Professional Documents
Culture Documents
Alcohol-Related Disorders
John F. Kelly, PhD, and John A. Renner Jr., MD
KEY POINTS
Incidence
Alcohol misuse is one of the leading causes of
morbidity and mortality in the US.
Epidemiology
The highest rates of alcohol use, heavy binge use, and
alcohol use disorders occur between the ages of 18
and 29 years.
Pathophysiology
Alcohol causes harm through three distinct, but
related pathways: intoxication, toxicity, and alcohol
use disorder.
Clinical Findings
Alcohol use disorders are heterogeneous disorders
that require assessment and an individualized clinical
approach.
It is possible to screen effectively and efficiently for
the presence of an alcohol use disorder using brief,
validated measures.
Differential Diagnoses
Presentation of an alcohol use disorder is often
complicated by the presence of co-morbid psychiatric
symptoms and disorders that require assessment and
monitoring, as well as an integrated treatment
approach.
Treatment Options
A number of effective pharmacological and
psychosocial treatment approaches exist for alcohol
use disorders that produce outcomes similar to, or
better than, outcomes for other chronic illnesses.
Complications
Heavy drinking can lead to accidents, violence,
unwanted pregnancies, and overdoses.
OVERVIEW
Alcohol is an ambiguous molecule1 often referred to as mans
oldest friend and oldest enemy.2 Compared to more structurally complicated substances, such as cannabis (C21H30O2),
cocaine (C17H21NO4), or heroin (C21H23NO5), beverage alcohol
(ethanol) possesses a simple chemical structure (C2H5OH)
that belies the complexities of its medical, psychological, and
social impact (Figure 26-1).
When the alcohol molecule reaches the human brain it is
generally perceived as good news; pleasant subjective experiences of euphoria, disinhibition, anxiety reduction, and sedation, are the most likely outcomes. These are often encouraged
and enhanced by social contexts and by culture-bound
customs. If too high a dose is imbibed too rapidly, however,
acute intoxication occurs, leading to a predictable sequence of
behavioral disinhibition and cognitive and motor impairments. If a large quantity of alcohol is consumed, especially
270
Alcohol-Related Disorders
substantial roles that alcohol use, misuse, and associated disorders play in medicine and psychiatry will enhance the detection of these problems and lead to more efficient and effective
targeting of clinical resources.
In this chapter we review pertinent clinical manifestations
of heavy alcohol use and outline strategies for effective management of alcohol-related problems. The nature, etiology,
epidemiology, and typologies of alcohol-related disorders are
described, and optimal screening and assessment methods (to
facilitate detection and appropriate intervention) are outlined.
In the final sections, details of current knowledge regarding
the mechanisms of action of heavy alcohol use are provided
and effective psychosocial and pharmacological treatment
approaches are reviewed.
271
Liver damage.
Trembling hands.
Tingling fingers.
Numbness. Painful nerves.
Ulcer.
In men:
Impaired sexual performance.
In women:
Risk of giving birth to deformed,
retarded babies or low birth
weight babies.
Imparied sensation
leading to falls.
Pattern of drinking
Average volume
Intoxication
Toxic effects
Chronic disease
Dependence
Accidents/
injuries (acute
disease)
Acute social
problems
Chronic social
problems
Figure 26-3. Patterns of drinking and pathways to harm. (From Babor TF, Caetano R, Casswell S, etal. Alcohol: no ordinary commodity-research
and public policy. ed 2. Oxford, UK, 2010, Oxford University Press.)
26
272
been met for at least 3 months but for less than 12 months
(with the exception that Criterion A4, Craving, or a strong desire
or urge to use alcohol, may be met).
In sustained remission: After full criteria for alcohol use disorder
were previously met, none of the criteria for alcohol use disorder
have been met at any time during a period of 12 months or
longer (with the exception that Criterion A4, Craving, or a
strong desire or urge to use alcohol, may be met).
Specify if:
In a controlled environment: This additional specifier is used if
the individual is in an environment where access to alcohol is
restricted.
Coding note based on current severity, for ICD-10-CM
codes: If an alcohol intoxication, alcohol withdrawal, or
another alcohol-induced mental disorder is also present, do
not use the codes below for alcohol use disorder. Instead, the
comorbid alcohol use disorder is indicated in the 4th
character of the alcohol-induced disorder code (see the
coding note for alcohol intoxication, alcohol withdrawal, or a
specific alcohol-induced mental disorder). For example, if
there is comorbid alcohol intoxication and alcohol use
disorder, only the alcohol intoxication code is given, with the
4th character indicating whether the comorbid alcohol use
disorder is mild, moderate, or severe: F10.129 for mild alcohol
use disorder with alcohol intoxication or F10.229 for a
moderate or severe alcohol use disorder with alcohol
intoxication.
Specify current severity:
305.00 (F10.10) Mild: Presence of 23 symptoms.
303.90 (F10.20) Moderate: Presence of 45 symptoms.
303.90 (F10.20) Severe: Presence of 6 or more symptoms.
Specify if:
In early remission: After full criteria for alcohol use disorder were
previously met, none of the criteria for alcohol use disorder have
Reprinted with permission from the Diagnostic and statistical manual of mental disorders, ed 5, (Copyright 2013). American Psychiatric Association.
ALCOHOL-INDUCED DISORDERS
Alcohol Intoxication
The action of alcohol on the brain is complex. Low blood
alcohol concentrations (BACs) produce activation and disinhibition, whereas higher BACs produce sedation. Behavioral
disinhibition is mediated by alcohols action as a -aminobutyric
acid (GABA) agonist, and its interactions with the serotonin
system may account for its association with violent behavior.
The GABA, N-methyl-D-aspartate (NMDA), and serotonin
systems have all been implicated in the escalation to violence.15,16 Blood alcohol concentrations (BACs, measured as
the percentage of alcohol in the blood) from 0.19% to 29%
may impair memory or lead to an alcoholic blackout, with
argumentativeness or assaultiveness developing at levels of
0.10%0.19% and coma or death occurring at 0.40%0.50%.
Yet, chronic alcoholics may be fully alert with a BAC of more
than 0.40%, owing to tolerance. Resolution of intoxication
follows steady-state kinetics, so that a 70-kg man metabolizes
Treatment
If it becomes necessary to sedate an intoxicated individual,
one should begin with a smaller-than-usual dose of a benzodiazepine to avoid cumulative effects of alcohol and other
sedative-hypnotics. Once the individuals tolerance has
been established, a specific dose can be safely determined.
Lorazepam (Ativan) (1 to 2mg) is effectively absorbed via oral
(PO), intramuscular (IM), or intravenous (IV) administration.
