and Evidence
Identification
Patients with unhealthy alcohol use often present either asymptomatically, with early-stage problems, or with problems that are not recognized as being alcohol-related. All adults should be screened with a validated survey instrument such as the CAGE questionnaire (where each of the letters in the acronym refers to one of the questions) or the Alcohol Use Disorders Identification Test (AUDIT)11 (Table 2 and the Supplementary Appendix, available with the full text of this article at www.nejm.org). The CAGE questionnaire is brief but was designed primarily to detect dependence. The AUDIT questionnaire is long but detects the spectrum of unhealthy drinking. Asking questions about consumption (AUDIT questions 1 to 3, question 3 alone, or questions about per-occasion drinking) with or without use of the CAGE questionnaire is a less well validated approach that directly determines the degree of risky drinking.3,15,16,17 There may be advantages (including increased truthfulness of patients and efficiency) to embedding screening for alcohol use in interviews about other health issues, but stand-alone screening is the best-studied approach.11
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Assessment and Diagnosis
Standardized interviews can diagnose alcohol abuse and dependence. Patients should be asked whether they have symptoms of alcohol-use disorders in order to determine the diagnosis, the severity of the problem, and the steps that should be taken to address it (Table 1). The assessment should identify common coexisting conditions and situations in which even a moderate amount of alcohol can be harmful, such as pregnancy; the use of medications that can interact with alcohol; the use of alcohol before situations that require attention, coordination, or skill (e.g., driving); a family history of alcoholism; and the presence of cirrhosis, depression, anxiety,19 personality disorders (particularly antisocial and histrionic personality),20 or other conditions that are potentially exacerbated by alcohol.3
Intervention
Detoxification
Among patients who consume approximately 20 standard alcoholic drinks per day, symptomatic withdrawal is likely with abstinence21; however, reported consumption is an imperfect predictor of symptoms associated with withdrawal. Withdrawal can lead to seizures, delirium tremens, or death. However, most often it is mild and easily managed. Benzodiazepines are the only medications proven to ameliorate symptoms and decrease the risk of seizures and delirium tremens; they are routinely indicated for patients with substantial symptoms of withdrawal and those at increased risk for complications (due to coexisting acute illnesses or a history of withdrawal seizures) (Table 3).22 Ethanol should not be used to treat withdrawal.
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"Brief intervention" generally refers to 10 to 15 minutes of counseling, with feedback about drinking, advice and goal setting, and follow-up contact (one or more discussions lasting 10 to 15 minutes with a clinician) (Table 4). Randomized trials in diverse settings (e.g., primary care facilities, emergency departments, hospitals, and colleges) have demonstrated that such brief interventions can decrease drinking and its consequences at six-month follow-up or later, with a reduction of 10.5 percent in the prevalence of risky drinking and a reduction in the intake of alcohol of three to nine drinks per week, as compared with no intervention.4,26,27 Single five-minute contacts appear to be less effective. When such a strategy is used with patients who are not seeking treatment, efficacy is limited to those without alcohol dependence.26
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Another study assessed the long-term effects of a brief intervention among middle-aged male drinkers who were selected on the basis of high serum levels of 
-glutamyltransferase. The intervention consisted of a monthly visit with a nurse and a quarterly visit with a physician for 18 to 48 months, including feedback regarding the importance of the patient's -glutamyltransferase levels and advice that the patient should restrict the use of alcohol. At the 16-year follow-up, alcohol-related mortality was lower in the group that received the intervention than in a group of patients who simply received a letter informing them of the results of the blood test and advising a 2-year follow-up (4 percent vs. 7 percent).29
Brief interventions should include counseling patients about setting a goal for a reduction in alcohol consumption and ways to achieve that goal (Table 4). Interventions may be effective regardless of a patient's readiness to change, but understanding the patient's perception of the problem and whether he or she is ready for change is considered to be important. Motivational-interviewing approaches (which emphasize empathic listening and the autonomy of patients in their own decision making and encourage people to identify their own reasons for change) have been shown to be more effective in reducing drinking than confrontational counseling (which imposes on the patient the clinician's view of the problem, minimizes the patient's perspective, and forces the patient to admit to having a problem).30
Treatment for Dependence
Data from observational and clinical studies indicate that with treatment for alcohol dependence (behavioral or pharmacologic), two thirds of patients have a reduction in the consequences of alcohol consumption (e.g., alcohol-related injury or job loss) and the amount of consumption (by more than 50 percent) after one year; one third of patients who are treated are either abstinent or drink moderately without consequences.31 All patients with alcohol dependence should be offered treatment. Controlled studies that have compared the results of recommendations by physicians that patients cut down their alcohol consumption with those of recommendations that patients abstain did not find differences in drinking outcomes,32 and no more than 11 percent of people with alcohol dependence achieved controlled drinking in the long term.33 Patients with alcohol dependence who are not ready to begin treatment may still benefit from referral to a specialist for confirmation of the diagnosis and recommendations.
