# Presentation: 085822

## Using the NIAAA Clinician’s Guide

**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 ***

**Using the NIAAA *****Clinician’s Guide***
**A note to Instructors: **
- This slide show is a companion to the *NIAAA Clinician’s Guide*. For best results, distribute copies of the *Guide* for students to review in conjunction with the presentation.
- To order free copies of the *Guide*, or to download the full-text PDF, visit ***www.niaaa.nih.gov/guide***.

- 05/2008

**Notes:**
May 2008
NOTES: Using the NIAAA Clinician’s Guide (Updated 2005 edition)
1. A note to Instructors-- This slideshow is a companion to the full text version of the NIAAA Clinician’s Guide.  For best results, distribute copies of the Guide for students to review during the presentation.

Additional Training Opportunity:  NIAAA introduces a new free online training resource: Video cases based on the Clinician’s Guide.
 - free CME/CE Credits available from Medscape
 - For details and links to the training, visit www.niaaa.nih.gov/guide

## The Guide’s Table of Contents

**The *****Guide’s *****Table of Contents**
**Introduction**........................................1
**What’s the Same, What’s New**......................2
**Before You Begin**.................................3
**How to Help Patients Who Drink Too Much:**
**A Clinical Approach**
-     Step 1: Ask About Alcohol Use...............4
-     Step 2: Assess for Alcohol Use Disorders....5
-     Step 3: Advise and Assist
-        At-Risk Drinking...............................6
-        Alcohol Use Disorders.........................7
-     Step 4: At Followup: Continue Support
-        At-Risk Drinking...............................6
-        Alcohol Use Disorders...........................7
**Appendix** (Support Materials, FAQs, etc.).....10-33

**Notes:**
May 2008

 The Guide’s Table of Contents
 Introduction...Page 1 
 What’s the Same, What’s New in this Update...Page 2
 Before You Begin...Page 3
 How to Help Patients Who Drink Too Much: A Clinical Approach
    Step 1: Ask About Alcohol Use...Page 4
    Step 2: Assess for Alcohol Use Disorders...Page 5
    Step 3: Advise and Assist
       At-Risk Drinking...Page 6
       Alcohol Use Disorders...Page 7
    Step 4: At Followup: Continue Support
       At-Risk Drinking...Page 6
       Alcohol Use Disorders...Page 7

 Appendix (Supporting Materials, FAQs, etc.)...Pages 10-33

## How Much Is “Too Much”?

**Individual responses to alcohol vary – **
- Drinking at lower levels may be problematic depending on many factors; for example...
-  Patient’s age
-  Co-existing conditions, and
-  Use of medication
**Note: The U.S. Surgeon General urges abstinence from drinking for women who are or may become pregnant.**

**HELPING PATIENTS WHO DRINK TOO MUCH**

**Introduction (cont’d)**

**Introduction**

- The *Guide* was written for primary care and mental health clinicians. It is produced by the National Institute on Alcohol Abuse and Alcoholism (NIAAA), a component of the National Institutes of Health (NIH), with guidance from physicians, nurses, advanced practice nurses, physician assistants, and clinical researchers.

**How Much is “Too Much”?**
**Drinking becomes too much when it...**
-   Causes or elevates the risk for alcohol-
-     related problems, or
-   Complicates management of other health
-     problems

**There are increased risks for alcohol-**
**related problems for...**
-   Men who drink more than 4 standard drinks in a day
-     (or more than 14 per week) and
-  Women who drink more than 3 standard drinks in a
-      day (or more than 7 per week)

**Notes:**
*Introduction
This guide is written for primary care and mental health clinicians. It has been produced by the National Institute on Alcohol Abuse and Alcoholism (NIAAA), a component of the National Institutes of Health, with guidance from physicians, nurses, advanced practice nurses, physician assistants, and clinical researchers.
*How much is “too much”?
Drinking becomes too much when it causes or elevates the risk for alcohol-related problems or complicates the management of other health problems. Men who drink more than 4 standard drinks in a day (or more than 14 per week) and women who drink more than 3 in a day (or more than 7 per week) are at increased risk for alcohol-related problems (see Reference Note 1).

Individual responses to alcohol vary, however. Drinking at lower levels may be problematic depending on many factors, such as age, co-existing conditions, and use of medication. 
Because it is not known whether any amount of alcohol is safe during pregnancy, the Surgeon General urges abstinence for women who are or may become pregnant.

## Introduction (cont’d)

**Introduction ****(cont’d)**
**  ****Why Screen for Heavy Drinking?**

******At-risk drinking and alcohol problems are common**
- About 3 in 10 adults drink at levels that elevate health risks.
- Among heavy drinkers, 1 in 4 has alcohol abuse or dependence.
- All heavy drinkers have a greater risk of hypertension, gastrointestinal bleeding, sleep disorders, major depression, hemorrhagic stroke,  cirrhosis of the liver, and several cancers.

****** ****Heavy drinking often goes undetected**
- Patients with alcohol dependence received the recommended quality of care only about 10 percent of the time.

****** ****Patients are likely to be more receptive, open,   and ready to change than you expect**
- Most patients don’t object to being screened for alcohol use by clinicians and are open to hearing advice afterward.
- Most primary care patients who screen positive for heavy drinking or alcohol use disorders show some motivational readiness to change; and
- Those who have the most severe symptoms are often the most ready to change.

****** ****You are in a prime position to make a difference**
- Brief interventions can promote significant, lasting reductions in drinking levels in at-risk drinkers who are not alcohol dependent.
- Some drinkers who are dependent will accept referral to addiction treatment programs. Even for patients who don’t accept referral, repeated alcohol-focused visits with health providers can lead to significant improvement.