Diazepam (Valium) and chlordiazepoxide (Librium) are erratically and slowly absorbed after IM administration unless they
are given in large, well-perfused sites. When incoordination
suggests that the additive effect of a benzodiazepine has produced excessive sedation, it may be advantageous to use
haloperidol 5 to 10mg PO or IM. The initial dose should be
followed by a delay of 0.5 to 1 hour before the next dose. If
there is no risk of withdrawal, the patient can safely be referred
to an outpatient program. Inpatient detoxification is preferable to outpatient care if the patient is psychosocially unstable;
has serious medical, neurological, or psychiatric co-morbidity;
has previously suffered from complications of withdrawal
(such as seizures or delirium tremens [DTs]); or is undergoing
Alcohol-Related Disorders
Life threatening
Loss of consciousness
Danger of lifethreatening alcohol
poisoning
Significant risk of death
in most drinkers due to
suppression of vital life
functions
Increased impairment
Perceived beneficial
effects of alcohol, such
as relaxation, give
way to increasing
intoxication
Increased risk of
aggression in some
people
Speech, memory,
attention, coordination,
balance further impaired
Significant impariments
in all driving skills
Increased risk of injury
to self and others
Moderate memory
impairments
Blood
Alcohol Content
(BAC)
0.310.45%
0.160.30%
Severe impairment
Speech, memory,
coordination, attention,
reaction time, balance
significantly impaired
All driving-related skills
dangerously impaired
Judgment and decision
making dangerously
impaired
Vomiting and other
signs of alcohol
poisoning common
Loss of consciousness
0.060.15%
0.00.05%
Mild impairment
Mild speech, memory,
attention, coordination,
balance impairments
Perceived beneficial
effects, such as
relaxation
Sleepiness can begin
Alcohol-induced Coma
Alcohol-induced coma, although rare, is a medical emergency.
It occurs when extraordinary amounts of alcohol are consumed, and it can occur in conjunction with use of other
drugs. Young adults/college-age youth may be particularly susceptible when goaded into drinking contests. This age group
is also at significantly higher risk for alcohol-related injuries.
A 2002 study by the federally supported Task Force on College
Drinking estimated that 1,400 college students in the US are
killed each year in alcohol-related accidents.
Seizures
Mild withdrawal
Severe withdrawal
273
Hallucinations
2
6
Days
10
12
Treatment
Rigid adherence to a single protocol for all cases of alcohol
withdrawal is unrealistic. Symptom-triggered dosing, in which
dosages are individualized and only administered on the
appearance of early symptoms, is often recommended. Assessment of the severity of alcohol withdrawals signs and symptoms is best accomplished with the use of standardized
alcohol withdrawal scales, such as the CIWA-Ar.21 This reduces
use of medication doses by a factor of four, substantially shortens the length of treatment, and shortens symptom duration
by a factor of six,17,22 although the benefits may be less dramatic in medically ill inpatients.23 Chlordiazepoxide (50 to
100mg PO) can be given initially, and be followed by 50 to
100mg every 1 to 2 hours until the patient is sedated and the
vital signs are within normal limits. Alternatively, diazepam
(10 to 20mg) may be given initially, and then repeated every
1 to 2 hours until sedation is achieved. Often a first days dose
of a long-acting benzodiazepine is sufficient for the entire
detoxification process because of the self-tapering effect and
slow elimination.24 Patients with impaired liver function, the
elderly, or individuals with co-occurring medical or psychiatric
26
274
Treatment
In patients without a prior seizure disorder, diphenylhydantoin offers no benefit over placebo, and given the potential
for side effects, diphenylhydantoin is therefore not recommended.28 Also, given that loading with carbamazepine or
valproate may not address the rapid time course of withdrawal
seizures, the most parsimonious approach remains effective
treatment with benzodiazepines. Prompt treatment of early
withdrawal symptoms, as described below, is the most effective measure to prevent the development of seizures. In cases
where there is a known seizure disorder, however, conventional management with an anticonvulsant is in order.
Treatment
Prevention is the key. Symptom-triggered dosing for alcohol
withdrawal has been shown to reduce DTs more than use of
standing doses of benzodiazepine in medically ill inpatients.23
Alcohol-Related Disorders
Controls
275
WK subject
MPFC (SMA)
DLPFC
Insula
and
IFG (VLPFC)
WernickeKorsakoff Syndrome
Victor and colleagues,34 in their classic monograph The
WernickeKorsakoff Syndrome, state that Wernickes encephalopathy and Korsakoffs syndrome in the alcoholic, nutritionally deprived patient may be regarded as two facets of the same
disease. Patients evidence specific central nervous system
pathology with resultant profound mental changes. Although
perhaps 5% of alcoholics have this disorder, in 80% of these
cases, the diagnosis is missed.32 In all of the cases reported by
Victor and colleagues,34 alcoholism was a serious problem and
was almost invariably accompanied by malnutrition. Malnutrition, particularly thiamine deficiency, has been shown to be
the essential factor.
Wernickes Encephalopathy
Wernickes encephalopathy appears suddenly and is characterized by ophthalmoplegia and ataxia followed by mental disturbance. The ocular disturbance, which occurs in only 17%
of cases, consists of paresis or paralysis of the external recti,
with nystagmus, and a disturbance in conjugate gaze. A globally confused state consists of disorientation, unresponsiveness, and derangement of perception and memory. Exhaustion,
apathy, dehydration, and profound lethargy are also part of
the picture. The patient is apt to be somnolent, confused, and
slow to reply, and may fall asleep in mid-sentence. Once treatment with thiamine is started for Wernickes encephalopathy,
improvement is often evident in the ocular palsies within
hours. Recovery from ocular muscle paralysis is complete
within days or weeks. According to Victor and colleagues,34
approximately one-third recovered from the state of global
confusion within 6 days of treatment, another third within 1
month, and the remainder within 2 months. The state of
global confusion is almost always reversible, in marked contrast to the memory impairment of Korsakoffs psychosis.
Ventral
occipitotemporal
cortex
Figure 26-6. Brain activation in WernickeKorsakoff (WK) patients
compared to controls. VLPFC, ventro lateral pre-frontal cortex; IFG,
inferior frontal gyrus. (From Caulo M, Van Hecke J, Toma L, etal.
Functional MRI study of diencephalic amnesia in WernickeKorsakoff
syndrome. Brain 128(Pt 7):15841594, 2005.)