Counseling
Effective treatment for alcohol dependence can be provided in the outpatient setting. Patients who have little social support, who have environments that are not supportive of recovery, or who have complex coexisting medical or psychiatric illnesses may need to be removed from environments in which alcohol is likely to be used.34
Cognitive behavioral therapy, 12-step facilitation, and motivational-enhancement therapy (in weekly sessions) are effective treatments that are detailed in written guides for therapists.35 Cognitive behavioral therapy emphasizes the learning of skills to cope with situations that precipitate heavy drinking.36 Twelve-step facilitation emphasizes the concept of alcoholism as a disease and active involvement in Alcoholics Anonymous (AA).37 Motivational-enhancement therapy is motivational interviewing as outlined in written guides.38 A large clinical trial that randomly assigned patients with alcohol dependence to these treatments showed that they had similar efficacy. At the one-year follow-up, abstinence was reported on 85 percent of days in all three groups on average, as compared with 20 to 30 percent of days at the time the study began; at three years, two thirds of the patients were abstinent. In addition, in all groups the proportions of patients who had a relapse of heavy drinking, depression, alcohol-related problems, and other drug use were reduced, as were liver-enzyme levels.
Self-Help
Publications outlining self-help strategies to decrease drinking on the basis of the principles of cognitive behavioral therapy also have proven efficacy. In a randomized trial that compared the results of group or individual sessions designed to encourage self-control with the results of use of a book outlining the same principles, alcohol consumption was similarly reduced in the two groups at 12 months.39 In another randomized trial, the consumption of alcohol above recommended limits was significantly less frequent at the six-month follow-up among drinkers who received a self-help manual, as compared with those who received a booklet with general information and advice (53 percent vs. 78 percent, respectively).40
Mutual Help
AA is a fellowship that provides support, at no charge, for people who want to stop drinking. This approach is appropriate for most persons with alcoholism, except perhaps for those who have great difficulty with social interaction or for those with less severe dependence; however, even those with poor social skills may benefit from the alcohol-free social network.
