Alcohol Use in Adults
Peter D. Friedmann, M.D., M.P.H.
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 57-year-old man with a history of alcohol dependence comes for an annual examination. He reports that he has reduced his drinking to two beers two to three times per week and has not had five or more drinks on any occasion or any adverse consequences for the past 2 years. He states that he drinks “for his health” and that “it is under control.” How should his case be assessed and managed?
The Clinical Problem
* The criteria are based on the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR).4 A patient who meets the criteria for both abuse and dependence is considered to have dependence, the more severe disorder. The table is adapted from the DSM-IV-TR and information from the National Institute on Alcohol Abuse and Alcoholism. /5/
Alcohol contributes to 79,000 deaths and $223.5 billion in societal costs annually in the United States.1,2 Almost 9% of U.S. adults (approximately 13% of those who drink) meet the criteria for an alcohol-use disorder3 (Table 1)4,5; the prevalence of alcohol-use disorders is higher in clinical settings.5 Alcohol consumption can have adverse social, legal, occupational, psychological, and medical consequences. The risk of harmful consequences and disability exists on a continuum6 (Fig. 1). Risk drinking is defined as an average of 15 or more standard drinks per week or 5 or more on an occasion for men and 8 or more drinks weekly or 4 or more on an occasion for women and people older than 65 years of age.5 A standard drink (i.e., 12 oz of beer, 5 oz of wine, or 1.5 oz of 80-proof liquor) contains 14 g of ethanol. High average consumption or frequent heavy drinking can be clinically silent yet have adverse health and social consequences7,8 (see Fig. S1 and S2 in the Supplementary Appendix, available with the full text of this article at NEJM.org).
Continued drinking despite adverse consequences constitutes an alcohol-use disorder4 (Table 1). The Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR), differentiates abuse from dependence,4 but recent research suggests that they represent one disorder, which the proposed taxonomy for the DSM-5 would consolidate into a single spectrum.9 At the severe end of the spectrum, chronic, severe dependence is a recurring brain disorder characterized by loss of control over drinking, drinking despite harm, daily or neardaily drinking, a compulsion to drink (“craving”), tolerance, withdrawal, and substantial disability.
Despite observational studies that suggest that drinking lowers cardiovascular risk, the possibility of confounding raises concerns about recommending alcohol for heart health.10 Definitive data from trials are lacking to prove the cardiovascular benefits of alcohol, and the harms associated with alcohol are well established7 (Fig. S1 and S2 in the Supplementary Appendix). For example, beverage alcohol is a carcinogen, and even light drinking is associated with increased risks of oropharyngeal, esophageal, and breast carcinomas.11 For people with a prior alcohol-use disorder, young adults at low risk for cardiovascular disease, women who are pregnant or trying to conceive, people with conditions that are caused or exacerbated by alcohol (Table S1 in the Supplementary Appendix), and people who are going to operate a vehicle or machinery, the risks of drinking outweigh any supposed health benefits.
Remission and Recovery
The DSM-IV-TR definition of remission from dependence is based only on consequences and does not require abstinence.4 Full remission (i.e., no consequences) differs from partial remission (fewer than three consequences after 1 month of no consequences). Remission is considered to be “early” after 3 months and “sustained” after 12 months.4 Of U.S. adults with prior alcohol dependence, 52% continue to drink with consequences, 18% abstain completely, 12% remain heavy drinkers without consequences, and only 18% drink within lower-risk limits.12 A longterm study showed that only 11% of men with alcohol dependence maintained nondependent drinking over a period of 50 years.13 Persons with alcohol dependence who have impaired self-control, severe alcohol problems, or affective symptoms are less likely than those without these features to maintain controlled drinking.14 The term “recovery,” as used in Alcoholics Anonymous (AA), can be defined as abstinence and active involvement in mutual support or treatment. In one study, 62% of persons with such involvement remained in remission at 3 years, as compared with only 43% of persons who did not receive help.15 Only one quarter of persons with alcohol dependence ever receive treatment.16
Strategies and Evidence
Screening
Health care providers should screen for and counsel risk drinkers as part of routine medical and preventive care. Risk drinking is often asymptomatic, so screening tools that elicit consumption patterns have supplanted older ones that focused on consequences. The National Institute on Alcohol Abuse and Alcoholism (NIAAA) recommends that adults be screened annually with a validated self-report tool5; several brief tools have been validated in clinical settings (Table 2).5,17-19 Medicare covers this screening, plus up to four visits in 12 months to counsel those with positive screening results. If universal screening is not feasible, then inquiry about alcohol use should be prompted by the presence of conditions, symptoms, or signs associated with alcohol use (e.g., sleep disturbance, erectile dysfunction, and hypertension)20 (see Table S1 in the Supplementary Appendix for a comprehensive list).