Treatment
Administration of the B vitamin thiamine (IM or IV) should
be routine for all suspected cases of alcohol intoxication and
dependence.35 The treatment for Wernickes encephalopathy
26
276
Epicanthal folds
Flat nasal bridge
Small palpebral fissures
Railroad track ears
Upturned nose
Smooth philtrum
Thin upper lip
Alcohol-Related Disorders
277
26
278
Epidemiology
Rates of alcohol use and AUD vary along several dimensions.
Some of the most important among these are gender,
life-stage, ethnicity, geographic location, and psychiatric
co-morbidity.
In general, just over half of all Americans report alcohol
consumption in the prior month.61 Among drinkers, the lifetime prevalence for an AUD is about 14.6%. Surveys assessing
past-year prevalence of these disorders indicate that nearly
8.5% (18 million) of American adults meet standard diagnostic criteria for DSM-5 AUD.14,62 The rates of AUD in the general
population vary by gender, with men having higher rates
(12.4%) than women (4.9%). Highest rates of past year AUD
occur among 1829 year olds (16.2%) and the lowest among
individuals age 65 years and older (1.5%). When translated
into the impact AUDs have on families in the US, surveys
show that more than half of all families report at least one
close relative as having a drinking problem. As alluded
to above, rates of heavy alcohol use and AUD among
adolescents, young adults, and adults vary by geographic location, due to subcultural differences across regions. The differences may be reflected in varying proscriptions against
intoxication and/or differences in alcohol policy (Figures
26-826-10).63
The highest rates of alcohol use, heavy/binge use, and
AUDs occur between the ages 18 and 29.61 Under-age drinking
is a major public health problem in its own right, with about
11 million under-age persons aged 12 to 20 years (28.7%)
reporting alcohol use in the past month, with the vast majority
of these (10 million) drinking heavily or binging on alcohol.
More males than females aged 12 to 20 years report binge
drinking (22.1% versus 17.0%) and heavy drinking (8.2%
Percentages
of persons
4.60 5.88
4.25 4.59
3.92 4.24
3.73 3.91
3.03 3.72
Figure 26-8. Prevalence of alcohol use disorders among adolescents (ages 1217) in the US, 20102011. (From Substance Abuse and Mental
Health Services Administration. Results from the 2010 National Survey on Drug Use and Health: Summary of National Findings. Rockville, MD,
2011, Substance Abuse and Mental Health Services Administration.)
Alcohol-Related Disorders
279
26
Percentages
of persons
17.66 20.70
15.98 17.65
14.88 15.97
13.33 14.87
10.13 13.32
Figure 26-9. Prevalence of alcohol use disorder among young adults (ages 1825) in the US, 20102011. (From Addiction Treatment Strategies.
Finger tapping study shows alcoholics may recruit other brain regions. 2012; http://www.addictionts.com/2012/08/17/finger-tapping-studyshows-alcoholics-may-recruit-other-brain-regions/, 2013.)
Percentages
of persons
7.87 10.77
7.18 7.86
6.66 7.17
5.58 6.65
4.59 5.57
Figure 26-10. Prevalence of alcohol use disorder among persons aged 12 and older and in the United States, 20102011. (From Substance
Abuse and Mental Health Services Administration. Results from the 2010 National Survey on Drug Use and Health: Summary of National Findings. Rockville, MD, 2011, Substance Abuse and Mental Health Services Administration.)
280
12
Percentage
10
8
6
4
2
0
Hispanics
Native
Americans
and Alaska
Natives
Whites
African
Asian
Americans Americans
and Pacific
Islanders
Race/ethnicity
Figure 26-11. Twelve-month prevalence of alcohol use disorders
across race/ethnic subgroups of the US. (From Substance Abuse and
Mental Health Services Administration. Results from the 2010 National
Survey on Drug Use and Health: Summary of National Findings. Rockville, MD, 2011, Substance Abuse and Mental Health Services
Administration.)
20
18
Percent with AUD
16
14
12
10
8
6
4
2
0
Serious
mental
illness
Moderate
mental
illness
Low (mild)
mental
illness
No mental
illness
Figure 26-12. Past year alcohol use disorder among adults aged 18
or older, by level of mental illness: 2011. (From Substance Abuse and
Mental Health Services Administration. Results from the 2010 National
Survey on Drug Use and Health: Summary of National Findings. Rockville, MD, 2011, Substance Abuse and Mental Health Services
Administration.)
Typologies
AUDs are complex and heterogeneous. Hence, attempts have
been made to try to identify more homogeneous subtypes.
Various typologies, some formal and others less formal, have
been proposed during the past 50 years. Early typologies relied
more on theoretically-framed, clinical observations. More
recently, data-driven, multi-variate sub-classifications have
been derived that have etiological significance and predictive
validity, and may have clinical utility.
One of the first and most well-known was Jellineks typology consisting of five subspecies of alcoholism simply labeled
using the first five letters of the Greek alphabet: alpha, beta,
delta, gamma, epsilon.72 Jellineks very broad definition of
alcoholism as any use that causes harm yielded a similarly
broad typology. Jellineks typology was not successfully validated, but it did highlight the important topic of heterogeneity and it sparked further interest and efforts to identify
particular subtypes of individuals suffering from alcoholism
for the purposes of tailoring treatments.
During the past 25 years, multi-variate typologies have
been investigated with the use of more complex data extraction methods (e.g., cluster and factor analysis). Cloningers
Type I or Type II and Babors Type A or B were the first of these.
Cloninger and colleagues73 identified two separate forms of
alcoholism based on differences in alcohol-related symptoms,
patterns of transmission, and personality characteristics using
data derived from a cross-fostering study of Swedish adoptees.
Type I was characterized by either mild or severe alcohol use
in the probands and no criminality in the fathers. These Type
I alcoholics came from relatively high socioeconomic backgrounds and were frequently associated with maternal alcohol
use. Type I alcoholics were thought to be more responsive to
environmental influence, to have relatively mild alcoholrelated problems, and to have a late age of onset (older than
25 years). On the other hand, Cloningers Type II alcoholism
is characterized as being associated with a family history,
having severe alcohol problems, having other drug use, and
having an early onset (before age 25). Although multi-variate
statistical methods were used to identify subtypes, Cloningers
types of alcoholism have been criticized due to the small
sample sizes (less than 200), sample selection methods, and
indirect assessment of family variables.74
A second typology was proposed by Babor and colleagues75
based on a sample of 321 alcoholic inpatients. Babors Type A
resembled Cloningers Type 1, and was characterized by a later
age of onset, fewer childhood behavior problems, and less
psychopathology. Type B resembled Type II alcoholism and
was defined by a high prevalence of childhood behavior problems, familial alcoholism, early onset of alcohol problems,
more psychopathology, more life stress, and a more chronic
treatment history.