**Notes:**
Why screen for heavy drinking? 
* At-risk drinking and alcohol problems are common. About 3 in 10 U.S. adults drink at levels that elevate their risk for physical, mental health, and social problems.  Of these heavy drinkers, about 1 in 4 currently has alcohol abuse or dependence. All heavy drinkers have a greater risk of hypertension, gastrointestinal bleeding, sleep disorders, major depression, hemorrhagic stroke, cirrhosis of the liver, and several cancers.
* Heavy drinking often goes undetected. In a recent study of primary care practices, for example, patients with alcohol dependence received the recommended quality of care, including assessment and referral to treatment, only about 10 percent of the time.
* Patients are likely to be more receptive, open, and ready to change than you expect. 
Most patients don’t object to being screened for alcohol use by clinicians and are open to hearing advice afterward. In addition, most primary care patients who screen positive for heavy drinking or alcohol use disorders show some motivational readiness to change, with those who have the most severe symptoms being the most ready.
* You are in a prime position to make a difference. Clinical trials have demonstrated that brief interventions can promote significant, lasting reductions in drinking levels in at-risk drinkers who are not alcohol dependent.  Some drinkers who are dependent will accept referral to addiction treatment programs. Even for patients who do not accept a referral, repeated alcohol-focused visits with a health provider can lead to significant improvement.

## Updated and new supporting materials

****** ****The approach presented in the original 2005 *****Guide***** remains unchanged.**

****** ****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](http://www.niaaa.nih.gov/guide)__ __ _

**Updated and new supporting materials**

**Same approach to screening and intervention**

**HELPING PATIENTS WHO DRINK TOO MUCH**

**Notes:**
What’s the Same, What’s New in This Update  
Same approach to screening and intervention – 
The approach to alcohol screening and intervention presented in the 2005 Guide remains unchanged. It still includes a simplified, single-question screening question; more guidance for managing alcohol-dependent patients; and an expanded target audience that includes mental health practitioners.  In the “how-to” section are two noteworthy changes, 1) the prescreening question on page 4 now reads, “Do you sometimes drink beer, wine, or other alcoholic beverages?” 2) on page 5, the assessment criteria remain the same, but the sequence now better reflects a likely progression of symptoms in alcohol use disorders.  
Updated and new supporting materials - 
-Updated medications section. The section on prescribing medications (pages 13–16) contains added information about treatment strategies and options. 
-Medication management support. Patients taking medications for alcohol dependence require some behavioral support, but this doesn’t need to be specialized alcohol counseling. For clinicians in general medicine and mental health settings, the Guide now outlines a brief, effective program of behavioral support that was developed for patients who received pharmacotherapy in a recent clinical trial (pages 17–22).
-Specialized alcohol counseling resource. For those who wish to provide specialized counseling for alcohol dependence, we’ve added information (page 31).  
-Online resources. See page 27 for samples of available Web forms, publications, and training resources.  
-New patient education handout. See page 26 or download it from www.niaaa.nih.gov/guide, also available in Spanish.  
-Transferred sections. Tthe sample questions for assessment and the preformatted progress notes for baseline and followup visits are now available online at www.niaaa.nih.gov/guide. The previous “Materials from NIAAA” section is now part of page 27. 

## Before You Begin... 

**Decide on a Screening Method**
**The *****Clinician’s Guide***** provides two methods for screening:**
**A single question about heavy drinking days* to use during a clinical interview; and**
**the AUDIT, a written self-report instrument; it takes less than five minutes to complete**

**BEFORE YOU BEGIN...**

- * The single interview question can be used at any time, either in conjunction with the AUDIT or alone.

**Notes:**
Before You Begin...
>Decide on a screening method--
The Guide provides two methods for screening: a single question to use during a clinical interview (about heavy drinking days) and a written self-report instrument (the AUDIT). 
The single interview question can be used at any time, either in conjunction with the AUDIT or alone. Some practices may prefer to have patients fill out the AUDIT before they see the clinician. It takes less than 5 minutes to complete and can be copied or incorporated into a health history.

## The AUDIT is found on page 11...

**The AUDIT is found on page 11...**

**...****and a Spanish translation is found on page 12. **

- For a complete Spanish translation of the *Clinician’s Guide*, visit ***www.niaaa.nih.gov/guide***

**Notes:**
Screening Instrument: The Alcohol Use Disorders Identification Test (AUDIT)
Your practice may choose to have patients fill out a written screening instrument before they see a clinician. In this Guide, the AUDIT is provided in both English and Spanish for this purpose. It takes only about 5 minutes to complete, has been tested internationally in primary care settings, and has high levels of validity and reliability. 
You may photocopy these pages.
A minimum score (for nondrinkers) is 0 and the maximum possible score is 40. 
Scores of 8 or more for men (up to age 60) or 4 or more for women, adolescents, and men over the age of 60 are considered positive screens.12,13,14 For patients who have scores near the cut-points, clinicians may wish to examine individual responses to questions and clarify them during the clinical examination. 
Note: The AUDIT’s sensitivity and specificity for detecting heavy drinking and alcohol use disorders varies across different populations. Lowering the cut-points increases sensitivity (the proportion of “true positive” cases) while increasing the number of false positives. Thus, it may be easiest to use a cut-point of 4 for all patients, recognizing that more false positives may be identified among adult men. 

Continuing with screening and assessment -- After the AUDIT is completed, continue with Step 1 of the Guide.

## Before You Begin...

**Set up your practice to simplify the process.**
- Decide who will conduct the screening or administer the AUDIT
- Use preformatted progress notes (see Online Materials, page 27)
- Use computer reminders
- Keep copies of the Pocket Guide and referral information in exam rooms
- Monitor your performance through practice audits

**Before You Begin...**
**Think about clinical indications for screening. Key opportunities include:**
- As part of a **routine examination**
- Before **prescribing a medication that interacts with alcohol **
- In the **emergency department** or
**    ****urgent care center**
- When seeing patients who...
**are pregnant** or trying to conceive
**are likely to drink heavily** (e.g. smokers, adolescents, young  adults)
- have **health problems that might be alcohol induced**
- have a chronic **illness not responding to treatment**