Evidence for the effectiveness of AA comes primarily from observational studies of individual and group counseling based on 12-step principles35,41 and of AA involvement.42 Follow-up of military veterans revealed a higher frequency of abstinence at 12 months among those participating in 12-step programs than among those participating in programs with a cognitive behavioral orientation (26 percent vs. 19 percent).41 Participation in AA (by attending meetings and having a sponsor) has been associated with increased rates of abstinence seven months after inpatient treatment, as compared with nonparticipation.42 However, AA may be inferior to inpatient treatment. In a randomized trial comparing these two approaches among persons with alcohol-use disorders, hospitalization in the subsequent year was significantly less common among those who had been initially assigned to inpatient treatment than among those assigned to participate in AA (23 percent vs. 63 percent).43
AA involves a belief in a "higher power," a term that does not necessarily refer to a deity but rather to any power greater than oneself. AA supports the use of medications for alcohol dependence (as described below), but some members may disapprove of such a strategy. Meeting types vary (e.g., closed or open and with smoking permitted or not), and schedules are available locally (www.alcoholics-anonymous.org).25
Al-Anon, Alateen (for teenagers), and Adult Children of Alcoholics can help family and friends understand alcoholism and not feel responsible for the illness. In a study in which "concerned significant others" were randomly assigned to participate in various strategies to engage problem drinkers in treatment (one being an approach based on Al-Anon), all strategies led to improvements in the functioning of the significant others and in the quality of the relationship between the family member and the person with the drinking problem.44
Pharmacotherapy
Naltrexone, acamprosate, and disulfiram have reduced heavy drinking and increased abstinence in randomized trials of patients with alcohol dependence, with pharmacotherapy generally lasting 3 to 12 months. Information regarding mechanisms, dosing, and side effects is summarized in Table 3.45,46 A meta-analysis showed that in placebo-controlled, randomized trials of a short duration (three months or less), naltrexone decreased the risk of a return to heavy drinking from 48 percent to 37 percent, and decreased drinking days by 4.5 percent; the proportion of patients who were abstinent was higher with naltrexone (35 percent, vs. 30 percent with placebo), but this finding was of borderline significance.46 In one study,47 even though the decrease in the proportion of patients who had a relapse with naltrexone was not significant (odds ratio, 0.75; 95 percent confidence interval, 0.53 to 1.08), the point estimate was consistent with those of other studies.46 In addition, this study included a severely affected population that may have required more intensive therapy (male veterans with long-standing alcoholism, most not married and many disabled).
A meta-analysis of placebo-controlled trials lasting 3 to 24 months showed that acamprosate increased the proportion of patients who were abstinent (from 15 percent to 23 percent).46 In a single-blind, 12-month study comparing naltrexone with acamprosate, the percentage of patients who reported no heavy drinking was higher with naltrexone than with acamprosate (41 percent vs. 17 percent). For the most recent six months, abstinence was reported by 54 percent and 27 percent, respectively, and percentages of days with heavy drinking were 33 percent and 53 percent, respectively.46 Another trial comparing the combination of the drugs with either drug alone found the combination to be as safe and more effective.48 Most efficacy studies of naltrexone and acamprosate have required detoxification first,46 but two controlled trials found naltrexone to be effective even when patients were not abstinent before starting to take the medication.46,49
Controlled studies suggest that disulfiram can decrease the number of drinking days.45 In small, controlled studies, administration of disulfiram under the supervision of another person improved abstinence as compared with unsupervised use.50 In a six-month controlled trial (in which supervised administration of vitamin C was used as the control), supervised administration of disulfiram resulted in a greater increase in the number of abstinent days.51 Abstinence is required before disulfiram therapy is started.
Counseling should be provided with pharmacotherapy, and primary care management is at least as effective as cognitive behavioral therapy when combined with pharmacotherapy. Primary care management, as tested in randomized trials, includes review of the patient's medical and alcohol-use history; development of a treatment plan with the patient; review of advice, medication issues, and goals for follow-up; referral to AA; and a follow-up session of 15 to 20 minutes every one to two weeks with a physician, nurse practitioner, or physician assistant to discuss adherence to the drug regimen, alcohol use, and any adverse effects of the drug regimen.52
Pharmacotherapy for Coexisting Psychiatric Conditions
Although a detailed review of the treatment of coexisting psychiatric illnesses is beyond the scope of this article, data from randomized trials suggest that pharmacotherapy with antidepressant or anxiolytic agents can decrease alcohol consumption. Increased time to a resumption of heavy drinking has been reported in a study of patients with coexisting anxiety who were treated with buspirone53 and in a study of patients with a coexisting major depression who were treated with desipramine54 or fluoxetine.55 The selective serotonin-reuptake inhibitors citalopram (Celexa) and fluvoxamine (Luvox) have also been reported to increase the proportion of patients who are abstinent among those who do not have depression.56
Areas of Uncertainty
Although screening for unhealthy alcohol use is routinely recommended, there are limited data that show improvements in clinical outcomes after implementation of screening. Despite good evidence to support brief intervention, some observers have questioned its effectiveness and value in practice.27 Limited data suggest that brief interventions have benefits beyond decreased consumption and are cost-effective.4,26,27,28,29,57 Widespread implementation of brief intervention in clinical practice remains a challenge.
