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Does This Patient Have an Alcohol Problem?: Sheri A. Keitz, MD, PhD, discusses the rational clinical examination for alcohol abuse.
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Does This Patient Have an Alcohol Problem?: Sheri A. Keitz, MD, PhD, discusses the rational clinical examination for alcohol abuse.
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Segment:0 .
>> I'm Ed Livingston, Deputy Editor of clinical content for the JAMA Network. Today I have the pleasure of speaking with Dr. Sheri Keitz about alcohol problems, a topic discussed in the Rational Clinical Examination. Dr. Keitz, please introduce yourself to our listeners. >> My name is Sheri Keitz. I am the Division Chief for General Internal Medicine at the University of Massachusetts. And I am the Education Editor for the Education Guides for JAMA's Rational Clinical Exam series. >> Dr. Keitz, what is the prevalence of alcohol use in the United States and worldwide?
How common are alcohol abuse and alcohol dependence? >> In the United States, more than 100 million Americans use alcohol. For many people, alcohol use is intermittent and moderate social behavior and not related to negative consequences. However, about 10% of adults who drink have alcohol-related problems that do adversely affect their lives and the lives of their families. A diagnosis of alcohol dependence is present in about 4% of U.S. adults. Unfortunately, there is also a four-fold increase in alcohol dependence in the children of alcohol-dependent parents.
A diagnosis of alcohol abuse is present in about 5% of the total U.S. population. This is not equally distributed between genders. Alcohol abuse is roughly three times higher in men than women. About 7% in men, 2.5% in women. And we shouldn't really talk about the prevalence of alcohol abuse and dependence without considering the associated burden of these diagnoses. Alcohol is a primary or secondary factor in a very long list of social and medical problems suicide, homicide, fatal motor vehicle accidents, domestic violence, cirrhosis, portal hypertension, fetal alcohol syndrome, to name just a few.
And 10% of all deaths in the U.S. are related in some way to alcohol, whether medical complications of alcohol abuse or deaths from violence or unintentional injury. Problem drinking is not just a U.S. phenomenon. This year, the World Health Organization issued a global status report on alcohol and health. About 5% of the global burden of disease is attributable to alcohol. Harmful use alcohol causes 3.3 million deaths, or 6% of all deaths worldwide on an annual basis.
Despite the extremely high prevalence worldwide, and the long list of adverse consequences, we clinicians do a terrible job of assessing drinking problems. Physicians fail to diagnose half of men who are problem drinkers and miss an even greater proportion for women and elderly. >> Can you comment on the difference between at-risk or harmful drinking versus alcohol abuse or dependence? >> So, this distinction is all about earlier versus later diagnoses. The American Psychiatric Association defines alcohol abuse and dependence in DSM-IV.
These diagnoses are based on adverse consequences of drinking already being present. So, I would call these "late in the game" diagnoses. Some of the criteria for dependence include the development of tolerance, presence of withdrawal symptoms, a maladaptive pattern of alcohol use that's associated with clinically significant problems. A diagnosis of abuse relates to persistent use of alcohol despite recurrent social or interpersonal problems. That would include situations which are physically hazardous, such as driving while impaired.
Problem drinking, on the other hand, is drinking behavior that increases the risk of subsequent psychologic or medical harm but has not yet reached the level of abuse or dependence. The terms "hazardous drinking," "at risk or harmful drinking," are all synonymous with problem drinking. The World Health Organization defined a numeric threshold for hazardous drinking as greater than four drinks per day in men, and greater than two drinks per day in non-pregnant women. Screening for at-risk drinking should allow us to identify patients for early intervention before it reaches dependence or abuse.
And if we make these diagnoses, we can do something about it. There is a substantial body of evidence that brief ambulatory interventions targeted at hazardous drinking can decrease levels of consumption and we hope decrease likelihood of subsequent harm and dependence. >> Dr. Keitz, several questionnaires exist to help clinicians detect alcohol disorders. Can you please provide an overview of some of the most commonly used questionnaires? >> Sure. There are many questionnaires used to detect alcohol disorders.
I will focus on three CAGE, AUDIT, and T-ACE. Before I start this overview, I will say that I'm not going to cover the scoring of these tools, which can be found in the appendix to the update for the Rational Clinical Exam chapter on alcohol screening, or online, as these tools are all in the public domain. CAGE is probably the most commonly used of the screening tools. It's common because it is short, easy to remember, and widely taught. CAGE stands for cut down, annoyed, guilty, and eye-opener.
The tool is four simple questions One, have you ever felt that you should cut down on your drinking? Two, have people annoyed you by criticizing your drinking? Three, have you ever felt bad or guilty about your drinking? And four, have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover, and that's what's called an eye-opener. CAGE has good test characteristics for predicting abuse or dependence but operates less well at identifying at-risk drinking.