A broad distinction of early-onset versus late-onset alcohol
dependence may have some clinical matching utility, although
evidence is limited. For example, use of selective serotonin
reuptake inhibitors (SSRIs) has produced modest drinking
reductions that may be more apparent in men with depression
and late-onset type alcoholism.76,77 Also, double-blind
placebo-controlled studies of anti-craving medications (e.g.,
ondansetron) have shown efficacy for early-onset alcoholics,
as have others (e.g., topiramate) for a broad range of unselected alcoholic patients.
Later studies examining typologies have found more than
two subtypes that have clinical and etiological significance,
particularly regarding gender, and internalizing/externalizing
disorders, in addition to family history and age of onset. For
example, several multi-variate, multi-dimensional analyses
have revealed that there may be as many as four general,
homogeneous subtypes of alcohol dependence78,79: chronic/
severe, depressed/anxious, mildly affected, and antisocial.80
These four subtypes of alcohol dependence are found within
both genders and across different ethnic subgroups, but more
prospective research is needed to examine their relative clinical course and responsiveness to various pharmacological and
psychosocial interventions. These approaches to AUD typologies have employed either empirical or clinical/observational
strategies using data derived principally from treatment
samples. However, only about one-fourth of those who meet
Alcohol-Related Disorders
281
26
282
Effects on Neurotransmitters
The typical subjective effects from alcohol include euphoria,
disinhibition, anxiety reduction, sedation, and sleep. These
effects are mediated by a variety of neurotransmitters including GABA, glutamate, serotonin, endorphins, and dopamine.
Alcohol effects neurotransmitter systems by causing either
neuronal excitation or inhibition.100 If alcohol is consumed
over extended periods (e.g., several days or weeks), receptors
adapt to its presence, producing neurotransmitter imbalances
that can result in sedation, agitation, depression, and other
mood and behavior disorders, as well as seizures.
The results of neuropsychological testing reveal that shortterm memory, performance on complex memory tasks, visualmotor coordination, visual-spatial performance, abstract
reasoning, and psychomotor dexterity are the areas most seriously damaged. Intelligence scores often do not change, and
verbal skills and long-term memory often remain intact. As a
consequence, it is possible for individuals to appear cognitively intact unless they are administered neuropsychological
tests.
Glutamate is the major excitatory neurotransmitter in the
brain and it is significantly effected by alcohol. Alcohol influences the action of glutamate, and research has shown that
chronic, heavy alcohol consumption increases glutamate
receptor sites in the hippocampus that can effect the consolidation of memory and may account for blackout phenomena. Contrary to popular belief, blackouts are much more
common among social drinkers than previously assumed.
In a large sample of college student drinkers, more than
half (51%) reported blacking out at some point in their
lives, and 40% reported experiencing a blackout in the prior
Alcohol
+
Glutamate inputs
(e.g., from cortex)
Opioid
peptides
VTA
interneuron
Alcohol
Alcohol
?
GABA
Dopamine
Dopamine
Glutamate inputs
(e.g., from amygdala
PPT/LDT)
Nucleus accumbens
Alcohol-Related Disorders
283
Intervention
Health care
system
influences
Adolescents and
adults
Subgroups:
Young adults/college
students
Adolescents
Adults
Seniors (65+)
Veterans
Pregnant women
Racial/ethnic minorities
Sex
Co-occurring medical or
psychiatric disorders
Varying severity
Screening
Alcohol misuse
Intervention
Adverse
effects of
screening
Intermediate
outcomes:
Measures of lowerrisk alcohol use
Adverse
effects of
intervention
26
Long-term outcomes:
Health
All-cause
mortality
Alcohol-related
deaths
Alcohol-related
morbidity
Alcohol-related
accidents and
injuries
Quality of life
Other:
Heath care
utilization
Sick days
Costs
Legal issues
Employment
stability
Figure 26-14. Screening and assessment process. (From Jonas DE, Garbutt JC, Brown JM, etal. Screening, behavioral counseling, and referral
in primary care to reduce alcohol use. Rockville, 2012, Agency for Health Research and Quality.)
284
Never
Monthly or less
2 to 4 times a
month
2 to 3 times
a week
4 or more times a
week
1 or 2
3 or 4
5 or 6
7 to 9
10 or more
Never
Monthly
Weekly
Never
Monthly
Weekly
Never
Monthly
Weekly
Never
Monthly
Weekly
Never
Monthly
Weekly
Never
Monthly
Weekly
No
No
Score
Total:
NOTE: This self-report questionnaire (the Alcohol Use Disorders Identification Test [AUDIT]) is from the World Health Organization. To reflect standard
drink sizes in the United States, the number of drinks in question 3 was changed from 6 to 5. A free AUDIT manual with guidelines for use in
primary care is available online at http://www.who.org.
Information from Reinert DF, Allen JP. The alcohol use disorders identification test: an update of research findings. Alcohol Clin Exp Res 31(2):185
199, 2007, and Bradley KA, DeBenedetti AF, Volk RJ, Williams EC, Frank D, Kivlahan DR. AUDIT-C as a brief screen for alcohol misuse in primary
care. Alcohol Clin Exp Res 31(7):12081217, 2007.
