# LMCC/Alcohol
## Definitions

One standard drink = 12 g of pure alcohol
* beer (5% EtOH) = 12 oz
* wine (12-17%) = 5 oz
* fortified wine = 3 oz
* hard liquor (80 proof) = 1.5 oz
Diagnostic categories are along a continuum
* Abstinence
* Low risk drinking
** <2 drinks/day
** <9 drinks/week for women, <14 drinks/week for men
* Alcohol abuse
** consumption above low risk level with one or more of a) alcohol related physical or social problems b) continued use despite hazardous consequences c) inability to fulfill major life roles d) legal problems associated with use, but no evidence of alcohol dependence
* Alcohol dependence

## Epidemiology

* 10-15% of patients in family practice are problem drinkers
* >500,000 Canadians are alcohol dependent
* 10% of premature deaths and 50% of fatal traffic accidents in Canada are alcohol related
* most likely to miss diagnosis in women, elderly, patients with high socioeconomic status

## Assessment
### Cage Questionnaire

C Have you ever felt the need to CUT down on your drinking?
A Have you ever felt ANNOYED at criticism of your drinking?
G Have you ever felt GUILTY about your drinking?
E Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover? EYE OPENER
* > 2 for men or > 1 for women indicates possibility of problem drinking and need for further assessment

### Questions for Alcohol Abuse - HALT FATAL BUMP DT

H do you ever drink to get High?
A do you ever drink Alone?
L do you ever Look forward to drinking?
T are you Tolerant to alcohol?
F any Family history of alcohol?
A ever been a member of AA?
T do you use Tranquilizer to calm your nerves?
A do you ever think about Atempting to quit?
L any Legal problems related to alcohol?
B have you ever had Blackouts?
U do you ever use alcohol in an Unplanned way?
M do you ever use alcohol for Medicinal reasons?
P do you tend to Protect your alcohol supply?
D do you ever drink and Drive?
T do you Think you are an alcoholic?
* asses drinking profile
** setting, time, place, occasion, with whom
** impact on: family, work, social
** quantity-frequency history
*** how many drinks per day?
*** how many drinks per week?
*** maximum number of drinks on any one day in the past month?
* if identified positive for alcohol problem
** screen for other drug use
** identify medical/psychiatric complications
** ask about drinking and driving
** ask about past recovery attempts and current readiness for change
* complications of problem drinking
** GI: gastritis, dyspepsia, pancreatitis, liver disease, bleeds, diarrhea, oral/esophageal cancer
** cardiac: hypertension, alcoholic cardiomyopathy
** neurologic: Wernicke-Korsakoff syndrome, peripheral neuropathy
** hematologic: anemia, coagulopathies
** other: truama, insomnia, family violence, anxiety/depression, social/family dysfunction, sexual dysfunction, fetal damage

## Investigations

* GGT and MCV for baseline and follow-up monitoring
* AST, ALT (AST:ALT = 2:1 in alcoholics)
* CBC (anemia, thrombocytopenia), PT (decreased clotting factor production by liver

## Management

* intervention should be consistent with patient's motivation for change
* regular follow up is crucial

### Motivational Interviewing Strategies for Alcohol Related Problems

| Stage of change | Possible intervention strategies |
| Precontemplation | Feedback on assessment of current level or pattern of drinking Discuss associated risks Discuss lifestyle/stresses and how alcohol fits in patient's life |
| Contemplation | Ask what are some good and less good thing about your use of alcohol? Explore reasons to quit and reasons to continue drinking Offer information on health effects of drinking Recommend cutting back on drinking and explore options for taking action |
| Action | Encourage commitment to action plan Address patient's concerns about changing behaviour Consider pharmacologic intervention (ie. disulfiram or naltrexone) Consider referral to treatment programs or mutual aid groups (ie. AA) |
| Maintenance | Foster confidence in patient's ability to sustain changes Help develop plan to prevent relapse Consider referral to mutual aid group (ie. AA) |
| Relapse | Explore reasons for relapse Encourage the belief that relapse does not mean failure Consider alternative treatments or coping strategies |

### Alcoholics anonymous

* outpatient/day programs for those with chronic or resistent problems
* family treatment (Al-Anon, Alateen, screen spouse and child for abuse)

### In patient programs

Use if:
* dangerous or highly unstable home environment
* severe medical/psychiatric problem
* addiction to drug that may require in patient detoxification
* refractory to other treatment programs

### Pharmacologic

* diazepam for withdrawl
* disulfiram (Antabuse)
** blocks conversion of acetaldehyde to acetic acid which leads to flushing, headache, nausea/vomiting, hypotension if alcohol is ingested.
* naltrexone
** competitive opioid antagonist that reduces cravings and pleasurable effects of drinking
** can trigger withdrawl in opioid dependent patients

## Prognosis

* relapse is common and should not be viewed as failure
* monitor regularly for signs of relapse
* 25-30% of abusers exhibit spontaneous improvement over 1 year
* 60-70% of individuals with jobs and families have an improved quality of life 1 year post treatment