Recognizing the alcoholic patient
■ Patients who struggle with alcohol can be difficult to spot. Better training, starting as early as medical school, can ensure these patients get needed treatment.
Some are easier to spot than others.
It may be as obvious as encountering an intoxicated patient in the emergency room. Or as subtle as noting a hypertensive patient who seems otherwise healthy but has mysteriously missed his or her last few appointments.
Alcoholism presents itself through a variety of signs, symptoms and severities, said Jeffrey Samet, MD, MPH, chief of general internal medicine at Boston Medical Center, professor of medicine at Boston University School of Medicine and professor of community health sciences at Boston University School of Public Health. He is president of the American Board of Addiction Medicine. (See correction)
“They come in a whole spectrum of obviousness,” he said. “It's not necessarily going to hit you over the head. It can be highly, highly challenging.”
Primary care physicians can feel ill-equipped to identify and care for such patients, but they play a crucial role in ensuring that individuals get treatment, said Raye Litten, PhD, associate director of the National Institute on Alcohol Abuse and Alcoholism's Division of Treatment and Recovery Research. Most people who have problems with alcohol use don't seek care from a specialist.
“Usually, the primary care physician may be the only medical professional that people with alcohol problems will see, and maybe not for the alcohol, but for whatever other problems it is causing,” Litten said.
For that reason, it's important that primary care physicians be able to identify those patients and get involved to help ensure they are treated to control their drinking, he said.
“In many cases, if the doctor doesn't get involved, the patient dies,” said Nicholas Pace, MD, clinical associate professor at New York University Langone Medical Center.
A June report by the National Center on Addiction and Substance Abuse at Columbia University in New York found that most health professionals are not sufficiently trained to identify or diagnose substance abuse. They often are unfamiliar with the signs and symptoms of addiction, and they don't know the best treatment options for patients. As a result, many of those who do provide treatment for addiction are not medical professionals and lack the knowledge and skills to provide the full range of available evidence-based treatments, the report said.
About one in seven Americans 12 and older (40.3 million people) meets the clinical criteria for substance abuse addiction. Seven percent of Americans have an addiction involving alcohol, either to alcohol alone or to alcohol and one or more other substances, said Susan E. Foster, vice president and director of the Columbia center's Division of Policy Research and Analysis and principal investigator on the report. The high prevalence of the disease makes it something that primary care physicians encounter on a regular basis, she said. (See correction)
“You can't practice primary care without seeing patients with current or past alcohol problems every day,” said Patrick G. O'Connor, MD, MPH, professor of medicine and chief of general internal medicine at Yale School of Medicine in Connecticut.
Beyond full-blown alcoholism, many more people are involved in risky levels of drinking. The National Institute on Alcohol Abuse and Alcoholism defines risky drinking as more than four drinks on any single day and no more than 14 drinks per week for men. For women, such drinking means no more than three drinks on any single day and no more than seven drinks per week. An estimated 18 million Americans have an alcohol use disorder and 40 million are high-risk drinkers, Litten said.
Obstacles to care
Primary care physicians face several challenges in identifying patients who have problems with alcohol. Many patients may not be comfortable talking with doctors about drinking, and doctors have a limited time to meet with each patient, Dr. Samet said.
“With primary care, if you're seeing a patient in a usual clinic, there are so many issues on the table that this one may be lost in the shuffle,” he said.
Depending on their training, physicians may not recognize that a patient is addicted to alcohol, Dr. O'Connor said. Historically, medical schools have not provided much training on treating people with alcohol problems, and that lack of training often continues into graduate medical education training, he said.
One issue is that medical schools have a lot of competing subjects to cover in four years. Even so, educating students about alcoholism should be a priority, Dr. O'Connor said.
“There are knowledge barriers in how to identify them, as well as what to do with them when you have them,” he said. “Given that alcohol use disorders are so common in medical populations, it's ridiculous to think that it's ignored as much as it is.”
In caring for these patients, there are other barriers, such as the availability of services, the patients' willingness to undergo treatment and insurance coverage for addiction services, O'Connor said.
Then there is the question of the doctor's attitude. Despite research proving that alcohol addiction is a disease with serious physiological consequences, some physicians still blame the patient, said Dennis H. Novack, MD, professor of medicine and associate dean of medical education at Drexel University College of Medicine in Philadelphia.