Probability of abuse/dependence
diagnosis
100
80
60
40
20
0
3
4
CRAFFT score
Alcohol-Related Disorders
285
Brief Intervention
A concerned and focused assessment with brief advice by a
health care provider can make a positive difference to drinking
problems. Brief interventions are generally recommended
for those who drink to excess, but are generally not showing
signs of addiction. Thus, its goal may be moderate drinking
rather than abstinence.135137 Brief interventions are generally
restricted to four or fewer sessions, lasting from a few minutes
to 1 hour each, designed to be conducted by clinicians, not
necessarily specialized in addiction.138
Research indicates that brief interventions for alcohol
problems are more effective than no intervention139142 and,
in some cases, can be as effective as more extensive intervention.135,143 Capitalizing on these findings, and in order to
expand access to treatment for alcohol-related problems, the
Center for Substance Abuse Treatment (CSAT) has devised an
initiative known as Screening, Brief Intervention, Referral,
and Treatment (SBIRT). The goal of the initiative is intended
to shift the emphasis to alcohol users whom the traditional
system has largely ignoredthe large number of individuals
who consume more than the medically-accepted limits but
are not yet dependent. Rejecting the notion that only people
with very heavy alcohol use levels or who are alcohol dependent need targeted interventions, SBIRT assumes that everyone, regardless of current level of alcohol consumption, can
benefit from learning the facts about safe alcohol consumption and knowing how their own usage compares to accepted
limits. Using the AUDIT/AUDIT-C as a screening device, frontline clinicians in any setting can assess for alcohol-related
problems quickly and easily. SBIRT triage guidelines provide
recommendations along the lines of an individuals alcohol
involvement. Simple clinical advice to cut down or stop is
recommended if someone scores between 7 and 16 on the
AUDIT; multiple sessions of brief treatment and monitoring
are recommended if an individual scores between 16 and 19
(or has consumed alcohol to intoxication five or more days
per month, as disclosed on screening interview); and if an
individual has an AUDIT score of 20 or more a referral for
more intensive assessment and treatment is recommended.144
What is it about brief interventions that make them effective? After reviewing the key ingredients in a variety of brief
intervention protocols, Miller and Sanchez145 proposed six
critical elements that they summarized with the acronym
FRAMES: Feedback, Responsibility, Advice, Menu, Empathy,
and Self-efficacy. The clinician completes some assessment
and provides Feedback on the patients alcohol-related problems (Your results show. ), stresses the patients Responsibility to address the problem (Its your choice. ), gives
clear Advice to change drinking behavior (I would recommend that you cut down or stop. ), provides a Menu of
treatment strategies (There a number of different things you
might do. ), expresses Empathy for the patients problem
(This can be difficult to hear and making changes is not
always easy, but. ), and stresses Self-efficacy (However, it
is quite possible for you to achieve this. )the expectation
is that the patient has the skills needed to successfully resolve
his or her drinking problems. Additional components of goalsetting, follow-up, and timing also have been identified as
important to the effectiveness of brief interventions.136,146 Even
brief contact with an addiction specialist has been shown to
yield improvement in 30% to 50% of patients. However, brief
interventions are more effective with those who have no prior
26
286
Intensive-Extensive Interventions
Three broad elements are important in recovery from AUDs:
deconditioning, skills training, and cognitive re-structuring.151
There is a broad array of evidence-based interventions for
AUDs that address these critical elements.132,133,152 Some of
these include Twelve-Step Facilitation (TSF), a professional
therapy designed to engage patients and support long-term
involvement in the fellowship of AA; motivational enhancement therapy (MET), an intervention based on the principles
of motivational interviewing146,153; a variety of cognitivebehavioral approaches, such as the Community Reinforcement Approach (CRA), designed to engage multiple therapeutic
elements in the community; interpersonal system-based interventions, such as behavioral marital therapy (BMT) and family
therapies; and pharmacotherapies (e.g., naltrexone/depot
natrexone, acamprosate, or disulfiram).
Although most interventions are directly focused on the
primary sufferer (the individual with the AUD), it is clear that
loved ones also suffer greatly as a result of the AUD. Community Reinforcement and Family Training (CRAFT) is a validated approach based on the concept that a supportive
environment community will help the alcohol-dependent
person achieve recovery. CRAFT targets individuals who refuse
to participate in treatment through their loved ones. It provides specific, contingency-based strategies that support family
members and friends in their efforts to help their loved one
become engaged in treatment. It has been shown also to substantially reduce psychological distress and symptoms among
the family members themselves.154
Despite vastly differing theoretical assumptions regarding
the specifics of treatment content, and for how long, at what
intensity, and by whom the treatment should be delivered,
comparisons of the relative efficacy of active treatments reveal
surprisingly similar effects, suggesting that they may all mobilize common change processes.155 However, it seems clear that
it is the duration and continuity of care that is linked to treatment outcome rather than amount or intensity.46,155157 Consequently, there have been recent shifts from intensive
inpatient services to extensive outpatient models of addiction recovery management and ongoing assessment and
re-intervention that match the chronic relapse-prone nature of
addictive disorders (e.g., telephone case monitoring and longterm outpatient treatment).158160
In recent years, there has tended to be an almost exclusive
focus on high-fidelity delivery of manualized treatment
content rather than a focus on the characteristics of the clinician who delivers the content and how it is delivered. The
issue of therapeutic alliance and successfully gaining the
patients trust is often fundamental to the success of treatment,
yet is seldom specifically addressed. A respectful, empathic,
patient-centered approach appears to be most helpful, and a
harsh, confrontational approach may increase the patients
resistance.132 The principles and practices of motivational
Pharmacological Interventions
Three medications have been approved by the FDA for the
treatment of alcohol dependence: disulfiram (approved in
1947), intended to prevent any drinking through the
Alcohol-Related Disorders
287
Pharmacokinetics/Pharmacodynamics
Effects
Disulfiram (Antabuse)
26
288
Cue induced
Stress induced
Relapse
Social
Drug induced
Psych
Neurobiology
Mutual help
(e.g., Alcoholics
Anonymous)
Biopsychosocial model
Figure 26-16. Biopsychosocial model of how mutual help organizations, such as Alcoholics Anonymous may attenuate relapse risk over time.
(From Kelly JF, Yeterian JD. Mutual-help groups for alcohol and other substance use disorders. In McCrady BS, Epstein EE, editors: Addictions:
a comprehensive guidebook. ed 2. New York, 2013, Oxford University Press.)131
CONCLUSIONS
Alcohol misuse and related disorders permeate virtually every
aspect of psychiatry and medicine. Preventing early exposure
Alcohol-Related Disorders
289
94. Everitt BJ, Robbins TW. Neural systems of reinforcement for drug
addiction: from actions to habits to compulsion. Nature Neurosci
8(11):14811489, 2005.
110. Fleming MF. Brief interventions and the treatment of alcohol
use disorders: current evidence. Rec Dev Alcohol 16:375390,
2003.
130. Kelly JF, Yeterian JD. Empirical awakening: the new science on
mutual help and implications for cost containment under health
care reform. Subst Abus 33(2):8591, 2012.
131. Kelly JF, Yeterian JD. Mutual-help groups for alcohol and other
substance use disorders. In McCrady BS, Epstein EE, editors:
Addictions: A comprehensive guidebook, ed 2, New York, 2013,
Oxford University Press.
133. Moyer A, Finney JW, Swearingen CE, etal. Brief interventions for
alcohol problems: a meta-analytic review of controlled investigations in treatment-seeking and non-treatment-seeking populations. Addiction 97(3):279292, 2002.
134. Maisel NC, Blodgett JC, Wilbourne PL, etal. Meta-analysis of
naltrexone and acamprosate for treating alcohol use disorders:
when are these medications most helpful? Addiction 108(2):275
293, 2013.
138. Madras BK, Compton WM, Avula D, etal. Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and alcohol
use at multiple healthcare sites: comparison at intake and 6
months later. Drug Alcohol Depend 99(13):280295, 2009.