**BEFORE YOU BEGIN...**

**Notes:**
Before You Begin...
>Decide on a screening method--
The Guide provides two methods for screening: a single question to use during a clinical interview (about heavy drinking days) and a written self-report instrument (the AUDIT). 
The single interview question can be used at any time, either in conjunction with the AUDIT or alone. Some practices may prefer to have patients fill out the AUDIT before they see the clinician. It takes less than 5 minutes to complete and can be copied or incorporated into a health history.
>Think about clinical indications for screening.  Key opportunities include:  as part of a routine examination; before prescribing a medication that interacts with alcohol (see box on page 29); in the emergency department or urgent care center; When seeing patients who-- 
*are pregnant or trying to conceive 
*are likely to drink heavily, such as smokers, adolescents, and young adults
*have health problems that might be alcohol induced, such as cardiac arrhythmia, dyspepsia, liver, disease, depression or anxiety, insomnia, trauma
*have a chronic illness that isn't responding to treatment as expected, such as chronic pain, diabetes, gastrointestinal disorders, depression, heart disease, hypertension
>Set up your practice to simplify the process.  
-Decide who will conduct the screening or administer the AUDIT;  
-Use preformatted progress notes (see Online Materials, page 27);   
-Use computer reminders; Keep copies of the Pocket Guide and referral information; 
-Monitor progress through practice audits

## STEP 1:

**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**

**Notes:**
HOW TO HELP PATIENTS: A CLINICAL APPROACH

STEP 1: Ask About Alcohol Use
Prescreen: Do you sometimes drink beer, wine, or other alcoholic beverages?

**HOW TO HELP PATIENTS: A CLINICAL APPROACH**

- Tip: It may be useful to show patients the **Standard Drinks** chart on page 24.

- Ask the screening question about heavy drinking days:**  **
**How many times in the past year have you had...**
**  **
**  **

**If ****YES****...**

**5 ****or more ****drinks in a day? (*****for men*****)**

**4 ****or more ****drinks in a day? (*****for women*****)**

**Notes:**
STEP 1 (Cont’d): 
Following the Prescreen...

If the answer is “NO” - then the screening is complete.
If the answer is “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? (men)
...4 or more drinks in a day? (women)

TIP: it may be useful to show patients the STANDARD DRINKS chart on page 24 in the Guide. 

## What’s a Standard Drink? (page 24)

**What’s a Standard Drink? ****(page 24)**
**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)****.**

**Notes:**
Page 24 of the Clinician’s Guide: What’s a Standard Drink?
   A standard drink is any drink that contains about 14 grams of pure alcohol (about 0.6 fluid ounces or 1.2 tablespoons). On Page 24 is a chart showing standard drink equivalents. These are approximate, as different brands and types of beverages vary in their actual content.    Many people do not know what counts as a standard drink, and thus are unaware of how many standard drinks are held in the containers in which these drinks are often sold. Some examples:
For beer, the approximate number of standard drinks in 
• 12 oz. = 1• 16 oz. = 1.3   
• 22 oz. = 2• 40 oz. = 3.3
For malt liquor, the approximate number of standard drinks in 
• 12 oz. = 1.5• 16 oz. = 2
• 22 oz. = 2.5 • 40 oz. = 4.5 
For table wine, the approximate number of standard drinks in 
• a standard 750 mL (25 oz.) bottle = 5
For 80-proof spirits, or “hard liquor,” the approximate number of standard drinks in 
• a mixed drink = 1 or more*• a pint (16 oz.) = 11 • a fifth (25 oz.) = 17• 1.75 L (59 oz.) = 39
*Note: It can be difficult to estimate the number of standard drinks served in a single mixed drink made with hard liquor. Depending on factors such as the type of spirits and the recipe, one mixed drink can contain from one to three or more standard drinks.

## STEP 1 (continued):

**STEP 1 **(continued):
**Is the Screening Positive****?**

**HOW TO HELP PATIENTS: A CLINICAL APPROACH**

***For patients given the *****AUDIT*****, start here: *****Positive Screening=**** **
** ****AUDIT score of**
**   ≥ ****8 for men**
**   ≥ ****4 for women**

**Positive Screening=**
**1 or more heavy drinking days, or...**

**Notes:**
STEP 1 continued: 
If the patient used a written self-report (such as the AUDIT), start here. 

Is screening positive?
1 or more heavy drinking days, or 
AUDIT score of ≥ 8 for men or ≥ 4 for women 

## Advise staying within these limits:

**STEP 1: Is the Screening Positive?****  **

**HOW TO HELP PATIENTS: A CLINICAL APPROACH**

**   ****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**

**Notes:**
STEP 1 (continued): 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

## STEP 1: Is the Screening Positive?  

**HOW TO HELP PATIENTS: A CLINICAL APPROACH**

*    **In addition...*
- 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 concerns it may raise
**Rescreen** annually

**Notes:**
STEP 1 (continued): Is the screening positive? 
If NO, then ... 

* Recommend lower limits or abstinence as medically indicated; for example, for patients who 
take medications that interact with alcohol
have a health condition exacerbated by alcohol 
are pregnant (advise abstinence)  
* Express openness to talking about alcohol use and any concerns it may raise
* Rescreen annually

## Your patient is an at-risk drinker. For a more complete picture of the drinking pattern, determine the weekly average:

**HOW TO HELP PATIENTS: A CLINICAL APPROACH**

**STEP 1: Is the Screening Positive?****  **

- 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?
- On a typical drinking day, how
-     many **drinks** do you have?
**                            **

**Weekly Average**

**Notes:**
STEP 1 (continued):
Is the screening positive? 
 YES if the patient’s response reflected
 1 or more heavy drinking days or 
 an AUDIT score of ≥ 8 for men or ≥ 4 for women 

Your patient is an at-risk drinker. For a more complete picture of the drinking pattern, determine the weekly average with the following questions:

* On average, how many days a week do you have an alcoholic drink? 
* On a typical drinking day, how many drinks do you have? 
Multiply the responses to determine the weekly average.

## Record the following: 

**HOW TO HELP PATIENTS: A CLINICAL APPROACH**

**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**

**STEP 1: Is the Screening Positive?****  **

**Notes:**
STEP 1 (continued):

*Record heavy drinking days in the past year and the weekly average.
To download preformatted progress notes and templates, go online to www.niaaa.nih.gov/guide (See details on page 27).

