Health and Wellness

How to screen patients for alcohol use disorders

Think you can spot a patient who abuses alcohol? If so, here’s something that may curb your self-confidence: In a recent study, healthcare professionals failed to identify nearly half the patients with alcohol use disorders (AUDs) during their hospital stays.
The chance you’ll encounter patients with a drinking problem is high. In a large national survey in 2004, more than 20% of the U.S. population reported episodic binge drinking within the previous 30 days, and 15.9 million Americans said they drank heavily. The National Hospital Discharge Survey found that a principal alcohol-related diagnosis—for instance, alcohol dependence, liver cirrhosis, alcoholic psychosis, or alcohol abuse—accounted for roughly 424,000 hospital discharges among persons age 15 and older. (This statistic doesn’t include such alcohol-related conditions as alcohol cardiomyopathy, Wernicke-Korsakoff syndrome, or trauma linked to alcohol use.)
So unless you routinely screen patients for AUDs, you’re likely to miss the opportunity to identify the problem and to incorporate this important information into the plan of care. As a result, serious alcohol-
related health consequences could go undiagnosed. Failure to screen also may mean missing the chance to prevent AUDs in patients at risk.
The National Institute on Alcohol Abuse and Alcoholism (NIAAA) recommends all healthcare providers screen every patient for AUDs. As a nurse, you have the ethical and legal responsibility to meet this new standard of care.

Alcohol-related health risks
Alcohol consumption increases the risk of:
• liver cirrhosis
• Wernicke-Korsakoff syndrome (characterized by acute confusion, ataxia, and abnormal eye movements)
• alcoholic cardiomyopathy
• acute respiratory distress syndrome
• breast cancer
• injuries (such as falls in the elderly).

Understanding the range of alcohol use
Not all alcohol use is dangerous. But if it causes or increases the risk of alcohol-related problems or complicates management of other medical problems, it’s definitely an issue.
For the general adult population, NIAAA recommends the following drinking limits:
•    Men: fewer than five standard drinks daily or 15 drinks weekly
•    Women: fewer than four standard drinks daily or eight drinks weekly
•    Adults age 65 and older: no more than one standard drink daily or seven drinks weekly.
For pregnant women, no level of alcohol consumption is safe.
A standard drink varies with alcohol type and glass size. (See How much alcohol does a standard drink contain? in the PDF format by clicking on the download now button.)

A greater danger to women and the elderly
Compared to a man’s body, a woman’s generally contains less water. This means that the alcohol a woman consumes ends up being less diluted, causing greater impairment at lower consumption levels and raising the risk of alcohol-induced organ damage.
The elderly have a lower ratio of body water to fat. Like women, they have less body water to dilute the alcohol. Also, with age, hepatic blood flow decreases and liver enzymes become less efficient, impairing alcohol metabolism. As a result, elevated blood alcohol levels last longer and the risk of hepatic damage is higher. Also, aging impedes the body’s ability to adapt to alcohol, reducing tolerance for it. So elderly people may develop alcohol-related problems even if they’re drinking no more than they did when younger.

Screening for alcohol use
Screening can distinguish patients with low-risk alcohol use from those with risky use, harmful use, or dependence. The main purpose of most alcohol screening tools is to identify patients with AUDs who can benefit from early intervention and treatment. But you can use the same tools to screen patients at risk for alcohol-related medical consequences and alcohol withdrawal symptoms.

Screening opportunities
You may want to screen for AUDs as part of a routine examination, especially if the patient is a smoker, an adolescent, or a young adult. Other screening opportunities include:
•    when a patient is prescribed a drug that could interact with alcohol
•    when a female of childbearing age has the potential to become pregnant
•    when a patient has a health problem that could be alcohol related, such as trauma, arrhythmia, hepatic disease, dyspepsia, depression, anxiety, or insomnia
•    when a patient has a chronic illness that’s not responding to treatment, such as chronic pain, diabetes, a GI problem, cardiac disease, hypertension, or depression.