157. White WL. Recovery management and recovery-oriented systems of
care: scientific rationale and promising practices, 2008, Northeast
Addiction Technology Transfer Center, Great Lakes Addiction
Technology Transfer Center, Philadelphia Department of Behavioral Health/Mental Retardation Services.
158. Dennis ML, Scott CK. Four-year outcomes from the Early
Re-Intervention (ERI) experiment using Recovery Management
Checkups (RMCs). Drug Alcohol Depend 121(12):1017, 2012.
164. McClellan A, Lewis D, OBrien C, etal. Drug dependence, a
chronic medical illness: implications for treatment, insurance,
and outcomes evaluation. JAMA 284(13):16891695, 2000.
167. White WL. Recovery/remission from substance use disorders: An
analysis of reported outcomes in 415 scientific reports, 18682011,
2012, Philadelphia Department of Behavioral Health and Intellectual disability Services, Great Lakes Addiction Technology
Transfer Center.
181. Humphreys K. Circles of recovery: self-help organizations for addictions, Cambridge, UK, 2004, Cambridge University Press.
187. Kelly JF, White W. Broadening the base of addiction recovery
mutual aid. J Groups Addict Recover 7(24):82101, 2012.
192. Kelly JF, Magill M, Stout RL. How do people recover from alcohol
dependence? A systematic review of the research on mechanisms
of behavior change in Alcoholics Anonymous. Addict Res Theory
17(3):236259, 2009.
194. Kelly JF, Hoeppner B. Does Alcoholics Anonymous work differently for men and women? A moderated multiple-mediation
analysis in a large clinical sample. Drug Alcohol Depend 130(1
3):186193, 2013.
26
Alcohol-Related Disorders
REFERENCES
1. Edwards G. Alcohol: the worlds favorite drug, New York, 2000, St
Martins Press.
2. Institute of Medicine. Broadening the base of treatment for alcohol
problems, Washington, DC, 1990, National Academy Press.
3. Goodwin DW, Crane JB, Guze SB. Alcoholic blackouts: a
review and clinical study of 100 alcoholics. Am J Psychiatry
126(2):191198, 1969.
4. Babor TF, Caetano R, Casswell S, etal. Alcohol: no ordinary
commodity-research and public policy, ed 2, Oxford, UK, 2010,
Oxford University Press.
5. Yao H, Takashima Y, Hashimoto M, etal. Subclinical cerebral
abnormalities in chronic kidney disease. Contrib Nephrol 179:24
34, 2013.
6. Bagnardi V, Rota M, Botteri E, etal. Light alcohol drinking and
cancer: a meta-analysis. Ann Oncol 24(2):301308, 2013.
7. Wodak AD, Saunders JB, Ewusi-Mensah I, etal. Severity of
alcohol dependence in patients with alcoholic liver disease. Br
Med J (Clin Res Ed) 287(6403):14201422, 1983.
8. U.S. Department of Health and Human Services and U.S.
Department of Agriculture. Dietary Guidelines for Americans,
2005, Washington, DC, 2005, HHS and USDA.
9. World Health Organization. Global status report on alcohol 2004,
Geneva, 2004, DMHSA.
10. Mokdad AH, Marks JS, Stroup DF, etal. Actual causes of
death in the United States, 2000. JAMA 291(10):12381245,
2004.
11. World Health Organization. Global status report on alcohol and
health, Geneva, Switzerland, 2011, World Health Organization.
12. Bouchery EE, Harwood HJ, Sacks JJ, etal. Economic costs of
excessive alcohol consumption in the U.S. 2006. Am J Prev Med
41(5):516524, 2011.
13. Harwood H. Updating estimates of the economic costs of alcohol
abuse in the United States: estimate, update methods and data, Washington, DC, 2000, National Institute on Alcohol Abuse and
Alcoholism, National Institutes of Health, Department of Health
and Human Services.
14. American Psychiatric Association. Diagnostic and statistical
manual of mental disorders, ed 5, Arlington, 2013, American Psychiatric Association.
15. Miczek KA, Fish EW, De Almeida RM, etal. Role of alcohol
consumption in escalation to violence. Ann N Y Acad Sci
1036:278289, 2004.
16. Heinz AJ, Beck A, Meyer-Lindenberg A, etal. Cognitive and neurobiological mechanisms of alcohol-related aggression. Nature
reviews. Neurosci 12(7):400413, 2011.
17. Daeppen JB, Gache P, Landry U, etal. Symptom-triggered vs
fixed-schedule doses of benzodiazepine for alcohol withdrawal:
a randomized treatment trial. Arch Int Med 162(10):11171121,
2002.
18. Booth BM, Blow FC. The kindling hypothesis: further evidence
from a U.S. national study of alcoholic men. Alcohol Alcohol
28(5):593598, 1993.
19. Tsai G, Gastfriend DR, Coyle JT. The glutamatergic basis of
human alcoholism. Am J Psychiatry 152(3):332340, 1995.
20. Castaneda R, Cushman P. Alcohol withdrawal: a review of clinical management. J Clin Psychiatry 50(8):278284, 1989.
21. Sullivan JT, Sykora K, Schneiderman J, etal. Assessment of
alcohol withdrawal: the revised clinical institute withdrawal
assessment for alcohol scale (CIWA-Ar). Br J Addict 84(11):1353
1357, 1989.
22. Saitz R, Mayo-Smith MF, Roberts MS, etal. Individualized treatment for alcohol withdrawal. A randomized double-blind controlled trial. JAMA 272(7):519523, 1994.
23. Jaeger TM, Lohr RH, Pankratz VS. Symptom-triggered therapy for
alcohol withdrawal syndrome in medical inpatients. Mayo Clinic
Proceed 76(7):695701, 2001.
24. Sellers EM, Naranjo CA, Harrison M, etal. Diazepam loading:
simplified treatment of alcohol withdrawal. Clin Pharmacol Ther
34(6):822826, 1983.
25. Rayner SG, Weinert CR, Peng H, etal. Dexmedetomidine as
adjunct treatment for severe alcohol withdrawal in the ICU. Ann
Intensive Care 2(1):12, 2012.
26. Rosenson J, Clements C, Simon B, etal. Phenobarbital for acute
alcohol withdrawal: a prospective randomized double-blind
289.e1
26
289.e2 PART IX
Psychiatric Disorders
77. Sellers EM, Higgins GA, Tomkins DM, etal. Opportunities for
treatment of psychoactive substance use disorders with serotonergic medications. J Clin Psychiatry 52(Suppl.):4954, 1991.
78. Del Boca FK. Sex, gender, and alcoholic typologies. Ann N Y Acad
Sci 708:3448, 1994.