GO TO STEP 2

## STEP 2: 

**STEP 2: **

**Assess for Alcohol Use Disorders (AUDs)**

**HOW TO HELP PATIENTS: A CLINICAL APPROACH**

**Determine if there is****—**
**a**** ****maladaptive pattern of alcohol use**

**causing ****clinically significant impairment ****or**** distress**

**Notes:**
STEP 2: Assess for Alcohol Use Disorders 
Determine whether there is a maladaptive pattern of alcohol use, causing clinically significant impairment or distress. 

## STEP 2: 

_***www.niaaa.nih.gov/guide***_

**STEP 2: **
**Assess for Alcohol Use Disorders (AUDs) cont’d**

**HOW TO HELP PATIENTS: A CLINICAL APPROACH**

**It is important to assess the severity and extent of all alcohol-related symptoms to inform your decisions about management.**

**The *****Guide *****presents a list of symptoms adapted from the *****DSM-IV, Revised*****.**

**Notes:**
STEP 2: Assess for Alcohol Use Disorders  Continued

It is important to assess the severity and extent of all alcohol-related symptoms to inform your decisions about management. 

Page 5 of the Clinician’s Guide presents a list of symptoms that is adapted from the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Revised (DSM-IV, Revised).

Sample assessment questions are available online at www.niaaa.nih.gov/guide.

**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)**

**Notes:**
STEP 2: Assess for Alcohol Use Disorders (Continued)
Determine whether, in the past 12 months, your patient’s drinking has REPEATEDLY caused or contributed to...
risk of bodily harm (drinking and driving, operating machinery, swimming) 
relationship trouble (family or friends)
role failure (interference with home, work, or school obligations)  
run-ins with the law (arrests or other legal problems)

If yes to one or more, your patient has alcohol abuse. 
In either case, proceed to assess for alcohol dependence symptoms.

## Alcohol Dependence

**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, or 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)

**HOW TO HELP PATIENTS: A CLINICAL APPROACH**

**If Yes to**** **_**three**_** **_**or**_** **_**more**_** your patient has**** **
**Alcohol Dependence**

**STEP 2: Assess for AUDs**** ****(cont’d)**

**Notes:**
STEP 2: Assess for Alcohol Use Disorders (continued)

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, or 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. 

## STEP 2: Assess for AUDs (cont’d)

**STEP 2: Assess for AUDs**** ****(cont’d)**

**HOW TO HELP PATIENTS: A CLINICAL APPROACH**

**If *****NO:***** patient is still at risk**** for developing alcohol-related problems****. **** ****Go to Steps 3****&****4 for **
***At-Risk Drinking***
**p****age 6**

**Does the patient meet the criteria for alcohol abuse or dependence?**

**Page 6**

**If *****YES:***** ****Your patient has an alcohol use disorder.  ****Go to Steps 3****&****4 for *****Alcohol Use Disorders***
**p****age 7**

**Notes:**
STEP 2: Assess for Alcohol Use Disorders (Continued)

Does the patient meet the criteria for alcohol abuse or dependence?

* If NO: your patient is still at risk for developing alcohol-related problems. 
   Proceed to Steps 3 and 4 on Page 6 for a patient with At-Risk Drinking.

* If YES: your patient has an alcohol use disorder.     Proceed to Steps 3 and 4 on Page 7 for a patient with an Alcohol Use Disorder.

## STEP 3: 

**Page 6**

**HOW TO HELP PATIENTS: A CLINICAL APPROACH**

***Example 1:***
***A patient with***

**AT-RISK DRINKING **
**(no **abuse or dependence**)**

**STEP 3: **
**Advise and Assist (Brief Intervention)**

**Notes:**
Page 6
First Example-- For a Patient with AT-RISK DRINKING (no abuse or dependence) 
STEP 3: Advise and Assist (Brief Intervention)

## STEP 3: Advise and Assist

**AT-RISK DRINKING **
**(no **abuse or dependence**)**

**STEP 3: Advise and Assist**
**State your conclusion and recommendation clearly**

**HOW TO HELP PATIENTS: A CLINICAL APPROACH**

- “You are drinking more than is medically safe.”

**Notes:**
For 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.” Relate to patient’s concerns and medical findings, if present. (Consider using the "Drinking Patterns" chart in the appendix to show increased risk.) 
“I strongly recommend that you cut down (or quit).” (See appendix for advice considerations.) 
Gauge readiness to change drinking habits:“Are you willing to consider making changes in your drinking?” 

## STEP 3: Advise and Assist

**AT-RISK DRINKING **
**(no **abuse or dependence**)**

**STEP 3: Advise and Assist**
**State your conclusion and recommendation clearly**

**HOW TO HELP PATIENTS: A CLINICAL APPROACH**

- Consider using the chart on page 25 to show increased risk.  See page 29 for advice considering recommendations.

- “I strongly recommend that you cut down (or quit), and I’m willing to help.”

**Notes:**
For 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.” Relate to patient’s concerns and medical findings, if present. (Consider using the "Drinking Patterns" chart in the appendix to show increased risk.) 
“I strongly recommend that you cut down (or quit).” (See appendix for advice considerations.) 
Gauge readiness to change drinking habits:“Are you willing to consider making changes in your drinking?” 

## STEP 3: Advise and Assist

**STEP 3: Advise and Assist**
**State your conclusion and recommendation clearly**

**HOW TO HELP PATIENTS: A CLINICAL APPROACH**

**Gauge readiness to change drinking habits**

- “Are you willing to consider making changes in your drinking?”

**AT-RISK DRINKING **
**(no **abuse or dependence**)**

**Notes:**
For 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.” Relate to patient’s concerns and medical findings, if present. (Consider using the "Drinking Patterns" chart in the appendix to show increased risk.) 
“I strongly recommend that you cut down (or quit).” (See appendix for advice considerations.) 
Gauge readiness to change drinking habits:“Are you willing to consider making changes in your drinking?” 

## Do not be discouraged. 

**AT-RISK DRINKING **
**(no **abuse or dependence**)**

**STEP 3: Advise and Assist**

**HOW TO HELP PATIENTS: A CLINICAL APPROACH**

**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.

**Notes:**
For AT-RISK DRINKING (no abuse or dependence): 
Step 3: Advise and Assist -- 
Is the patient ready to commit to change at this time? 
RESPONSE: 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. For now, 
Restate your concern about his or her health. 
Encourage reflection: Ask patients to weigh what they like about drinking versus their reasons for cutting down. What are the major barriers to change? 
Reaffirm your willingness to help when he or she is ready. 