Assessment and Diagnosis
When risk drinking is suspected, the assessment should include consumption pattern, criteria for alcohol-use disorders (Table 1), alcohol-related health problems (Table S1 in the Supplementary Appendix), and readiness to change drinking. Evaluation of consumption includes the typical number of days per week on which alcohol is consumed, the number of standard drinks consumed on a typical day, the maximum number of standard drinks consumed on an occasion, and the number of days per month of heavy drinking (five or more drinks for men and four or more for women). Frequent heavy drinking or high severity scores on screening tools are associated with an alcohol-use disorder. For example, a score of 7 to 9 on the Alcohol Use Disorders Identification Test–Consumption Questions (range, 0 to 12, with higher scores indicating risk drinking) (Table 2) is associated with a likelihood ratio of more than 3 for alcohol dependence.21 In patients with positive screening results for risk drinking, a report of drinking in physically hazardous situations or drinking more or for longer than intended is 94 to 95% sensitive and 62 to 77% specific for an alcohol-use disorder.22 Brief assessment can also include a symptom checklist (Table 1).
For patients with an alcohol-use disorder, either current or past, the history taking should include dates, duration, and type of prior substance- use treatment; other substance use; involvement in support groups; attempts to cut back and periods of sobriety; the circumstances surrounding recurrent drinking; and the recovery environment — i.e., whether the patient has a supportive place to live (e.g., with sober, supportive family members) and a structured daily life (e.g., regular employment or school attendance). This information is useful in identifying triggers for drinking and helping the patient devise strategies to avoid the triggers and thus reduce the risk of relapse23 (Table S2 in the Supplementary Appendix).
Table 2. Brief Self-Report Screening Tests for Risk Drinking.
Much research on behavioral change supports the idea that assessment of the patient’s motivation to change is an essential bridge from screening to brief intervention.24 A simple approach is to ask, “On a scale of 0 to 10, how ready are you to make a change right now in your drinking?” with 10 indicating ready to change right now, and 0 not ready to consider a change.24 During a brief intervention, this scale can be used to elicit self-motivating statements. If the patient rates his readiness as 3, the clinician can inquire, “Why did you not say 0?” which will prompt the patient to voice reasons for considering a change. Discussion of how drinking and its consequences may conflict with the patient’s beliefs, values, and goals may also build motivation. 24
Brief Interventions
Brief interventions provide nonjudgmental, individualized feedback about drinking and its potential harms, recommendations about lowerrisk drinking, negotiation of an acceptable goal for changing risk drinking, and arrangement of follow-up to assess progress toward the goal. If the assessment does not identify high-risk features, reducing consumption to a level below the threshold for risk is a reasonable goal. Metaanalyses of randomized trials in primary care settings have shown that brief interventions reduce consumption in risk drinkers without alcohol dependence; these interventions have also been reported to reduce alcohol-related harms and mortality.25 Data regarding the efficacy of brief interventions are less consistent in acute care settings where alcohol dependence predominates. 26,27
Figure 1. Continuum of Risk Associated with Alcohol Use and Possible Clinical Responses. Risk drinking is defined as an average of 15 or more standard drinks per week or 5 or more on an occasion for men and 8 or more drinks weekly or 4 or more on an occasion for women and people older than 65 years of age.5 Persons in remission from an alcohol-use disorder remain at risk for recurrent drinking and adverse consequences.
Randomized clinical trials have shown that online interventions that assess drinking patterns and provide normative feedback can modestly reduce risk drinking.28 As with any brief intervention, follow-up care should focus on reinforcing success or providing a referral for specialty treatment if the patient cannot stop or cut back.