79. Del Boca FK, Hesselbrock M. Gender and alcoholic subtypes.
Alcohol Health Res World 20(1):5662, 1996.
80. Hesselbrock VM, Hesselbrock MN. Are there empirically supported and clinically useful subtypes of alcohol dependence?
Addiction 101(Suppl. 1):97103, 2006.
81. Dawson DA, Grant BF, Stinson FS, etal. Recovery from DSM-IV
alcohol dependence: United States, 20012002. Addiction
100(3):281292, 2005.
82. Moss HB, Chen CM, Yi HY. DSM-IV criteria endorsement patterns in alcohol dependence: relationship to severity. Alcohol Clin
Exper Res 32(2):306313, 2008.
83. Rourke S, Loberg T. Neurobehavioral correlates of addiction, New
York, 1996, Oxford University Press.
84. Bates ME, Bowden SC, Barry D. Neurocognitive impairment
associated with alcohol use disorders: implications for treatment. Exp Clin Psychopharmacol 10(3):193212, 2002.
85. Gansler DA, Harris GJ, Oscar-Berman M, etal. Hypoperfusion
of inferior frontal brain regions in abstinent alcoholics: a pilot
SPECT study. J Stud Alcohol 61(1):3237, 2000.
86. Sullivan EV, Deshmukh A, Desmond JE, etal. Cerebellar volume
decline in normal aging, alcoholism, and Korsakoffs syndrome:
relation to ataxia. Neuropsychology 14(3):341352, 2000.
87. Oscar-Berman M, Marinkovic K. Alcohol: effects on neurobehavioral functions and the brain. Neuropsychol Rev 17(3):239257,
2007.
88. Zahr NM, Sullivan EV. Translational studies of alcoholism:
bridging the gap. Alcohol Res Health 31(3):215230, 2008.
89. Oscar-Berman M. Neuropsychological vulnerabilities in chronic alcoholism, Bethesda, 2000, National Institute on Alcohol Abuse and
Alcoholism.
90. McQueeny T, Schweinsburg BC, Schweinsburg AD, etal. Altered
white matter integrity in adolescent binge drinkers. Alcohol Clin
Exper Res 33(7):12781285, 2009.
91. Bava S, Tapert SF. Adolescent brain development and the risk for
alcohol and other drug problems. Neuropsychol Rev 20(4):398
413, 2010.
92. Pfefferbaum A, Lim KO, Zipursky RB, etal. Brain gray and white
matter volume loss accelerates with aging in chronic alcoholics:
a quantitative MRI study. Alcohol Clin Exp Res 16(6):10781089,
1992.
93. Moselhy HF, Georgiou G, Kahn A. Frontal lobe changes in alcoholism: a review of the literature. Alcohol Alcohol 36(5):357368,
2001.
94. Everitt BJ, Robbins TW. Neural systems of reinforcement for drug
addiction: from actions to habits to compulsion. Nature Neurosci
8(11):14811489, 2005.
95. Kalivas PW. The glutamate homeostasis hypothesis of addiction.
Nature Rev Neurosci 10(8):561572, 2009.
96. Kalivas PW, Volkow ND. The neural basis of addiction: a pathology of motivation and choice. Am J Psychiatry 162(8):1403
1413, 2005.
97. Bencherif B, Wand GS, McCaul ME, etal. Mu-opioid receptor
binding measured by [11C]carfentanil positron emission tomography is related to craving and mood in alcohol dependence.
Biol Psychiatry 55(3):255262, 2004.
98. Heinz A, Reimold M, Wrase J, etal. Correlation of stable elevations in striatal mu-opioid receptor availability in detoxified
alcoholic patients with alcohol craving: a positron emission
tomography study using carbon 11-labeled carfentanil. Arch Gen
Psychiatry 62(1):5764, 2005.
99. Weerts EM, Wand GS, Kuwabara H, etal. PET imaging of muand delta-opioid receptor binding in alcohol dependent and
healthy control subjects. Alcohol Clin Exp Res 35(12):21622173,
2011.
100. Weiss F, Porrino LJ. Behavioral neurobiology of alcohol addiction: recent advances and challenges. J Neurosci 22(9):3332
3337, 2002.
101. White AM, Jamieson-Drake DW, Swartzwelder HS. Prevalence
and correlates of alcohol-induced blackouts among college students: results of an e-mail survey. J Am Coll Health 51(3):117
119, 122131, 2002.
102. Oscar-Berman M, Marinkovic K. Alcoholism and the brain: an
overview. Alcohol Res Health 27(2):125133, 2003.
103. Crews FT, Braun CJ, Hoplight B, etal. Binge ethanol consumption causes differential brain damage in young adolescent rats
compared with adult rats. Alcohol Clin Exp Res 24(11):1712
1723, 2000.
104. Valenzuela CF. Alcohol and neurotransmitter interactions.
Alcohol Health Res World 21(2):144148, 1997.
105. Kumar S, Porcu P, Werner DF, etal. The role of GABA(A) receptors in the acute and chronic effects of ethanol: a decade of
progress. Psychopharmacology (Berl) 205(4):529564, 2009.
106. Enoch MA, Gorodetsky E, Hodgkinson C, etal. Functional
genetic variants that increase synaptic serotonin and 5-HT3
receptor sensitivity predict alcohol and drug dependence. Mol
Psychiatry 16(11):11391146, 2011.
107. Sari Y, Johnson VR, Weedman JM. Role of the serotonergic
system in alcohol dependence: from animal models to clinics.
Prog Mol Biol Transl Sci 98:401443, 2011.
108. Gianoulakis C. Influence of the endogenous opioid system on
high alcohol consumption and genetic predisposition to alcoholism. J Psychiatry Neurosci 26(4):304318, 2001.
109. Ramchandani VA, Umhau J, Pavon FJ, etal. A genetic determinant of the striatal dopamine response to alcohol in men. Mol
Psychiatry 16(8):809817, 2011.
110. Fleming MF. Brief interventions and the treatment of alcohol use
disorders: current evidence. Rec Dev Alcohol 16:375390, 2003.
111. Langenbucher J. Rx for health care costs: resolving addictions in
the general medical setting. Alcohol Clin Exp Res 18(5):1033
1036, 1994.
112. Ewing JA. Detecting alcoholism. The CAGE questionnaire. JAMA
252(14):19051907, 1984.
113. Reinert DF, Allen JP. The alcohol use disorders identification test:
an update of research findings. Alcohol Clin Exp Res 31(2):185
199, 2007.