## For now...

**AT-RISK DRINKING **
**(no **abuse or dependence**)**

**STEP 3: Advise and Assist**

**HOW TO HELP PATIENTS: A CLINICAL APPROACH**

**Is the patient ready to commit to change at this time?**

**NO**

**Restate your concern** about his or her health.

**Notes:**
For AT-RISK DRINKING (no abuse or dependence): 
Step 3: Advise and Assist -- 
Is the patient ready to commit to change at this time? 
RESPONSE: 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. For now, 
Restate your concern about his or her health. 
Encourage reflection: Ask patients to weigh what they like about drinking versus their reasons for cutting down. What are the major barriers to change? 
Reaffirm your willingness to help when he or she is ready. 

## STEP 3: Advise and Assist

**AT-RISK DRINKING **
**(no **abuse or dependence**)**

**STEP 3: Advise and Assist**

**HOW TO HELP PATIENTS: A CLINICAL APPROACH**

**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?

**Notes:**
For AT-RISK DRINKING (no abuse or dependence): 
Step 3: Advise and Assist -- 
Is the patient ready to commit to change at this time? 
RESPONSE: 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. For now, 
Restate your concern about his or her health. 
Encourage reflection: Ask patients to weigh what they like about drinking versus their reasons for cutting down. What are the major barriers to change? 
Reaffirm your willingness to help when he or she is ready. 

## Reaffirm your willingness to help when he or she is ready. 

**AT-RISK DRINKING **
**(no **abuse or dependence**)**

**STEP 3: Advise and Assist**

**HOW TO HELP PATIENTS: A CLINICAL APPROACH**

**Is the patient ready to commit to change at this time?**

**NO**

**Reaffirm your willingness to help **when he or she is ready.

**Notes:**
For AT-RISK DRINKING (no abuse or dependence): 
Step 3: Advise and Assist -- 
Is the patient ready to commit to change at this time? 
RESPONSE: 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. For now, 
Restate your concern about his or her health. 
Encourage reflection: Ask patients to weigh what they like about drinking versus their reasons for cutting down. What are the major barriers to change? 
Reaffirm your willingness to help when he or she is ready. 

## Help set a goal to cut down to within maximum limits (see Step 1) or abstain for a period of time.

**STEP 3: Advise and Assist**

**HOW TO HELP PATIENTS: A CLINICAL APPROACH**

**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.

**AT-RISK DRINKING **
**(no **abuse or dependence**)**

**Notes:**
For AT-RISK DRINKING (no abuse or dependence): 
Step 3: Advise and Assist -- 
Is the patient ready to commit to change at this time? 
RESPONSE: YES
Help set a goal: Cut down to within maximum limits (see Step 1) or abstain for a period of time. 
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 drinking will be tracked (diary, kitchen calendar) 
how the patient will manage high-risk situations 
who might be willing to help, such as a spouse or nondrinking friends 
Provide educational materials (see appendix, page 29). 

## STEP 3: Advise and Assist

**STEP 3: Advise and Assist**

**HOW TO HELP PATIENTS: A CLINICAL APPROACH**

**Is the patient ready to commit to change at this time?**

**AT-RISK DRINKING **
**(no **abuse or dependence**)**

**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)

**YES**

**Notes:**
For AT-RISK DRINKING (no abuse or dependence): 
Step 3: Advise and Assist -- 
Is the patient ready to commit to change at this time? 
RESPONSE: YES
Help set a goal: Cut down to within maximum limits (see Step 1) or abstain for a period of time. 
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 drinking will be tracked (diary, kitchen calendar) 
how the patient will manage high-risk situations 
who might be willing to help, such as a spouse or nondrinking friends 
Provide educational materials (see appendix, page 29). 

## STEP 3: Advise and Assist

**STEP 3: Advise and Assist**

**HOW TO HELP PATIENTS: A CLINICAL APPROACH**

**Is the patient ready to commit to change at this time?**

**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

**AT-RISK DRINKING **
**(no **abuse or dependence**)**

**YES**

**Notes:**
For AT-RISK DRINKING (no abuse or dependence): 
Step 3: Advise and Assist -- 
Is the patient ready to commit to change at this time? 
RESPONSE: YES
Help set a goal: Cut down to within maximum limits (see Step 1) or abstain for a period of time. 
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 drinking will be tracked (diary, kitchen calendar) 
how the patient will manage high-risk situations 
who might be willing to help, such as a spouse or nondrinking friends 
Provide educational materials (see appendix, page 29). 

## Provide educational materials—See page 26 for “Strategies for Cutting Down” and                             on page 27

**STEP 3: Advise and Assist**

**HOW TO HELP PATIENTS: A CLINICAL APPROACH**

**Is the patient ready to commit to change at this time?**

**AT-RISK DRINKING **
**(no **abuse or dependence**)**

**YES**

**Provide educational materials**—See page 26 for **“Strategies for Cutting Down”** and                             on page 27

_**online materials**_

**Notes:**
For AT-RISK DRINKING (no abuse or dependence): 
Step 3: Advise and Assist -- 
Is the patient ready to commit to change at this time? 
RESPONSE: YES
Help set a goal: Cut down to within maximum limits (see Step 1) or abstain for a period of time. 
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 drinking will be tracked (diary, kitchen calendar) 
how the patient will manage high-risk situations 
who might be willing to help, such as a spouse or non-drinking friends 

Provide educational materials—See page 26 for “Strategies for Cutting Down” and online materials from www.niaaa.nih.gov/guide – materials are listed at page 27 

## STEP 4: At Followup: 

**STEP 4: At Followup: **
**Continue Support**

**HOW TO HELP PATIENTS: A CLINICAL APPROACH**

**REMINDER: **At each visit—
- document alcohol use, and
- review goals

*Obtain the**** drinking quantity and frequency ****at followup visits*

**AT-RISK DRINKING **
**(no **abuse or dependence**)**

- Tip: Download **Progress Notes** from
- _[www.niaaa.nih.gov/guide](http://www.niaaa.nih.gov/guide)_**  **--
- see** **materials listed on Page 27