Supervised Withdrawal
Supervised withdrawal is used to manage acute withdrawal and its complications, ensure a supportive environment in which to initiate sobriety, and link the patient to specialty treatment. Most patients with alcohol dependence can withdraw without supervision or medication. For patients in mild-to-moderate withdrawal and for those who live in an unstable environment for recovery, clinically managed residential detoxification programs deliver supportive care; some are medically supervised and provide medication. A medically monitored inpatient or residential setting is appropriate for patients at risk for severe withdrawal (e.g., persons with acute medical illness, an age of 60 years or older, misuse of sedative hypnotic agents, daily consumption of 20 or more standard drinks, or a history of severe withdrawal, seizures, or alcohol withdrawal delirium), for whom long-acting or intermediate-acting benzodiazepines are the standard of care.29 Symptomtriggered doses of benzodiazepines administered by trained personnel using a withdrawal-severity tool are preferable to fixed doses, except for patients who are unable to communicate, those receiving medications that mask withdrawal manifestations (e.g., beta-adrenergic antagonists), and those at highest risk for severe withdrawal (who should receive medical care in a hospital).
Specialty Treatment
Specialty treatment provides a supportive, structured environment for early sobriety, psychosocial counseling, and facilitated mutual support. High-quality specialty providers also address medical problems and psychological and social instability and initiate alcohol pharmacotherapy. Specialty treatment should be longitudinal and comprehensive, with adjustment in intensity and setting according to the severity of the disorder, coexisting conditions, treatment response, and the recovery environment. Most specialty treatment is delivered in a regular outpatient setting, but persons with an unstable recovery environment or a severe alcohol-use disorder can require intensive outpatient treatment, day-hospital treatment, or residential treatment. Counseling can be provided in group, individual, couples, or family sessions. A systematic review of seven multisite studies of treatment for alcohol-use disorders showed that 17 to 33% of patients were abstinent in the year after a single treatment episode, and another 7 to 12% reduced their drinking and no longer had adverse consequences.30
Specialty treatment should be recommended if the assessment shows any alcohol-use or drug-use disorder, continued use despite consequences (including medical contraindications), or unsuccessful attempts to stop or cut back. Clinicians should preferentially refer patients to programs that use approaches proved to be effective in randomized trials, such as motivational-enhancement therapy, cognitive-behavioral therapy, 12-step facilitation therapy, community-reinforcement approach, behavioral couples therapy, and pharmacotherapy.30
Pharmacotherapy
Medications approved by the Food and Drug Administration (FDA) for the treatment of alcohol dependence are disulfiram, acamprosate, and two forms of naltrexone (oral and extended-release injectable). All are modestly effective31-34 but greatly underused.35 Table 3 lists their mecha- nisms of action, recommended doses, and adverse effects.
Table 3. Medications for Alcohol Dependence.*
Other agents may be effective but are not FDA-approved for alcohol dependence. Short-term randomized trials have shown improved rates of abstinence and reduced heavy drinking with topiramate (but with side effects including weight loss, dizziness, and neurocognitive problems, often leading to discontinuation),37 reductions in recurrent drinking with selective serotonin-reuptake inhibitors in persons with later-onset alcohol dependence or concurrent depression,38,39 and reduced consumption with baclofen or ondansetron, the latter in persons with early-onset alcohol dependence. 40 However, data from longer-term studies are needed to establish the effectiveness of these agents in patients with alcohol dependence.
