Asking about alcohol: What doctors need to find out

Joseph A. Troncale, MD, was trained as a family physician and thought he knew about alcoholism. But it wasn't until he and several other family doctors were asked to take over a 28-bed detoxification and rehabilitation unit for the Lancaster (Pa.) General Hospital that he realized there were aspects he didn't completely grasp and that maybe he had overlooked patients in trouble. Often, he now admits, he didn't even think to ask about alcohol.

"When I was in regular family practice I lacked an understanding of the prevalence of addiction, so I took many symptoms at face value such as depression, GI distress, accidents, anxiety, marital strife," says Dr. Troncale, now certified in addiction medicine and a medical director for the Caron Foundation in Wernersville, Pa. "When I started doing addiction treatment as a large part of my practice, it became clear that the same person I would see in my office as depressed or as a chronic pain patient was really someone who needed treatment for their addiction."

Dr. Troncale's realization is supported by statistics that underscore the breadth of the problem. Nearly 18 million Americans with alcohol-use problems need treatment, but only about 4 million ever receive it. Moreover, alcohol-related disorders occur in up to 26% of general medical patients and more than 50% of hospitalized patients. These at-risk drinkers have a greater incidence of burns, falls, depression, anxiety, stomach upsets and sleep problems. Still, the root cause -- the drinking -- often continues without remark.

Studies show, however, that primary care physicians can intervene effectively by asking simple questions. But about 45% of patients seeking substance abuse treatment say their primary care physician was unaware.

"People come in and are never asked. We are treating complications versus the underlying illness," says David C. Lewis, MD, professor of medicine and community health at Brown University Medical School and founder of the Brown University Center for Alcohol and Addictions, both in Providence, R.I.

Nonetheless, recognizing the problem is a challenge. There are many reasons that explain why a diagnosis does not come to light, says Richard Saitz MD, MPH, a primary care physician and associate professor of medicine and epidemiology at Boston University School of Medicine and Public Health. Patients may not admit it. And doctors are inundated with hundreds of recommended screenings for early interventions.

Pleas for help

Michael Sands, 58, a media consultant in California who has been in recovery for a decade, offers himself as an example of a patient whose his drinking problem evaded notice, despite frequent contact with the health care system.

Sands was juggling five primary care doctors. He drank a lot. He took pills for depression, Seconal to sleep. He was constantly sick and lost a great deal of weight. He experienced severe anxiety attacks. He even had four DUIs. Still, no one asked. "I made life so hard for myself. I wanted help, but no one offered it," Sands said. He wishes his doctors had offered pamphlets or telephone numbers for Alcoholics Anonymous in the waiting room.

It was Howard Shapiro, MD, a psychiatrist and senior attending at Cedars Sinai Medical Center in Los Angeles, who finally intervened. "People don't come to the doctor and announce that they need to be treated for alcoholism," Dr. Shapiro says. "You have to see the signs."

Thus, in the primary care setting, asking is part of helping. At each visit, bringing up alcohol-related questions is key. For example, ask patients how many drinks they consume per week and the maximum number of drinks per occasion they've had in a past month.

Generally, more than 14 drinks per week or more than four per occasion for men and more than seven drinks per week or more than three per occasion for women are signs of possible abuse or dependence.

And while the CAGE assessment, a well-established screening method designed in the 1970s, is a good initial tool, sometimes changing the questions can help a physician better understand a patient's situation. Dr. Troncale recommends asking patients what drinking or using drugs means to them. Other suggestions include asking when and how much a patient drinks, how big is the glass he or she uses, and to what point does he or she fill it?

For physicians who are unclear about how to begin these kinds of conversations, there is support. For instance, April 8 is National Alcohol Screening Day, an annual event that offers participating physicians a screening kit with a training video to help primary care physicians recognize at-risk drinking in patients and conduct a screening interview. The kit also includes educational materials on motivational interviewing.

Forces behind the disease

There are several types of alcohol problems: binge and risky drinking, alcohol abuse and alcohol dependence. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition describes alcohol abusers as those who drink despite recurrent social, interpersonal and legal problems as a result of alcohol use.

