Alcohol use is associated with 73% of felonies, 83% of homicides and 41% of rapes in the United States.1-3 Alcoholism is the leading drug problem in this country, and its sequelae cost upward of $200 billion per year.1-5
Alcohol use disorders are associated with high rates of medical and psychiatric comorbidity as well as early mortality.5
In addition, alcohol is the drug of choice among America's youth.6,7 Seventy-two percent of students have consumed alcohol (more than just a few sips) by the end of high school, and 39% have done so by 8th grade.7 In 2008, 55% of 12th graders and 18% of 8th graders reported having been drunk at least once.6,7 Compare this to the 10% to 20% of high school seniors reporting cocaine use and 40% to 50% reporting marijuana use.8
Clearly, alcohol abuse is a significant health issue. NPs and PAs can play an essential role in identifying patients with alcohol addiction by asking about alcohol use at every office visit and by administering screening tools when appropriate.
Generally speaking, a person is considered an alcoholic when his or her drinking becomes unmanageable and causes trouble in his or her personal, professional, family and social life.9 People are considered addicted to alcohol if they are unable to predict when they will stop drinking, how much they will drink, or what the results of their drinking will be.9
The National Institute on Alcohol Abuse and Alcoholism has described moderate drinking as four drinks on any day by men, with an average of 14 drinks per week.10 For women, it is consuming three drinks in any one day and an average of seven drinks per week.10 The effects of alcohol are determined by a variety of factors, including a person's size, weight, age and sex, as well as the amount of food and alcohol consumed. The disinhibiting effect of alcohol is one of the main reasons it is used in so many social situations. Also, drinking patterns appear to be as important as the amounts consumed.
Experts have stated that the key to healthy, moderate alcohol consumption is a regular pattern of one to three drinks per day.10 The standard alcoholic drink is a 12-ounce can or bottle of regular beer, an 8-ounce glass of malt liquor, a 5-ounce glass of dinner wine, or a 1.5 ounce shot of 80-proof liquor or spirits (vodka, tequila or rum served straight or in a mixed drink).10
Research shows that moderate consumption of alcohol promotes cardiovascular health in a number of ways, including the following:11,12
• Improved cholesterol profile: increased high-density lipoprotein (HDL) levels, decreased low-density lipoprotein levels (LDL) and improved HDL and LDL particle size
• Decreased thrombosis via reduced platelet aggregation and fibrinogen and increased fibrinolysis
• Reduced coronary artery spasm in response to stress
• Increased coronary artery blood flow
• Reduced blood pressure
• Reduced blood insulin level
• Increased estrogen levels.
These health benefits are associated with moderate drinking only. Too much alcohol eliminates the health benefits. Therefore, the way to maximize the health benefits of alcohol to consume it at low levels.
Diagnosis of Alcohol Addiction
Adequate assessment of alcohol use requires a multifaceted and concise history focused on the quantity and frequency of alcohol consumption, its impact on functioning, and the psychologic and physiologic effects of consumption and cessation. The actual diagnosis of alcohol abuse and dependence is made on the basis of criteria published in the Diagnostic and Statistical Manual of Mental Disorders (see table).9,12,13
During the physical examination, a patient who is addicted to alcohol may demonstrate tremulousness, elevated blood pressure, rhinophyma (bulbous ruddy nose), telangiectasias, tachycardia, hepatosplenomegaly, peripheral neuropathy and evidence of physical trauma. All patients with suspected alcoholic liver disease should be examined for signs of chronic liver disease; these include spider angiomata, ascites, hepatosplenomegaly and gynecomastia. It is important to note that the physical examination can be completely normal despite the presence of alcoholism. Most physical findings are not demonstrated early in the course of alcoholism.
Alcoholic liver disease may be associated with a number of laboratory abnormalities, but no laboratory tests can definitively identify alcoholism. Most tests are used to help detect chronic alcohol use or to determine relapse in patients who deny it. It also helps evaluate organ damage. According to the Substance Abuse and Mental Health Administration, these tests include:14,15
• Gamma-glutamyl transferase (GGT). This liver enzyme increases with heavy alcohol intake and other conditions that affect the liver.