**Notes:**
For AT-RISK DRINKING (no abuse or dependence): 
STEP 4: At Follow Up --
Continue Support 
REMINDER: Document alcohol use and review goals at each visit 

* Obtain the drinking quantity and frequency at followup visits

TIP: Download progress notes from www.niaaa.nih.gov/guide 
see Page 27 for details

## STEP 4: At Followup:

**STEP 4: ****At ****Followup****:**

**HOW TO HELP PATIENTS: A CLINICAL APPROACH**

**AT-RISK DRINKING **
**(no **abuse or dependence**)**

**Was the patient able to meet and sustain the drinking goal?**

**NO**

**Acknowledge change is difficult.**
**Support any positive change**** **and address barriers to reaching the goal.
**Renegotiate the goal and plan****;** consider a trial of abstinence.
**Consider engaging significant others.**
**Reassess the diagnosis**** **if the patient is unable to either cut down or abstain (Go to Step 2.)

**Notes:**
For AT-RISK DRINKING (no abuse or dependence): 
STEP 4: At Follow Up--
Was the patient able to meet and sustain the drinking goal? 
RESPONSE: NO
Acknowledge that change is difficult. 
Support any positive change and address barriers to reaching the goal. 
Renegotiate the goal and plan; consider a trial of abstinence. 
Consider engaging significant others. 
Reassess the diagnosis if the patient is unable to either cut down or abstain. (Go to Step 2.) 

## STEP 4: At Followup:

**STEP 4: ****At ****Followup****:**

**HOW TO HELP PATIENTS: A CLINICAL APPROACH**

**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.

**AT-RISK DRINKING **
**(no **abuse or dependence**)**

**YES**

**Was the patient able to meet and sustain the drinking goal?**

**Notes:**
For AT-RISK DRINKING (no abuse or dependence): 
STEP 4: At Follow Up--
Was the patient able to meet and sustain the drinking goal? 
RESPONSE: YES
Reinforce and support continued adherence to recommendations. 
Renegotiate drinking goals as indicated (e.g., if the medical condition changes or if an abstaining patient wishes to resume drinking). 
Encourage patient to return if unable to maintain adherence. 
Rescreen at least annually 

## Steps 3 and 4

**However, if the patient assessment completed in ****Step 2**** indicates an *****Alcohol Use Disorder:***

**This completes**** ****Example 1****, a patient with**
***At-Risk Drinking*****.**

**GO TO**
**Steps 3**** and ****4**
- page 7

**Notes:**
This completes Steps 3 and 4 for Example 1, a patient with At-Risk Drinking. 

However, if a patient’s assessment completed in Step 2 indicates the patient has an Alcohol Use Disorder, go to Steps 3 and 4 presented on Page 7, as follows...

## Example 2 --

***Example 2 --***
***For patients who meet the criteria for ***

**Alcohol Use Disorders **
**(abuse or dependence)**

**STEP 3: **
**Advise and Assist (Brief Intervention)**

**Notes:**

Example 2: For Patients with
 ALCOHOL USE DISORDERS (abuse or dependence): 
 STEP 3: Advise and Assist (Brief Intervention)

## STEP 3: Advise and Assist

**STEP 3: Advise and Assist**
**State your conclusion and recommendation clearly.**

**ALCOHOL USE DISORDERS **(abuse or dependence)

**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.” **

**HOW TO HELP PATIENTS: A CLINICAL APPROACH**

**Notes:**
FOR ALCOHOL USE DISORDERS (abuse or dependence): 
STEP 3: Advise and Assist -- 
Advise and Assist 
* State your conclusion and recommendation clearly: 
- “I believe that you have an alcohol use disorder.  I strongly recommend that you quit drinking and I’m willing to help.” 
* Relate to the patient's concerns and medical findings if present. 

## STEP 3: Advise and Assist 

**STEP 3: Advise and Assist**** **
**Negotiate a drinking goal:**
**Abstaining is the safest course for most patients with ****alcohol use disorders (A****UDs****)****. **
**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)** **

**ALCOHOL USE DISORDERS **(abuse or dependence)

**HOW TO HELP PATIENTS: A CLINICAL APPROACH**

**Notes:**
FOR ALCOHOL USE DISORDERS (abuse or dependence): 
STEP 3: Advise and Assist --  
Negotiate a drinking goal: 
Abstaining is the safest course for most patients with alcohol use disorders.
Patients who have milder forms of abuse or dependence and are unwilling to abstain may be successful at cutting down. (See Step 3 for At-Risk Drinking, page 6.) 

## STEP 3: Advise and Assist 

**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)

**Notes:**
FOR ALCOHOL USE DISORDERS (abuse or dependence): 
STEP 3: Advise and Assist -- 
Consider referring for additional evaluation by an addiction specialist, especially if the patient is dependent. (See Page 23 for tips on finding treatment resources) 
Consider recommending a mutual help group. 

## For patients who have alcohol dependence, consider...

**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)

**Notes:**
FOR 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 appendix, Page 31). 

## For patients who have alcohol dependence, consider...

**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**)

**Notes:**
FOR ALCOHOL USE DISORDERS (abuse or dependence): 
STEP 3: Advise and Assist -- 
For patients who have ALCOHOL DEPENDENCE, consider...
prescribing a medication for alcohol dependence for patients who endorse abstinence as a goal (see appendix, Page 13). 