Remember from an earlier question that the prevalence of abuse or dependence in the U.S. is roughly 3% to 4%. A positive CAGE screen will increase the probability of dependence or abuse to about 20%. And a negative screen will decrease that probability to about 1%. What it will not do is tell you about the probability of at-risk behavior that would allow early intervention. CAGE was not designed to identify at-risk behavior and has test characteristics that are not as favorable.
So, in recognition of the importance of screening for at-risk drinking, the World Health Organization sponsored a collaborative project to develop such a tool. The result was the AUDIT questionnaire, which stands for Alcohol Use Disorders Identification Test. The full AUDIT screen is 10 questions. And unlike the CAGE, it's not easily memorized and take a longer time to administer in the clinical setting. Thus, a second iteration of the AUDIT tool, which is called AUDIT-C, where C stands for consumption, is much shorter.
And it has similar and good diagnostic test characteristics as compared to the longer tool. Although AUDIT, the original tool, has been more thoroughly studied, the practical advantage of implementing a three-question tool is very compelling, especially when the two versions of the tool have similar operating characteristics. So, AUDIT-C includes three questions that focus on the frequency and quantity of alcohol use. In short, I would call this "how often and how many?" Question 1, how often do you have a drink containing alcohol?
Question 2, how many drinks containing alcohol do you have on a typical day when you're drinking? Question 3, how often do you have six or more drinks on one occasion? A positive AUDIT-C has a likelihood ratio of 12. So, for listeners who are used to thinking about likelihood ratios, 12 is a really good likelihood ratio. Given the prevalence of risky drinking in primary care clinics of about 15%, a positive screen will increase the probability of hazardous drinking to 68%.
A negative AUDIT-C, which has a likelihood ratio of less than 1, .62, which will only modestly decrease the probability of at-risk drinking from 15% to about 10%. The third and last tool I want to mention is called T-ACE. And I choose this tool because it was developed for screen in pregnancy. Pregnant women who drink two or more drinks per day may expose the fetus to developmental delay, growth retardation, cardiac defects, and cranial-facial abnormalities.
So, special attention to drinking behaviors during pregnancy is appropriate. T-ACE is a pneumonic that stands for tolerance, annoyed, cut down, and eye-opener. The T in T-ACE is a tolerance question. How many drinks does it take to make you feel high? Where a positive response is considered more than two drinks. The ACE of T-ACE is annoyed, guilty, eye-opener. Those questions come from the CAGE. A positive T-ACE score for pregnant women has a likelihood ratio of 3.6. This would increase the probability of at-risk drinking from 15% in the ambulatory setting to nearly 40%.
A negative T-ACE has a likelihood ratio of .15, which would decrease that probability to 3%. So, T-ACE is a very good screening tool for pregnancy and has also been tested and operates well for women in primary care. >> Dr. Keitz, are there biochemical and hematologic tests available to screen for alcohol abuse? >> Well, unfortunately, the short answer to this question is no. Increases in biochemical markers like liver enzymes, AST, ALT, or gamma-GGT, or increase in MCV, a hematologic marker, are insensitive in detecting alcohol abuse.
None of these tests, alone or in combination, perform as well as the screening questionnaires we just discussed. So, unfortunately, blood tests won't help us here. >> Is there anything else you'd like to tell our listeners about the clinical examination for problem drinking? >> I'd like to leave our listeners with a few take-home messages. One, different populations have different needs and different tools have different characteristics. So, in the end of the day, you're going to choose what tool you should use based on the characteristics of the population in your clinic.
CAGE is easy to remember and well-known, predicts abuse and dependence. But is not intended for identifying problem or at-risk drinking or use in pregnant women. AUDIT-C asks how often and how many. Short and likely as effective as its longer parent AUDIT. It has good characteristics for identifying at-risk for problem drinking. Unfortunately, it has not been well studied in pregnant women. T-ACE, the tolerance and ACE questions from CAGE is the tool that is best for screening in pregnant women, may also be good for at-risk drinking and abuse and dependence in adults, especially in clinic populations with may clinic patients.
So, summing up, problem drinking, alcohol abuse and dependence, are world-wide high-prevalence problems with severe medical and social consequences. Despite this, alcohol-related diagnoses are woefully underrecognize by clinicians. We have accurate, quick, and easy screening tools and the potential to intervene. So, the bottom line is simple. You should use the tools we have and screen for problem alcohol use in all adult patients. >> Thank you Dr. Keitz, for this helpful discussion about alcohol problems.
