Case Answers:

Case answers will be presented after review of the HPI.

Answer 1
Include questions about alcohol consumption and other substance use when discussing nutrition and the use of prescription or OTC medications.

You should also include the following:

• Quantity and Pattern of use: average, maximum per day and average per week. For example: Do you drink alcohol? How often? What do you like to drink? How many drinks per day? Per week? Have you ever drank more heavily in the past? When was your last drink? Do you use any drugs: prescription, nonprescription, other drugs? In what amount? How often...?
• CAGE Questionnaire (MAST, AUDIT). CAGE has a sensitivity of 90% and a specificity of 75-80% using at least 2 positive responses as the cutoff.
• Skinner Trauma Scale: Was alcohol use related to:a. ankle sprainb. collar bone fracture
• Use open-ended questions to uncover adverse consequences of alcohol use.
  Identify patters of hazardous use
     at work: construction site
     driving
  Relationships
• Assess the patient's relationship with the substance:
  For example: Where do you normally drink? Is your drinking different now than it was 5 years ago? How does drinking affect your presenting symptoms? Does drinking ever help relieve tremulousness, symptoms of alcohol withdrawal? Blackouts?
• Increasing pattern of use, evidence of tolerance.
• Assess risk factors and psychosocial problems which may be associated with substance use (divorce, job loss); family history of alcoholism.
• Investigate for evidence of domestic violence.
• Relationship to current symptoms: Insomnia, fatigue, HTN; any relevant ROS? Identify past medical problems which may be associated with substance use (trauma-related injuries, cardiac complaints, chronic pain, insomnia, hepatitis, liver disease, gastritis, pancreatitis, etc). Articulating this relationship to the patient may be crucial in enabling him to begin to understand the need to quit drinking.

Answer 2
12 ounces of beer = 4 ounces wine = 1.5 ounces 80 proof liquor (a shot) = 10 - 12 grams of ethanol. One can of beer is usually 12 ounces so his 16 beers/week works out to 160 - 192 grams of ethanol. Each gram of alcohol has approximately 7 kcals and on average, ethanol accounts for about half an alcoholic’s caloric intake.

Answer 3
There is no "typical alcoholic personality." This questions is meant to stimulate discussion of personal biases towards alcoholics. The "skid row bum" stereotype is invalid, representing only about 5% of those with alcohol dependence. 50% of male drinkers have temporary alcohol-induced problems, usually in the late-teen to young-adult years; 10% of men and 5% of women develop pervasive and persistent alcohol-related problem, also termed "alcoholism". Most have jobs and family members who may be affected the alcoholism. In the medical setting, particularly the inpatient ward, prevalence is even higher and may reach 20-30%.

Answer 4
This patient does not drink in moderation (>2 drinks/day max., inconsistent limits, drinks alone, not heed warnings). He demonstrates risky use (driving while intoxicated) and hazardous use (>4 drinks per occasion for men, and >14 drinks per week on average). Harmful drinking is demonstrated by his DUI, effect on his interpersonal relations with his girlfriend, missed days at work, and potential cause of his collar bone fracture and ankle sprain. Alcohol dependence is demonstrated by his increased drinking pattern suggestive of tolerance, and drinking for relief. If his morning "illness" is thought to be secondary to mild alcohol withdrawal, this would signify alcohol dependence.

Answer 5
DSM Criteria for alcohol dependence includes evidence of abuse (alcohol-related life impairment interfering with functioning within the previous 12 months) and evidence of a strong compulsion to use alcohol, accompanied by increased alcohol tolerance, or physical signs of withdrawal when ethanol intake is abruptly reduced or ceases. Duration criterion: some symptoms of the disturbance have persisted for at least 1 month, or have occurred repeatedly over the previous 12 months. Dependence criteria require that three or more of the following items be met:

• Tolerance: need for markedly increased amounts of alcohol (> 50% increase) in order to achieve intoxication or desired effect, or markedly diminished effect with continued use of the same amount of alcohol.
• Withdrawal: symptoms or use of alcohol to avoid/relieve symptoms.
• Impaired control: persistent desire or unsuccessful efforts to cut down or control drinking.
• Impaired control: drinking in larger amounts or over a longer period than the person intended.
• Neglect of activities: important social, occupational, or recreational activities given up or reduced because of drinking
• Inability to fulfill roles: frequent intoxication or withdrawal symptoms when expected to fulfill major role obligations at work, school, or home; a great deal of time spent in activities necessary to obtain alcohol, to drink, or to recover from its effects.
• Continued drinking despite knowledge of having a persistent or recurring social, psychological, or physical problem that is caused or exacerbated by alcohol use; recurrent alcohol-related legal or interpersonal problems.

Dependence and abuse are determined by functional impairment, NOT the absolute quantity of the substance used.

This patient has significant functional impairment, but additional questions to better characterize his morning illness (is it withdrawal?), his recent escalation of intake (is it due to tolerance?), etc. should be asked.

Answer 6

• Signs of intoxication: odor on breath, psychomotor impairment
• Signs of withdrawal: autonomic hyperactivity (fever, elevated BP and HR), tremor
• Signs of complications of alcoholism: cognitive impairment, parotid enlargement, Dupuytren’s contractures, cirrhosis with hyperestrogenism (telangiectasias, gynecomastia, testicular atrophy), portal HTN (hepatomegaly, splenomegaly, caput medusa), hepatitis (jaundice, tender liver), peripheral neuropathy

Answer 7
There is no test available to diagnose alcoholism. The ALT and AST have very low sensitivity in diagnosing alcoholism. However, if the AST/ALT ratio is greater than 2, it is likely that the patient has alcoholic liver disease. The GGT is a more sensitive marker for alcoholic liver disease, although it is very nonspecific and may go up for other reasons, such as phenytoin, phenobarbital, pregnancy, or other liver disease. The GGT seems to go up after binge drinking and stay up for a couple of weeks. It may be useful as laboratory confirmation of a clinical diagnosis. Some have estimated its sensitivity at 60% and its specificity at 80-90%. Bilirubin, alkaline phosphatase and LDH have less importance in the diagnosis since they are insensitive and nonspecific. Normal LFT’s do not rule-out the diagnosis of alcoholism. BAL (blood alcohol level) is useful in the acute intoxication setting, as in the ED and gives you some idea of tolerance - if the serum level is high with little apparent impairment, it is suggestive of a high degree of tolerance. The MCV is usually high but is non-specific and not diagnostic; the elevation results from a direct toxic effect of EtOH on erythroblasts in the marrow.

Answer 8
This patient is in denial and demonstrates ambivalence about his problems. Discussion should include the six components of a brief intervention:

• Develop a therapeutic relationship using all your IPM-1 skills - reflection, support, empathy, partnership, respect, open-ended questioning
• Relate to the patient’s primary concern - in this case, elevated blood pressure, insomnia, dyspepsia, fatigue
• Focus on the evidence - be direct but not argumentative; expect some defensiveness
• Avoid negative labels such as alcoholic or addict and instead focus on the adverse health consequences of their use of the substance
• Assess the patient’s perception of the problem and their readiness to change
• Develop a mutually-agreed upon plan

This strategy mirrors the FRAMES program described in the O’Connor article. Both have been shown to result in decreased alcohol intake.