## Arrange followup appointments

**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)

**Notes:**
FOR ALCOHOL USE DISORDERS (abuse or dependence): 
STEP 3: Advise and Assist -- 
Arrange followup appointments, including medication management support if needed (see page 17)

## STEP 4: At Followup: 

**ALCOHOL USE DISORDERS**

**HOW TO HELP PATIENTS: A CLINICAL APPROACH**

**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](http://www.niaaa.nih.gov/guide)_**  **--
- see** **materials listed on Page 27

**Notes:**
FOR ALCOHOL USE DISORDERS (abuse or dependence): 
STEP 4: AT FOLLOWUP: Continue Support  

REMINDER: Document alcohol use and review goals at each visit 
TIP: Download progress notes from www.niaaa.nih.gov/guide
- see materials listed on page 27

## STEP 4: At Followup:

**STEP 4: At Followup****:**

**HOW TO HELP PATIENTS: A CLINICAL APPROACH**

**Was the patient able to meet and sustain the drinking goal?**

**ALCOHOL USE DISORDERS**

**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.

**Notes:**
FOR ALCOHOL USE DISORDERS (abuse or dependence): 
STEP 4: AT FOLLOWUP: Continue Support
REMINDER: Document alcohol use and review goals at each visit 
TIP: Download progress notes from www.niaaa.nih.gov/guide
- see page 27 for details.

Was the patient able to meet and sustain the drinking goal?
RESPONSE: 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. 
If these 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 as a goal. 
Address coexisting disorders—medical and psychiatric—as needed. 

## STEP 4: At Followup:

**STEP 4: At Followup****:**

**HOW TO HELP PATIENTS: A CLINICAL APPROACH**

**ALCOHOL USE DISORDERS**

- 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 as a goal

**Was the patient able to meet and sustain the drinking goal?**

**NO**

**Notes:**
FOR ALCOHOL USE DISORDERS (abuse or dependence):
STEP 4: AT FOLLOWUP: Continue Support
Was the patient able to meet and sustain the drinking goal?

RESPONSE: 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. 
If these 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 as a goal. 
Address coexisting disorders—medical and psychiatric—as needed. 

## STEP 4: At Followup:

**STEP 4: At Followup****:**

**HOW TO HELP PATIENTS: A CLINICAL APPROACH**

**ALCOHOL USE DISORDERS**

**Address coexisting disorders**—medical and psychiatric—as needed.

**Was the patient able to meet and sustain the drinking goal?**

**NO**

**Notes:**
FOR ALCOHOL USE DISORDERS (abuse or dependence): 
STEP 4: AT FOLLOWUP: Continue Support
Was the patient able to meet and sustain the drinking goal?
RESPONSE: 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. 
If these 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 as a goal. 
Address coexisting disorders—medical and psychiatric—as needed. 

## STEP 4: At Followup:

**STEP 4: At Followup****:**

**HOW TO HELP PATIENTS: A CLINICAL APPROACH**

**ALCOHOL USE DISORDERS**

**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.

**Notes:**
FOR ALCOHOL USE DISORDERS (abuse or dependence): 
STEP 4: AT FOLLOWUP: Continue Support  
Was the patient able to meet and sustain the drinking goal?
  RESPONSE: YES
Reinforce and support continued adherence to recommendations. 
Coordinate care with a specialist if the patient has accepted referral. 
Maintain medications for alcohol dependence for at least 3 months and as clinically indicated thereafter. 
Treat coexisting nicotine dependence for 6 to 12 months after reaching the drinking goal. 
Address coexisting disorders—medical and psychiatric—as needed. 

## STEP 4: At Followup: 

**STEP 4: At Followup****: **

**HOW TO HELP PATIENTS: A CLINICAL APPROACH**

**ALCOHOL USE DISORDERS**

**Was the patient able to meet and sustain the drinking goal?**

**Maintain medications **for _**alcohol dependence**_ for at least 3 months and as clinically indicated thereafter.

**YES**

**Notes:**
FOR ALCOHOL USE DISORDERS (abuse or dependence): 
STEP 4: AT FOLLOWUP: Continue Support  
Was the patient able to meet and sustain the drinking goal?
  RESPONSE: YES
Reinforce and support continued adherence to recommendations. 
Coordinate care with a specialist if the patient has accepted referral. 
Maintain medications for alcohol dependence for at least 3 months and as clinically indicated thereafter. 
Treat coexisting nicotine dependence for 6 to 12 months after reaching the drinking goal. 
Address coexisting disorders—medical and psychiatric—as needed. 

## STEP 4: At Followup:

**STEP 4: At Followup****:**

**HOW TO HELP PATIENTS: A CLINICAL APPROACH**

**ALCOHOL USE DISORDERS**

**Was the patient able to meet and sustain the drinking goal?**

**Treat coexisting nicotine dependence** for 6 to 12 months after reaching the drinking goal.
**Ad****dress coexisting disorders**—medical and psychiatric—as needed.

**YES**

**Notes:**
FOR ALCOHOL USE DISORDERS (abuse or dependence): 
STEP 4: AT FOLLOWUP: Continue Support  
Was the patient able to meet and sustain the drinking goal?
  RESPONSE: YES
Reinforce and support continued adherence to recommendations. 
Coordinate care with a specialist if the patient has accepted referral. 
Maintain medications for alcohol dependence for at least 3 months and as clinically indicated thereafter. 
Treat coexisting nicotine dependence for 6 to 12 months after reaching the drinking goal. 
Address coexisting disorders—medical and psychiatric—as needed. 

## Appendix —

**Clinician support materials (pages 10 to 23):**
**Screening Instrument: The Alcohol Use Disorders Identifica-tion Test (AUDIT)****...****10-12**
**Prescribing Medications for Alcohol Dependence **
**Supporting Patients Who Take Medications for Alcohol Dependence **
**Medication Management Support for Alcohol Dependence **
**- Initial Session Template**
**- Followup Session Template**
**Referral Resources**

***Following the clinical approach outlined on pages 6-7, the *****Guide *****provides additional resources featured in the***
**Appendix **—
**Clinician Support Materials.........10-23**
**Patient Education Materials.........24-26**
**Online Materials for Clinicians and Patients................27**
**Frequently Asked Questions.........28-32**

**Notes:**
Following the clinical approach outlined on pages 6-7, 
the Guide provides additional resources featured in the Appendix--
* Clinician Support Materials: pages 10-23
* Patient Education Support Materials: pages 24-26
* Online Materials for Clinicians and Patients: page 27
* Frequently Asked Questions: pages 28-32

CLINICIAN SUPPORT MATERIALS (pages 10 to 12)
* Screening Instrument: The Alcohol Use Disorders Identification Test (AUDIT) (pages 10-12)
Practitioners may choose to have patients fill out a written screening instrument before they see a clinician. In this Guide, the AUDIT is provided in both English (page 11) and Spanish (page 12) for this purpose. It takes only about 5 minutes to complete, has been tested internationally in primary care settings, and has high levels of validity and reliability.