Additional information about this topic is available in the Rational Clinical Examination. This has been Ed Livingston of the JAMA Network talking with Dr. Sheri Keitz about alcohol abuse for JAMAevidence.
Segment:0 .
>> I'm Ed Livingston, Deputy Editor of clinical content for the JAMA Network. Today I have the pleasure of speaking with Dr. Sheri Keitz about alcohol problems, a topic discussed in the Rational Clinical Examination. Dr. Keitz, please introduce yourself to our listeners. >> My name is Sheri Keitz. I am the Division Chief for General Internal Medicine at the University of Massachusetts. And I am the Education Editor for the Education Guides for JAMA's Rational Clinical Exam series. >> Dr. Keitz, what is the prevalence of alcohol use in the United States and worldwide?
How common are alcohol abuse and alcohol dependence? >> In the United States, more than 100 million Americans use alcohol. For many people, alcohol use is intermittent and moderate social behavior and not related to negative consequences. However, about 10% of adults who drink have alcohol-related problems that do adversely affect their lives and the lives of their families. A diagnosis of alcohol dependence is present in about 4% of U.S. adults. Unfortunately, there is also a four-fold increase in alcohol dependence in the children of alcohol-dependent parents.
A diagnosis of alcohol abuse is present in about 5% of the total U.S. population. This is not equally distributed between genders. Alcohol abuse is roughly three times higher in men than women. About 7% in men, 2.5% in women. And we shouldn't really talk about the prevalence of alcohol abuse and dependence without considering the associated burden of these diagnoses. Alcohol is a primary or secondary factor in a very long list of social and medical problems suicide, homicide, fatal motor vehicle accidents, domestic violence, cirrhosis, portal hypertension, fetal alcohol syndrome, to name just a few.
And 10% of all deaths in the U.S. are related in some way to alcohol, whether medical complications of alcohol abuse or deaths from violence or unintentional injury. Problem drinking is not just a U.S. phenomenon. This year, the World Health Organization issued a global status report on alcohol and health. About 5% of the global burden of disease is attributable to alcohol. Harmful use alcohol causes 3.3 million deaths, or 6% of all deaths worldwide on an annual basis.
Despite the extremely high prevalence worldwide, and the long list of adverse consequences, we clinicians do a terrible job of assessing drinking problems. Physicians fail to diagnose half of men who are problem drinkers and miss an even greater proportion for women and elderly. >> Can you comment on the difference between at-risk or harmful drinking versus alcohol abuse or dependence? >> So, this distinction is all about earlier versus later diagnoses. The American Psychiatric Association defines alcohol abuse and dependence in DSM-IV.
These diagnoses are based on adverse consequences of drinking already being present. So, I would call these "late in the game" diagnoses. Some of the criteria for dependence include the development of tolerance, presence of withdrawal symptoms, a maladaptive pattern of alcohol use that's associated with clinically significant problems. A diagnosis of abuse relates to persistent use of alcohol despite recurrent social or interpersonal problems. That would include situations which are physically hazardous, such as driving while impaired.
Problem drinking, on the other hand, is drinking behavior that increases the risk of subsequent psychologic or medical harm but has not yet reached the level of abuse or dependence. The terms "hazardous drinking," "at risk or harmful drinking," are all synonymous with problem drinking. The World Health Organization defined a numeric threshold for hazardous drinking as greater than four drinks per day in men, and greater than two drinks per day in non-pregnant women. Screening for at-risk drinking should allow us to identify patients for early intervention before it reaches dependence or abuse.
And if we make these diagnoses, we can do something about it. There is a substantial body of evidence that brief ambulatory interventions targeted at hazardous drinking can decrease levels of consumption and we hope decrease likelihood of subsequent harm and dependence. >> Dr. Keitz, several questionnaires exist to help clinicians detect alcohol disorders. Can you please provide an overview of some of the most commonly used questionnaires? >> Sure. There are many questionnaires used to detect alcohol disorders.
I will focus on three CAGE, AUDIT, and T-ACE. Before I start this overview, I will say that I'm not going to cover the scoring of these tools, which can be found in the appendix to the update for the Rational Clinical Exam chapter on alcohol screening, or online, as these tools are all in the public domain. CAGE is probably the most commonly used of the screening tools. It's common because it is short, easy to remember, and widely taught. CAGE stands for cut down, annoyed, guilty, and eye-opener.
The tool is four simple questions One, have you ever felt that you should cut down on your drinking? Two, have people annoyed you by criticizing your drinking? Three, have you ever felt bad or guilty about your drinking? And four, have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover, and that's what's called an eye-opener. CAGE has good test characteristics for predicting abuse or dependence but operates less well at identifying at-risk drinking.
