Diagnosis and Management of Alcohol Problems

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Alcohol abuse is defined by the DSM-IV as a maladaptive pattern of alcohol use leading to clinically significant impairment as manifested by one or more of the following symptoms during a 12-month period:


1. Recurrent drinking resulting in a failure to fulfill major obligations at work, home, or school
2. Recurrent drinking in situations that are physically hazardous
3. Recurrent alcohol-related legal problems
4. Continued use of alcohol despite having persistent or recurrent social or interpersonal problems caused by or exacerbated by drinking alcohol

Additionally, the symptoms have never met the criteria for alcohol dependence. The ICD-10 analogue to alcohol abuse is labeled "harmful use" of alcohol and is defined as a pattern of drinking disruptive to physical or mental health.

Although it is important to make a precise diagnosis, it usually is best not to proceed immediately to asking the patient about the symptoms of alcohol dependence or abuse. One usually begins by obtaining a more general drinking history. To obtain valid answers, it has been suggested that the drinking history should be couched in questions about health risk or promotion activities. The questions should be open ended rather than those that are likely to elicit yes or no responses and should be asked in an empathetic manner.

Doing a formal diagnostic interview can be time consuming. Fortunately, practical screening tests for alcohol dependence and abuse consisting of only a few questions have been developed. These require only a few minutes to do and may be very helpful in indicating an alcohol problem at an initial visit. Depending on the circumstances, a formal diagnostic interview can await a subsequent visit.

A diverse array of these brief screening tests has been developed. The most commonly used are the CAGE, the Michigan Alcoholism Screening Test (MAST), and the Short MAST (SMAST). A new screening test with some potential advantages is the Alcohol Use Disorders Identification Test (AUDIT).

The CAGE questionnaire consists of only four items:
1. Have you ever felt you should Cut down on your drinking?
2. Have people Annoyed you by criticizing your drinking?
3. Have you ever felt bad or Guilty about your drinking?
4. Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover ( Eye opener)?

In general, the cut-off for the CAGE is two positive responses, but some authors recommend a cut-off at a single affirmative response.
The major advantage of the CAGE is brevity. Having only four items, it is convenient for the busy physician. Further, the acronym for the test makes it easy for practitioners to remember the items that constitute it and to integrate them into a clinical interview. A limitation of the CAGE questionnaire is that it does not ask about quantity and frequency of drinking. Also, because no time frame is given for the items, positive responses must be followed up by questions to establish whether the reported symptom is current or occurred in the past and is no longer present. Because the items of the CAGE seem to presuppose a fairly long history of drinking, the measure may be less useful with younger patients. CAGE scores appear to be more related to a formal diagnosis of alcohol dependence rather than the amount and frequency of alcohol consumption.

Finally, because the first three questions focus on emotional and perceived social reactions to drinking, individuals who are less emotionally perceptive or those living in heavy-drinking social environments may be more inclined to respond negatively to the items.
A CAGE score of two or more is reasonably sensitive (71%) and quite specific (91%). The higher the CAGE score, the greater the probability of alcohol dependence.

Nearly as popular as the CAGE is the MAST. The MAST is considerably longer, although a variety of shorter versions (e.g., SMAST) have been constructed, reducing its 25 items to a more manageable number. Again, as with the CAGE, the MAST itself does not ask the questions in relation to time of occurrence. The MAST has also been criticized for its heavy emphasis on late-stage symptoms of alcoholism, such as having delirium tremens or directly seeking alcohol treatment. Finally, the MAST assigns varying points (1-5) for different questions.

A newer screening test is the AUDIT. At least at face value, it appears useful for medical settings because it contains questions inquiring about alcohol consumption as well as consequences of drinking. The AUDIT consists of 10
multiple-choice questions and is shown in appendix. Seven of the items deal with the past year. The first three questions of the AUDIT assess quantity, frequency, and peak intensity of drinking. The AUDIT is scored by summing the weights associated with the response selected for each item. The usual cut-off is 8 points. Special efforts were made in constructing the AUDIT to develop an unbiased gender and ethnic screening test. AUDIT scores have also been found to correspond well with reports of significant others about the patientís drinking. In addition, responses on the AUDIT can serve as the basis for treatment. Showing the patient how his or her drinking behavior compares with that of the general population may well motivate change, for example. Feedback on this information might include pointing out health risks associated with drinking in this manner.

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