114. Bradley KA, DeBenedetti AF, Volk RJ, etal. AUDIT-C as a brief
screen for alcohol misuse in primary care. Alcohol Clin Exp Res
31(7):12081217, 2007.
115. Knight JR, Sherritt L, Shrier LA, etal. Validity of the CRAFFT
substance abuse screening test among adolescent clinic patients.
Arch Pediatr Adolesc Med 156(6):607614, 2002.
116. Anton RF. Carbohydrate-deficient transferrin for detection and
monitoring of sustained heavy drinking. What have we learned?
Where do we go from here? Alcohol 25(3):185188, 2001.
117. Miller PM, Anton RF. Biochemical alcohol screening in primary
health care. Addict Behav 29(7):14271437, 2004.
118. Thon N, Weinmann W, Yegles M, etal. Direct metabolites of
ethanol as biological markers of alcohol use: basic aspects and
applications. Fortschr Neurol Psychiatr 2013.
119. Purshouse RC, Brennan A, Rafia R, etal. Modelling the costeffectiveness of alcohol screening and brief interventions in
primary care in England. Alcohol Alcohol 48(2):180188, 2013.
120. Rappaport D, Chuu A, Hullett C, etal. Assessment of alcohol
withdrawal in Native American patients utilizing the Clinical
Institute Withdrawal Assessment of Alcohol Revised Scale.
J Addict Med 7(3):196199, 2013.
121. Spitzer RL, Williams JB, Gibbon M, etal. The Structured Clinical
Interview for DSM-III-R (SCID). I: History, rationale, and
description. Arch Gen Psychiatry 49(8):624629, 1992.
122. Babor TF, Higgins-Biddle JC, Saunders JB, etal. The alcohol use
disorders identification test: Guidelines for use in primary care, ed 2,
Geneva, Switzerland, 2001, World Health Organization.
123. Kelly JF, Magill M, Slaymaker V, etal. Psychometric validation of
the Leeds Dependence Questionnaire (LDQ) in a young adult
clinical sample. Addict Behav 35(4):331336, 2010.
124. Raistrick D, Bradshaw J, Tober G, etal. Development of the
Leeds Dependence Questionnaire (LDQ): a questionnaire to
measure alcohol and opiate dependence in the context of a treatment evaluation package. Addiction 89(5):563572, 1994.
125. American Psychiatric Association. Handbook of psychiatric measures, Washington, DC, 2000, American Psychiatric Association.
126. Antony MM, Barlow DH. Handbook of assessment and treatment
planning for psychological disorders, New York, 2000, Guilford
Press.
127. American Society of Addiction Medicine. Patient placement criteria, ed 2, Chevy Chase, 1994, American Society of Addiction
Medicine.
Alcohol-Related Disorders
289.e3
26
289.e4 PART IX
Psychiatric Disorders
196. Room R, Greenfield T. Alcoholics anonymous, other 12-step
movements and psychotherapy in the US population, 1990.
Addiction 88(4):555562, 1993.
197. Kelly JF, Yeterian JD. Mutual-help groups. In ODonohue W,
Cunningham JA, editors: Evidence-based adjunctive treatments,
New York, NY, 2008, Elsevier.
198. Kelly JF, McKellar JD, Moos R. Major depression in patients with
substance use disorders: relationship to 12-Step self-help
involvement and substance use outcomes. Addiction 98(4):499
508, 2003.
199. Kelly JF, Myers MG, Brown SA. A multivariate process model of
adolescent 12-step attendance and substance use outcome following inpatient treatment. Psychol Addict Behav 14(4):376389,
2000.
200. Kelly JF, Myers MG, Brown SA. Do adolescents affiliate with
12-step groups? A multivariate process model of effects. J Stud
Alcohol 63(3):293304, 2002.
201. Timko C, Debenedetti A, Billow R. Intensive referral to 12-Step
self-help groups and 6-month substance use disorder outcomes.
Addiction 101(5):678688, 2006.
202. Bergman BG, Greene MC, Hoeppner BB, etal. Psychiatric
comorbidity and 12-step participation: A longitudinal investigation of treated young adults. Alcohol Clin Exp Res 38(2):501510,
2014.
203. Nowinski J, Baker S, Carroll K, editors: Twelve-Step facilitation
therapy manual: A clinical research guide for therapists treating
Alcohol-Related Disorders
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Alcohol-Related Disorders
289.e7
age, which is to some extent reversible with abstinence, suggesting that some of these changes are secondary to changes
in brain tissue hydration.
Q7 The answer is: The CAGE.
The National Institute on Alcohol Abuse and Alcoholism
(NIAAA) has recommended either the use of a single alcohol
screening question (SASQ) or administration of the 10-question Alcohol Use Disorders Identification Test (AUDIT) selfreport questionnaire as standard screening procedures for the
detection of alcohol-related problems. The AUDIT with a
manual is available for free (and in Spanish), and has been
validated across a variety of cultural and ethnic groups. When
using the SASQ clinicians are advised to ask if an individual
has consumed five or more standard drinks (for a man) on
one occasion during the last year (four drinks for women). A
positive response may indicate an alcohol-related problem
and requires more detailed assessment.
A more traditional alternative screening interview is captured
by the 4-question CAGE acronym. However, compared to the
SASQ or the AUDIT the CAGE lacks sensitivity to detect hazardous/problem drinking. Similar to the CAGE interview, the
TWEAK interview (i.e., Tolerance, others Worried about
your drinking, Eye-opener, Amnesia, ever wanted to/tried
to Cut down), is brief and has good psychometric properties, but similar to the CAGE lacks sensitivity to detect hazardous drinking.
The 24-question Michigan Alcoholism Screening Test (MAST)
is another self-report measure with good psychometric properties, but is longer than the AUDIT.
Medical screens may also be used. Screening for recent alcohol
use can be a carried out with a breathalyzer, or a sample of
urine or saliva. For more chronic use, laboratory markers, such
as the serum gamma-glutamyl transpeptidase (GGT), the
mean corpuscular volume (MCV), and the carbohydrate-
deficient transferrin (CDT), can be used. However, these measures lack sensitivity, but can be helpful if used in combination
and when used with other screening measures, such as the
AUDIT.
Screening for alcohol withdrawal is also critical since, as mentioned previously, the alcohol withdrawal syndrome can be
life-threatening. The Clinical Institute Withdrawal Assessment
for Alcohol Dependence (CIWA-AD) is a semi-structured,
8-item, 5-minute interview, used to assess and quantify severity of withdrawal from alcohol. It is easy to administer and
possesses very good psychometric properties. Thus, it is an
efficient and reliable method that can prevent serious, lifethreatening problems and is useful to help clinicians determine levels of care.
26