## Clinician support materials (pages 10 to 23):

**Clinician support materials (pages 10 to 23):**
**Screening Instrument: The Alcohol Use Disorders Identification Test (AUDIT)**
**Prescribing Medications for Alcohol Dependence...13-16 **
**Supporting Patients Who Take Medications for Alcohol Dependence **
**Medication Management Support for Alcohol Dependence **
**Initial Session Template**
**Followup Session Template**
**Referral Resources**

**This section features a ****Medications Chart**** with details about--**
**Naltrexone – available in 2 forms: oral and extended-release injectable**
**Acamprosate**
**Disulfiram**

**Oral form Naltrexone**

**Extended-release injectable Naltrexone**

**Acamprosate**

**Disulfiram**

**Notes:**
CLINICIAN SUPPORT MATERIAL
Prescribing Medications for Alcohol Dependence...13-16 

This section offers a medications chart and additional details about--
*Naltrexone – available in 2 forms: 
--oral and 
--extended-release injectable
*Acamprosate
*Disulfiram

## Clinician support materials (pages 10 to 23):

**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**

**Notes:**
Appendix – Clinician Support Materials
*Screening Instrument: the AUDIT: page 10-12
*Prescribing Medications for Alcohol Dependence: page 13-16
*Supporting Patients Who Take Medications for Alcohol Dependence: page 17-18
*Medication Management Support for Alcohol Dependence: page 19-20
-Initial Session Template
-Followup Session Template
*Referral Resources: page 22

## Patient education  materials (pages 23 to 26):

**Patient education  materials (pages 23 to 26):**
**What’s a Standard Drink..................24 **
**U.S. Adult Drinking Patterns................25**
**Strategies for            Cutting Down.........26**

**Notes:**
Patient support materials (pages 23 to 26):

* What’s a Standard Drink..................24 
* U.S. Adult Drinking Patterns................25
* Strategies for Cutting Down.....................26

## A Family History of Alcoholism: Are You at Risk? 

***Examples of Free Patient Education Materials from NIAAA – in English and Spanish***

***Alcohol: A Women's Health Issue***

**APPENDIX**

***Drinking and Your Pregnancy***

**Online Materials for Clinicians and Patients... page 27**
**Visit the NIAAA Web site at **_***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**
**To order materials **
**-call NIAAA at 301-443-3860**
**-or write to: NIAAA Publications Distribution Center, P.O. Box 10686, Rockville, MD 20849-0686**

**Notes:**
Appendix – Online Materials
Visit the NIAAA Web site at www.niaaa.nih.gov/guide for these and other materials to support you in alcohol screening, brief interventions, and followup patient care. 

NIAAA continually develops and updates materials for practitioners and patients; please check the Web site for new offerings. 

You may also order materials by 
-call NIAAA at 301-443-3860
- write to --
  NIAAA Publications Distribution Center, 
  P.O. Box 10686, 
  Rockville, MD 20849-0686 

Patient Education Materials
Examples of free educational materials from NIAAA (see appendix, page 27)
* Alcoholism: Getting the Facts
*Alcohol: A Women’s Health Issue
*Alcohol: What You Don’t Know Can Harm You

## The Guide provides answers to important Frequently Asked Questions regarding...

**FREQUENTLY ASKED QUESTIONS**

**When should I recommend abstaining versus cutting down?**

**Should I recommend any particular behavioral therapy for patients with alcohol use disorders?**

**How should alcohol withdrawal be managed?**

**Are laboratory tests available to screen for or monitor alcohol problems?**

**What can I do to help patients who struggle to remain abstinent or relapse?**

**How effective are brief interventions?**

**The Guide provides answers to important ****Frequently Asked Questions**** regarding...**
**screening and brief interventions**
**drinking levels and advice**
**diagnosing and helping patients with AUDs**

**Notes:**
The Guide provides answers to important Frequently Asked Questions regarding...
* Screening and brief interventions
* Drinking levels and advice
*Diagnosing and helping patients with AUDs

Class instructors teaching the Guide may choose to highlight particular questions of interest to individual classes, e.g., 

* How effective are brief interventions?
* When should I recommend abstaining versus cutting down?
* Should I recommend any particular behavioral therapy for patients with alcohol use disorders?
* How should alcohol withdrawal be managed? 
* Are laboratory tests available to screen for or monitor alcohol problems? 
* What can I do to help patients who struggle to remain abstinent or who relapse?

## NIAAA also offers a condensed Pocket Guide.   It features the same step-by-step format and includes the medications chart and other supporting materials.

**NIAAA also offers a condensed**** ****Pocket Guide****.**** ****  It features the same step-by-step format and includes the medications chart and other supporting materials.**

**Notes:**
NIAAA also offers a condensed Pocket Guide.   It features the same step-by-step format and includes the medications chart and other supporting materials
The photo shows the Pocket Guide to scale.
Also seen is a view of the front leaf and the back leaf of the Pocket Guide showing the step by step organization from the Clinician’s Guide.

## Four engaging, 10-minute video cases,        plus a 20-minute tutorial

**Free CME/CE credits through **_***Medscape.com***_

- Online technology brings training to your desktop

- Experts offer insights and ask what you would do in each situation

**ONLINE TRAINING OPPORTUNITIES**

- NIAAA Introduces...
**Free Interactive Web-based Training**

- Meet the patients:
- ...four 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

**Notes:**
NIAAA Introduces...
Free Interactive Web-based Training
For details and links visit www.niaaa.nih.gov/guide

-Four engaging, 10-minute video cases and a 20-minute tutorial
-Free CME/CE credits through Medscape.com
-Features of the online training –
* Online technology brings training to your desktop
* Meet the patients: four 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
* Interactive program creates a dynamic and flexible learning environment

## 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

**POCKET GUIDE**

**Notes:**
FINAL SLIDE: To order free copies of the Guide or the Pocket Guide, 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