Remember from an earlier question that the prevalence of abuse or dependence in the U.S. is roughly 3% to 4%. A positive CAGE screen will increase the probability of dependence or abuse to about 20%. And a negative screen will decrease that probability to about 1%. What it will not do is tell you about the probability of at-risk behavior that would allow early intervention. CAGE was not designed to identify at-risk behavior and has test characteristics that are not as favorable.
So, in recognition of the importance of screening for at-risk drinking, the World Health Organization sponsored a collaborative project to develop such a tool. The result was the AUDIT questionnaire, which stands for Alcohol Use Disorders Identification Test. The full AUDIT screen is 10 questions. And unlike the CAGE, it's not easily memorized and take a longer time to administer in the clinical setting. Thus, a second iteration of the AUDIT tool, which is called AUDIT-C, where C stands for consumption, is much shorter.
And it has similar and good diagnostic test characteristics as compared to the longer tool. Although AUDIT, the original tool, has been more thoroughly studied, the practical advantage of implementing a three-question tool is very compelling, especially when the two versions of the tool have similar operating characteristics. So, AUDIT-C includes three questions that focus on the frequency and quantity of alcohol use. In short, I would call this "how often and how many?" Question 1, how often do you have a drink containing alcohol?
Question 2, how many drinks containing alcohol do you have on a typical day when you're drinking? Question 3, how often do you have six or more drinks on one occasion? A positive AUDIT-C has a likelihood ratio of 12. So, for listeners who are used to thinking about likelihood ratios, 12 is a really good likelihood ratio. Given the prevalence of risky drinking in primary care clinics of about 15%, a positive screen will increase the probability of hazardous drinking to 68%.
A negative AUDIT-C, which has a likelihood ratio of less than 1, .62, which will only modestly decrease the probability of at-risk drinking from 15% to about 10%. The third and last tool I want to mention is called T-ACE. And I choose this tool because it was developed for screen in pregnancy. Pregnant women who drink two or more drinks per day may expose the fetus to developmental delay, growth retardation, cardiac defects, and cranial-facial abnormalities.
So, special attention to drinking behaviors during pregnancy is appropriate. T-ACE is a pneumonic that stands for tolerance, annoyed, cut down, and eye-opener. The T in T-ACE is a tolerance question. How many drinks does it take to make you feel high? Where a positive response is considered more than two drinks. The ACE of T-ACE is annoyed, guilty, eye-opener. Those questions come from the CAGE. A positive T-ACE score for pregnant women has a likelihood ratio of 3.6. This would increase the probability of at-risk drinking from 15% in the ambulatory setting to nearly 40%.
A negative T-ACE has a likelihood ratio of .15, which would decrease that probability to 3%. So, T-ACE is a very good screening tool for pregnancy and has also been tested and operates well for women in primary care. >> Dr. Keitz, are there biochemical and hematologic tests available to screen for alcohol abuse? >> Well, unfortunately, the short answer to this question is no. Increases in biochemical markers like liver enzymes, AST, ALT, or gamma-GGT, or increase in MCV, a hematologic marker, are insensitive in detecting alcohol abuse.
None of these tests, alone or in combination, perform as well as the screening questionnaires we just discussed. So, unfortunately, blood tests won't help us here. >> Is there anything else you'd like to tell our listeners about the clinical examination for problem drinking? >> I'd like to leave our listeners with a few take-home messages. One, different populations have different needs and different tools have different characteristics. So, in the end of the day, you're going to choose what tool you should use based on the characteristics of the population in your clinic.
CAGE is easy to remember and well-known, predicts abuse and dependence. But is not intended for identifying problem or at-risk drinking or use in pregnant women. AUDIT-C asks how often and how many. Short and likely as effective as its longer parent AUDIT. It has good characteristics for identifying at-risk for problem drinking. Unfortunately, it has not been well studied in pregnant women. T-ACE, the tolerance and ACE questions from CAGE is the tool that is best for screening in pregnant women, may also be good for at-risk drinking and abuse and dependence in adults, especially in clinic populations with may clinic patients.
So, summing up, problem drinking, alcohol abuse and dependence, are world-wide high-prevalence problems with severe medical and social consequences. Despite this, alcohol-related diagnoses are woefully underrecognize by clinicians. We have accurate, quick, and easy screening tools and the potential to intervene. So, the bottom line is simple. You should use the tools we have and screen for problem alcohol use in all adult patients. >> Thank you Dr. Keitz, for this helpful discussion about alcohol problems.
Additional information about this topic is available in the Rational Clinical Examination. This has been Ed Livingston of the JAMA Network talking with Dr. Sheri Keitz about alcohol abuse for JAMAevidence.
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