Different from abuse is alcohol dependence, a disease in the brain's mesolimbic dopamine system. In dependence, there is a chemical disregulation due to one or more of six chemical neurotransmitters normally in that pathway, says Carlton K. Erickson, PhD, director of the Addiction Science Research and Education Center and professor of pharmacology and toxicology at the University of Texas at Austin. "These people actually feel something different when they drink," he says. "Dependence is pathological, and the patient has no control."

Overall, dependence is marked by a compulsion to drink, a loss of control over drinking and withdrawal symptoms -- sweating, rapid pulse, tremors, insomnia, nausea, vomiting, hallucinations, agitation, anxiety or seizures -- when trying to stop or cut down. To avoid such symptoms, dependent people often begin drinking early in the morning.

It's been known that genetics play a role in alcohol dependence. But research published in the January issue of Alcoholism: Clinical and Experimental Research by investigators at Washington University School of Medicine in St. Louis and others was the first to identify a particular gene-- gamma-aminobutyric acid -- that appears to increase the risk of alcoholism. Related to a receptor that allows for the movement of GABA between nerve cells, it is the major inhibitory chemical in the central nervous system.

Still, Danielle M. Dick, PhD, Washington University research assistant professor of psychiatry, says it is important to point out that genetic makeup does not necessarily mean a person will become alcohol dependent.

"One reason it is so difficult to find genes involved in psychiatric disorders is that there is interplay between genetic and environmental factors," she says. "A person can carry all kinds of genes that predispose them to alcohol dependence, but if they never take a drink, they won't become an alcoholic."

In the same issue of Alcoholism: Clinical & Experimental Research, researchers at Virginia Commonwealth University in Richmond reported that genetics also can explain why people differ in motivations for drinking.

Still, identifying the genetics that place people at risk is only part of the equation. Treatment is still critical -- especially because alcohol use and abuse contributes to 100,000 deaths annually, making it the third leading cause of preventable mortality in the United States, after tobacco and diet-activity patterns.

Nonetheless, even though every dollar spent on treating alcohol dependence saves seven health care dollars, few insurers cover such costs. That's why Dr. Shapiro often gets patients started with Alcoholics Anonymous.

But beyond this intervention, there is hope for medications that could address alcohol dependence.

For a long time, Antabuse (disulfiram) was the only pharmacological option. Around since the 1940s, the drug manufactured by Odyssey Pharmaceutical Inc. works by blocking the metabolism of alcohol, thereby leading to accumulation of acetylaldehyde. Because acetylaldehyde is toxic to the body, it produces unpleasant symptoms such as facial flushing, nausea and vomiting. It's always been considered difficult to tolerate.

More recently, oral naltrexone, an opioid receptor blocker that causes alcohol to lose its appeal, has been shown to reduce the desire to drink in some people. But its most profound effect is that the drink doesn't get its usual response, says James Garbutt, MD, professor of psychiatry at the University of North Carolina at Chapel Hill.

Meds only work if they're taken

For now, the biggest problem with naltrexone is compliance, and most recommend its use in conjunction with a 12-step program or cognitive behavioral therapy. The University of Pennsylvania Medical Center in Philadelphia reported that more than 40% of patients were noncompliant with the daily oral naltrexone regimen. A large study by the Dept. of Veteran Affairs indicated that naltrexone did not work, but Dr. Garbutt says other oral naltrexone studies have found positive treatment effects in a subpopulation of compliant patients.

An injectable form of naltrexone, Vivitrex, manufactured by Alkermes Inc., is now in phase III trials. Meanwhile, other drugs being tested include Topomax (topiramate), an antiseizure drug manufactured by Ortho-McNeil Pharmaceutical, and Zofran (ondansetron hydrochloride), an anti-epileptic drug manufactured by GlaxoSmithKline. "They are Food and Drug Administration approved for other applications," Dr. Erickson says. "They are now in trial for this indication. They seem to reduce craving, but they need more study."

Overall, these kinds of developments make the future exciting, he says. "We are going to have better diagnostic tests, eventually there will be a brain scan that shows this chemical problem and a genetic test. And if we could better understand the disease, there would be a tremendous impact on children, families, individuals."

Today, Dr. Troncale says he's learned so much from nurses, counselors and patients. "Your patients will teach if you are willing to listen. Everyone has a story, an insight, a problem that has unique qualities," he says. "The other thing I learned was that many of my patients who were labeled as addicts were great human beings."