Promising strategies, such as additional brief counseling sessions for nondependent, unhealthy drinkers and treatment either with medications in doses as needed for craving49,58 or with more than one medication, require study. The role of new medications for treating alcohol dependence — including ondansetron,59 topiramate,60 and depot preparations of naltrexone61 — remains unclear. Data are limited to guide decisions regarding the type of therapy, the necessary duration and timing of treatments in relation to detoxification,46,49 management in the context of other drug use, and the use of less sedating medications to manage withdrawal.
Guidelines
The U.S. Preventive Services Task Force recommends routine screening for unhealthy alcohol use with the use of the AUDIT or CAGE questionnaires in primary care settings. The group also recommends brief counseling interventions in primary care settings to reduce alcohol misuse and referral to specialty treatment for those with alcohol dependence.5 The American Society of Addiction Medicine recommends the administration of benzodiazepines for the management of alcohol withdrawal and has published criteria for recommending specialty care.22,34
Conclusions and Recommendations
Unhealthy alcohol use can and should be identified with the use of questions validated for this purpose (the AUDIT or CAGE questionnaires or validated questions about alcohol consumption). Asking questions in a matter-of-fact way in the context of the general health history can facilitate discussion of what can be a sensitive topic. For the patient who was described in the vignette, the consumption of alcohol — both per occasion and per week — poses health risks; his sleep disturbance may well be related to his drinking. The patient should be assessed for additional consequences (e.g., depression and hypertension) and symptoms of dependence. Brief counseling should be provided; the counselor should make explicit the relationship between drinking and health consequences, assess the patient's readiness to change, advise him to cut down on alcohol consumption (for nondependent use) or to abstain and obtain specialized treatment (for dependent use), negotiate a plan for reducing consumption, and follow up (at least once and as needed thereafter).
After detoxification, all patients with alcohol dependence should receive treatment from someone with expertise in the field. That treatment should include medication and counseling (on the basis of local availability but favoring a reproducible, tested approach), participation in AA, and weekly follow-up for a month with decreasing frequency thereafter to assess drinking, consequences, medication use, counseling, and participation in AA. Either naltrexone or acamprosate is first-line therapy; naltrexone is the better choice if the patient has not abstained from drinking for at least three to five days. Disulfiram is an alternative that works best when dosing is supervised.
Supported by grants from the National Institute on Alcohol Abuse and Alcoholism (R-01 AA12617, R-01 13216, R-01 13304, R-25 13822, and P60 AA013759), from the National Heart, Lung, and Blood Institute (K30 HL04124), and from the Center for Substance Abuse Treatment at the Substance Abuse and Mental Health Services Administration (04-3314093).
I am indebted to colleagues for discussing an umbrella term to encompass risky drinking and alcohol-use disorders and to Jeffrey H. Samet for critical review of the manuscript.
Source Information
From the Clinical Addiction Research and Education (CARE) Unit, Section of General Internal Medicine, Department of Medicine, Boston University School of Medicine and Boston Medical Center; and the Youth Alcohol Prevention Center and the Department of Epidemiology, Boston University School of Public Health — both in Boston.
Address reprint requests to Dr. Saitz at Boston Medical Center, 91 E. Concord St. #200, Boston, MA 02118, or at rsaitz{at}bu.edu.
References
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Related Letters:
Unhealthy Alcohol Use
Schwan R., Allen J. P., Saitz R.
Extract |
Full Text |
PDF
N Engl J Med 2005;
352:2139-2140, May 19, 2005.
Correspondence
This article has been cited by other articles:
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