Screening instruments
In the 1970s, researchers began developing and testing self-report screening instruments for identifying alcohol consumption, abuse, and dependence. These instruments (for example, the four-question CAGE questionnaire) were designed to distinguish persons with probable alcohol dependence from those without apparent dependence. However, they lack a means of differentiating across the continuum of alcohol use.
Instead, NIAAA recommends healthcare professionals use the Alcohol Use Disorders Identification Test (AUDIT). This tool asks 10 questions to determine how much and how often the patient consumes alcohol, identify the pattern of alcohol use, and gauge whether the patient may have an AUD.

Clinical application
AUDIT is part of a screening algorithm described in NIAAA’s publication Helping Patients Who Drink Too Much: A Clinician’s Guide. Here are the four basic steps of the algorithm:
1.    Ask about alcohol use. Start with the question. “Do you sometimes drink beer, wine, or other alcoholic beverages?” If the patient answers “Yes,” ask, “How many times in the past year have you had five or more drinks in a day?” (For a woman, use four or more drinks). At this point, you can administer the AUDIT. If the patient isn’t currently drinking, find out about past alcohol use by asking, “Have you sometimes had alcoholic beverages during your lifetime?” Someone who is abstinent now but previously consumed large amounts of alcohol for long periods might be experiencing medical complications from earlier alcohol use. Stay especially alert for this in elderly patients who’ve cut back on alcohol after using it for 40 years or more.
2.    Assess for AUDs. Look for a maladaptive pattern of alcohol use that’s causing clinically significant impairment or distress
3.    Advise and assist. State your conclusion and recommendations clearly. For instance, “You’re drinking more than is medically safe. I strongly advise you to cut down or quit, and I’m willing to help.” Gauge the patient’s readiness to alter drinking habits.
4.    Continue support. At each visit, document the patient’s alcohol use and review the goals.
Once you complete this process, you’ll have important information about the patient’s alcohol use. If your patient reports current alcohol consumption but screens negative for an AUD, emphasize the need to stay within maximum limits. As indicated, recommend lower limits of alcohol use depending on the patient’s medication use or medical status. Advise a patient who is pregnant or may become pregnant to abstain totally.
A patient who reports one or more heavy drinking days in the past year or who has an AUDIT score of 8 or higher (if male) or 4 or higher (if female) needs further evaluation. The NIAAA recommends considering making a referral to an addictions specialist for assessment, although this isn’t practical in some settings.
If a patient is currently abstinent, assess for alcohol-related physical and mental problems if he reports a history of exceeding recommended limits of alcohol consumption for a long period. This assessment may involve laboratory tests, such as liver function tests and thiamine levels, as well as evaluation of cardiovascular and mental status.
If a patient admitted for inpatient care is currently drinking at high levels, assess for possible alcohol withdrawal every 4 hours over a 5-day period.

Screening as a standard of nursing care
The approach outlined here is a guide to incorporating AUD screening into nursing assessment. By making such screening routine, you can make real inroads toward preventing and ensuring early intervention for AUDs and reducing the health consequences of alcohol use.

Selected references
Dawson D, Grant B, Li T. Quantifying the risks associated with exceeding recommended drinking limits. Alcohol Clin Exp Res. 2005;
29:902-908. www3.interscience.wiley.com/
journal/118650419/abstract. Accessed November 9, 2008.
Haack M, Adger H. Strategic plan for interdisciplinary faculty development. Subst Abus. 2002;23(3S):345.
National Institute on Alcohol Abuse and Alcoholism. Helping Patients Who Drink Too Much: A Clinician’s Guide. Updated 2005 Edition. http://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/guide.pdf. Accessed November 9, 2008.
National Quality Forum. National Voluntary Consensus Standards for the Treatment of Substance Use Conditions: Evidenced-Based Treatment Practices. Washington, DC: National Quality Forum; 2007.
Visit www.AmericanNursetoday.com for a complete list of selected references and the complete AUDIT tool.

Christine Savage  is an Associate Professor and Director of the Community Health Masters Program at the College of Nursing at the University of Cincinnati College of Nursing in Cincinnati, Ohio.

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