• Mean corpuscular volume (MCV). This may increase over time in heavy drinkers but it may also be affected by other conditions. Alcohol is a common cause of macrocytosis. Approximately 90% of patients with alcohol dependence have macrocytosis (MCV between 100 and 110 femtoliters) in their complete blood count, even before anemia appears. This abnormality can be induced by the regular ingestion of 80 grams of alcohol each day (e.g., one bottle of wine). Abstinence results in resolution of the macrocytosis within 2 to 4 months.
• Aspartate aminotransferase (AST) and alanine aminotransferase (ALT). These can indicate liver damage often related to alcohol use. The most common pattern of liver biochemical test abnormalities in patients with alcoholic hepatitis is a disproportionate elevation of serum AST compared with ALT. This ratio is usually greater than 2.0, a value that is rarely seen in other forms of liver disease.
• Carbohydrate-deficient transferrin (CDT). This can indicate relapse in heavy drinking after a period of abstinence. The sensitivity and specificity for significant alcohol intake are in the range of 60% to 70% and 80% to 90%, respectively. The test performance is better than for other biomarkers for alcohol, such as GGT and MCV. Rising CDT concentrations are suggestive of relapse. However, lower sensitivities have been reported in selected populations and in patients with iron overload, and the test is not widely available. In addition, pregnancy may alter the results.
• Ethyl glucuronide (EtG) and ethyl sulfate (EtS). These biomarkers direct analytes of the breakdown of alcohol.
• Phosphatidyl ethanol (PEth). This new and promising biomarker can indicate recent drinking.
Other laboratory tests used to detect problematic drinking may include a comprehensive metabolic panel or liver panel (may be included in some CMP test groups) to evaluate organ and liver function; magnesium, which can be low in alcoholics due to insufficient dietary intake; and a medical (not legal) blood alcohol level (ethanol test) to determine if a person has recently ingested alcohol. This latter test does not diagnose alcoholism; it is used to document whether a person has consumed ethanol and to measure the amount of ethanol present.
Overall, the utility of laboratory testing for the diagnosis of alcohol abuse is limited. Similar to the physical examination, no abnormalities are required for the disorder to be diagnosed.
Hundreds of alcohol screening tests are available to assist in diagnosis in primary care and emergency healthcare settings. Some contain up to 100 questions, and some have only a few. (See a list of screening tools with links at http://pubs.niaaa.nih.gov/publications/AssessingAlcohol/factsheets.htm.) The shorter tests may not be as accurate or sensitive as the longer ones, but they still are useful in screening for harmful drinking or alcohol dependence and can be followed up with further in-depth assessment using the more elaborate tests.
The CAGE Test is one of the oldest and most popular screening tools for alcohol abuse.15,16 It contains four questions that diagnose alcohol problems over a lifetime. It does not detect the full spectrum of unhealthy alcohol use and it is not recommended as a screening tool, but it can be useful to quickly determine when someone who screens positive on a single-item screening question has or has had a more severe problem (by answering two or more in the affirmative).18
C - Have you ever felt you should cut down on your drinking?
A- Have people annoyed you by criticizing your drinking?
G - Have you ever felt bad or guilty about your drinking?
E - Eye opener: Have you ever had a drink first thing in the morning to steady your nerves or to get rid of a hangover?
The problem with the CAGE test is that it is most accurate for white, middle-aged men. It is not very accurate for identifying alcohol abuse in older people, black people, white women and Hisupic people.17
The T-ACE Test contains four questions, three of which are on the CAGE test, but it has proved to be more accurate in diagnosing alcohol problems in both men and women.19
T - Does it take more than three drinks to make you feel high?
A - Have you ever been annoyed by people's criticism of your drinking?
C - Are you trying to cut down on drinking?
E - Have you ever used alcohol as an eye opener in the morning?
As with the CAGE, "yes" answers to two of these four questions indicate possible alcohol abuse or dependence.