“There is a lot of misunderstanding and bias, even among physicians,” Dr. Novack said. “Until physicians see alcoholism as a chronic disease for which there is no cure, you can't help the patient.”
Instituting some type of standardized screening process can make a difference, Dr. Pace said. The Alcohol Use Disorders Identification Test can help physicians identify patients with alcohol issues. It involves asking patients questions about how much they drink, what they drink and when they drink.
“Alcoholism is the big masquerader,” Dr. Pace said. “If the patient has several issues and a physician can't figure out what's really wrong, they should really think about alcohol and alcoholism. You have to keep in mind that you see the whole spectrum of the disease. It comes in all sizes, shapes and colors and really mimics so many other problems.”
Patients struggling with alcohol use may display a variety of symptoms, including indigestion, hypertension and liver problems, Dr. O'Connor said. Physicians should routinely screen patients for alcohol use, he said.
In talking with patients, physicians should make it clear that their discussions are confidential, Dr. O'Connor said. They also should discuss what could happen if the patient pursues treatment. Alcohol counseling can be brief, similar to discussions on other health issues such as diabetes and hypertension.
“If you don't address those issues, they will make other medical issues worse,” Dr. O'Connor said.
Excessive alcohol use raises blood pressure and can contribute to a litany of medical problems, Dr. O'Connor said. Hypertension can lead to cardiac arrhythmia; problems with the gastrointestinal system, liver and pancreas; and neurological problems such as dementia.
The NIAAA provides resources for physicians and the public. Its guide for doctors recommends asking patients how many times in the past year they have had more than five drinks at a time. Asking that single question can help physicians identify up to 82% of people who have alcohol problems, Litten said.
It's important that physicians not be reproachful or judgmental of patients, but express concern for their health and welfare, said David Bronson, MD, a general internist and president of the American College of Physicians. If doctors immediately ask a patient about drinking, the patient may feel attacked. It's important to frame the question as a series of other general health questions that the doctor would ask of all patients.
“You have to make them feel comfortable about it,” Dr. Bronson said. “It should be a routine for all of your patients.”
Educating young doctors about alcohol
Some medical schools are working to make sure students are exposed to the issues of alcohol addiction early in their training. For example, first-year students at Drexel University College of Medicine are required to attend an Alcoholics Anonymous meeting. Two AA members also come to the school to talk with students about their experiences in small group sessions.
“We want our students to understand and see AA as a resource, but we also want our students to understand what people with this disease are going through,” Dr. Novack said. “They have gone through hell and back, and they have a lot that they can share that I think can help break some of the biases of our students.”
At the GME level, Dr. Pace has been leading a course for first-year internal medicine residents on alcoholism and substance abuse for about 10 years. The four-day course is offered once a month to residents at four New York hospitals.
As part of the course, AA members meet one on one with residents. They tell their stories, and residents present those to the class at the end of the course. Students also attend an AA meeting and work with trained actors to practice interviewing patients about their alcohol use. They also meet a physician who has struggled with substance abuse addiction, and they hear how it affected careers and personal lives, Dr. Pace said.
All internal medicine residents at Lenox Hill Hospital are required to take the course, said Robin Dibner, MD, director of the hospital's internal medicine residency program and clinical associate professor at NYU School of Medicine.
“I just felt that there was nowhere in medical school that they were learning about this,” she said. “I think it should be a major part of curriculum for all residencies.”
Nicole Lapinel, MD, chief medical resident at Lenox Hill, said the program was eye-opening. Being able to talk one on one with an AA member and hear stories made a strong impression.
“You got to know this individual — when they first recognized that they had a problem and how they went about seeking treatment,” Dr. Lapinel said. “Sitting there listening to their very personal stories — as a physician you don't normally get that perspective.”
The American Board of Addiction Medicine also is working to fill gaps in expertise about alcohol and substance abuse addictions. In 2011, the board launched its first residency programs in addiction medicine. There now are 10 programs around the country, Dr. Samet said.
Specialized training will help ensure that more patients who need help can get treatment, Dr. O'Connor said. “There is a huge dearth of specially trained physicians in this area.”