Medical-Management Counseling
Patients with alcohol dependence who do not access specialty treatment for any reason can be treated in the primary care setting with pharmacotherapy and brief medical-management counseling. 36 Medical-management counseling includes providing feedback on changes in laboratory tests, medical conditions, and other consequences to increase motivation; recommending abstinence as the safest goal while allowing the patient to work toward it; monitoring and facilitating medication adherence; and encouraging the use of mutual support groups.5 A large trial involving patients with alcohol dependence who had recently become abstinent showed that naltrexone with brief medical-management counseling resulted in a greater proportion of abstinence days than with more extensive counseling.36
Mutual Support Groups
Randomized trials suggest that facilitating involvement in mutual support groups, such as AA, can reduce the risk of relapse.41 Although the 12 steps of AA guide a process of self-improvement, observational research suggests that their main effect is to build social support for sobriety.42 Patients who object to aspects of AA can be counseled regarding the benefits of attending sessions in order to meet sober people, obtain telephone numbers to call in case of craving or imminent drinking, and find a sponsor.43
Continuing Care
Up to three quarters of patients have a relapse in the year after alcohol-use treatment.15,44,45 Relapse risks are highest during the first 3 months of sobriety and around the 1-year anniversary.44 Specialty “aftercare” offers low-intensity, longitudinal management that includes ongoing relapseprevention counseling and monitoring for relapse, but dropout is common. Generalist clinicians should also deliver continuing care.23 The clinician should emphasize that care is not contingent on abstinence and should inquire at regular visits in a nonjudgmental manner about progress toward functional and treatment goals, medication adherence, attendance at specialty aftercare and mutual support groups, alcohol consumption, craving, triggers, and coping strategies. Randomized trials have suggested that providing feedback regarding objective health improvements (e.g., graphing baseline and serial serum γ-glutamyltransferase levels and reviewing the plot with the patient) can reduce drinking and possibly mortality.46,47 Alcohol biomarkers may be useful as motivational tools and indicators of relapse. Randomized studies have shown that supportive telephone monitoring and brief counseling can reduce recurrent drinking.48
Areas of Uncertainty
Although annual screening is recommended,5 whether a different screening interval would be more effective is unknown. Brief interventions have uncertain effectiveness for heavier drinkers49 and in the acute care setting.50 Simple advice might be as effective.51 The usefulness of ultra-brief and computer-based interventions requires further study.52 Whether a strategy of screening, brief intervention, and referral for treatment works for persons with alcohol dependence is uncertain, and predicting which of them can cut back successfully remains a challenge.53,54 The effectiveness of efforts by primary care clinicians to promote and monitor remission is also unknown. Medications for alcohol dependence have shortterm efficacy, but long-term effectiveness remains undetermined. Chronic, severe dependence is often resistant to existing interventions, and effective strategies are needed to engage and treat patients with refractory alcohol dependence.
Guidelines
The U.S. Preventive Services Task Force gives a grade B recommendation (fair evidence that the benefit outweighs the harm) for screening and brief interventions for high-risk alcohol use in adult primary care settings.55 The NIAAA clinician’s guide includes an algorithm for alcohol screening, brief intervention, and referral for specialty treatment, as well as a guideline on the use of FDA-approved medications for alcohol dependence. 5 The recommendations in this article are consistent with those guidelines.
Conclusions and Recommendations
Adults should be screened annually for risk drinking with the use of a validated measure of alcohol consumption. For risk drinkers, the assessment should determine the consumption pattern, consequences of alcohol use, alcoholrelated health problems, and readiness to change drinking. Brief interventions can reduce alcohol consumption and adverse consequences in risk drinkers without alcohol dependence. Most patients with any substance-use disorder, with continued drinking despite consequences, or with unsuccessful attempts to cut back should be referred to specialty treatment programs and mutual help groups. Primary care clinicians should provide effective pharmacotherapy plus brief medical-management counseling, especially for patients who do not obtain specialty care. Given the safety profiles of naltrexone and acamprosate, either agent is recommended, though disulfiram can be considered if the patient has an abstinence goal, someone to supervise dosing, and no contraindications.
Although the patient in the vignette is considered to be in “full, sustained remission”4 (i.e., he has had no adverse consequences for >12 months) and should be lauded for cutting down on his use of alcohol, he should understand that he continues to be at risk for relapse. He should be counseled that abstinence remains his safest option,45 because only about 1 in 10 men with alcohol dependence can maintain controlled drinking over the long term.13 The clinician should inquire at regular follow-up visits about his alcohol consumption; its consequences and related health problems; attendance at specialty aftercare and mutual support groups; progress toward functional goals; craving, triggers, and coping strategies; and readiness to consider further reductions in drinking.
The views expressed in this article are those of the author and do not necessarily reflect the position or policy of the Department of Veterans Affairs or the U.S. government.
Disclosure forms provided by the author are available with the full text of this article at NEJM.org.
I thank Richard Saitz for helpful comments on earlier drafts of the manuscript.
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Copyright © 2013 Massachusetts Medical Society.
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