The Alcohol Use Disorders Identification Test (AUDIT) is one of the most accurate tests available (94%).17 Developed by the World Health Organization, it is also accurate across ethnic and gender groups.17,19 The test contains 10 multiple choice questions that are scored on a point system (http://www.merfweb.org/files/resources/audit_info_scoring.pdf). A score higher than 9 indicates an alcohol problem. The one disadvantage of the AUDIT test is that it takes longer to administer and it is more difficult to score than the shorter tests.17,19
Click to view larger graphic.
The TWEAK Test is a five-item test developed to screen for risk drinking during pregnancy.16,19 It includes three of the CAGE questions and also asks about the patient's tolerance and blackouts. The Michigan Alcohol Screening Test (MAST) is one of the oldest and most accurate alcohol screening test available.18 It contains 22 yes-or-no questions; six positive responses indicate a drinking problem. The disadvantage to the MAST test is its length and the time required to score in a busy office. One advantage of this test is that it also effectively diagnoses adolescents.16
The FAST Test is a four-question quiz designed specifically for patients being treated in urgent care or emergency room situations.18,19 The test is quick and easy to score, but research shows it only detects 90% of alcohol problems that are detected using the AUDIT test.19
Several tests are specifically designed to diagnose alcohol problems in adolescents.20 They include the Adolescent Alcohol Involvement Scale, the Adolescent Obsessive-Compulsive Drinking Scale, the Alcohol Expectancy Questionnaire-Adolescent Form, the Comprehensive Adolescent Severity Inventory, the Customary Drinking and Drug Use Record, the Personal Experience Screening Questionnaire, the Problem Recognition Questionnaire, and the Teen Addiction Severity Index.
Healthcare providers should ask all adolescent and adult patients about alcohol use, and they must be prepared to provide detailed information to patients who report use that is frequent or excessive. Here are a few tips and guidelines to share with patients who consume alcohol:
• Know the alcohol content of different drinks. Anything above 5% alcohol is considered strong and should be consumed with caution.
• Never mix alcohol with drugs. Many prescription and over-the-counter medications interact with alcohol. Always ask a healthcare provider or pharmacist if you can consume alcohol while taking medication. Combining illegal drugs and alcohol is extremely dangerous and should never be done.
• Never drink and drive. If you know that you have to drive, don't consume alcohol. Driving with any alcohol in your system impairs your judgment.
• Never drink during pregnancy. Alcohol can cause birth defects and developmental disabilities.
• Do not expect coffee or a cold shower to sober you up! The effects of alcohol only wear off after the body has enough time to metabolize the alcohol and remove it from the bloodstream. To slow the absorption of alcohol in the bloodstream, try drinking water in between sips of alcohol. The only sure way to sober up is with sleep.
• Resist social pressure to drink. Someone at a party may encourage you to drink more than you want or need. If polite refusals don't work, keep your glass full of water or soda and sip it slowly. If you still do not feel comfortable, go home.
• Don't drink alcohol on an empty stomach. That's a recipe for intoxication. Food slows the rate at which alcohol enters the bloodstream. Always eat before drinking, and eat something while drinking.
• Pace yourself. One drink per hour with a two-drink maximum is a good rule of thumb.
• People who are petite or have small frames are more vulnerable to the effects of alcohol.
• If your friends or family members keep telling you that you have a problem with alcohol, seek help.
• Do not make drinking a habit. One or two drinks a day may not pose a major health risk, but routine drinking is a warning sign of possible alcohol dependence.
1. Alcohol-related disease impact. http://www.cdc.gov/alcohol/ardi.htm
2. National Council on Alcoholism and Drug Dependence. Alcoholism and alcohol-related problems: a sobering look. NCADD Fact Sheet. http://www.docstoc.com/docs/83368744/NCADD-FACT-SHEET-Alcoholism-and-Alcohol-Related-Problems
3. Harwood HJ. Updating Estimates of the Economic Costs of Alcohol Abuse in the United States: Estimates, Update Methods and Data. http://pubs.niaaa.nih.gov/publications/economic-2000/alcoholcost.PDF
4. Bouchery EE, et al. Economic costs of excessive alcohol consumption in the U.S., 2006. Am J Prev Med. 2011;41(5):516-524.
5. Salize HJ, et al. Treating alcoholism reduces financial burden on care-givers and increases quality-adjusted life years. Addiction. 2013;108(1):62-70.
6. Saitz R, Naimi TS. Adolescent alcohol use and violence: are brief interventions the answer? JAMA. 2010;304(5):575-577.
7. Johnston LD, et al. Monitoring the future national results on adolescent drug use: overview of key findings 2008. NIH Publication No. 09-7401. Bethesda, MD: National Institute on Drug Abuse; 2009.
8. Substance Abuse and Mental Health Services Administration. Results from the 2008 National Survey on Drug Use and Health: National Findings. HHS Publication No. SMA 09-4434. Rockville, MD; 2009.
9. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed, Text Revision. American Psychiatric Association: Washington DC; 2000.
10. National Institute on Alcohol Abuse and Alcoholism. Helping Patients Who Drink Too Much: A Clinician's Guide. NIH Publication 07-3769. Bethesda, MD: National Institutes of Health; 2007.
11. Moss HB, et al. Prospective follow-up of empirically derived alcohol dependence subtypes in wave 2 of the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC): recovery status, alcohol use disorders and diagnostic criteria, alcohol consumption behavior, health status, and treatment seeking. Alcohol Clin Exp Res. 2010;34(6):1073-1083.
12. U.S. Department of Health and Human Services. Healthy People 2010 Conference Edition. Bethesda, MD: DHHS; 2000.
13. Morse RM, Flavin DK. The definition of alcoholism. The Joint Committee of the National Council on Alcoholism and Drug Dependence and the American Society of Addiction Medicine to Study the Definition and Criteria for the Diagnosis of Alcoholism. JAMA. 1992;268(8):1012-1014.
14. Hasin DS, et al. Prevalence, correlates, disability, and comorbidity of DSM-IV alcohol abuse and dependence in the United States: results from the National Epidemiologic Survey on Alcohol and Related Conditions. Arch Gen Psychiatry. 2007;64(7):830-842.
15. Smith PC, et al. Primary care validation of a single-question alcohol screening test. J Gen Intern Med. 2009;24(7):783-788.
16. Knight JR, et al. Validity of brief alcohol screening tests among adolescents: a comparison of the AUDIT, POSIT, CAGE, and CRAFFT. Alcohol Clin Exp Res. 2003;27(1):67-73.
17. National Council on Alcoholism and Drug Dependence of the San Fernando Valley. Michigan Alcohol Screening Test. http://www.globaladdiction.org/dldocs/GLOBALADDICTION-Scales-MichiganAlcoholScreeningTestMAST.pdf
18. Primary Care Alcohol Information Service. Screening tools for healthcare settings. http://www.dldocs.stir.ac.uk/documents/alccontools.pdf
19. National Institute on Alcoholism and Alcohol Abuse. Assessing Alcohol Problems. A Guide for Clinicians and Researchers. NIH Publication No. 03-3745. Bethesda, MD: NIH: 2003.
20. Millstein SG, Marcell AV. Screening and counseling for adolescent alcohol use among primary care physicians in the United States. Pediatrics. 2009;111(1):114-122.
The Association of Family Practice Physician Assistants (AFPPA) is a growing organization of physician assistants and nurse practitioners who practice in primary care settings such as family practice, internal medicine, emergency medicine, pediatrics, women's health and occupational medicine. The AFPPA offers peer-to-peer continuing medical education in small group settings at conferences held throughout the year. Learn more at www.afppa.org. ADVANCE for NPs & PAs is proud to be the official journal of AFPPA.
Ben Taylor is a physician assistant at Doctors Care of Aiken in Aiken, S.C. He is the president of the Association of Family Practice Physician Assistants. He has completed a disclosure statement and reports no relationships related to this article.