How to treat alcohol addiction Teetotalling isn't the only option An interview with Lisa Lefebvre, MD

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How do you screen for alcohol use disorders?
Alcohol use disorders are common in Canada and place a significant burden on our healthcare system. Lifetime prevalence is estimated to be between 13.7 and 23.5%. Worldwide, alcohol dependence is the fourth leading cause of disability. Since not everybody is ready to admit freely to an alcohol problem, you should question all your patients about their drinking habits. Ask specifically about quantity and frequency because people are often in denial or unaware of the safe limits.

One useful question to pick out those with alcohol dependence and abuse is: "What's the most alcohol you have had in one sitting over the last 3 months?" Another good screening tool is the simple 4-item CAGE questionnaire, which is 75-85% sensitive in identifying a drinking problem (see Table 1). Make a point of reassuring your patient that there's help, and do your screening in an open, nonjudgemental manner.

Once you've picked up on a problem, a specific diagnosis is very important. You need to distinguish between patients with alcohol dependence and those with alcohol abuse, as the treatment recommendations vary between these two conditions. The DSM-IV criteria are the tools of choice to make the distinction (Tables 2&3).

Are there alternatives to "cold turkey"?
You should advise people who meet the criteria for alcohol dependence that abstinence is their best bet for successful treatment. This being said, I would still offer my support if a patient insisted on trying to drink in moderation before going cold turkey. Generally speaking, though, the approach to cut down is more promising in those who meet the criteria for alcohol abuse rather than dependence. I recommend the Low-Risk Drinking Guidelines, which allow a maximum of 2 standard drinks per day (see Table 4), with a total of 14 drinks per week for men and 9 drinks per week for women. I make sure I check in with my patients after 1-2 months -- if at this point they haven't been able to moderate their alcohol intake to within these guidelines, I'm firmer in my recommendation of abstinence. You should also assess for the presence of any complications of alcohol abuse (Table 5) and treat these as indicated.

How do you deal with withdrawal?
If a patient elects abstinence, you need to assess withdrawal risk as there's a danger of seizures, delirium tremens, brain damage and relapse if withdrawal goes untreated. Those who've consumed the equivalent of 6 standard drinks daily for at least the past 2 weeks are at risk. You may supervise individuals with little medical co-morbidity during a "Day Detox" in your office, but you should refer patients with significant co-morbidities -- such as uncontrolled hypertension, impaired liver or kidney function, the elderly, co-occurring benzodiazepine use, etc. -- to an inpatient medical withdrawal facility. Even if you don't elect to supervise a person undergoing detox in your office, you may find yourself tending to someone going through this process in the emergency department (ED) -- so here's what you need to know.

In a Day Detox, you instruct the person not to consume any alcohol after 7 pm the evening prior to the detoxification. You then set them up in an examining room, where a nurse or physician assesses them every hour, using the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-A) scale (see references for a link to the pdf). If the score is greater than 10, you should give a single dose of oral diazepam 20 mg -- or lorazepam 2 mg if there's a history of liver disease. This routine continues hourly, with medication given for CIWA-A scores greater than 10, until three consecutive CIWA-A scores are under 10, at which point the patient should be accompanied home by a friend or family member and shouldn't drive.

Lisa Lefebvre, MDCM, CCFP is the Addiction Medicine Consultant and Coordinator for Undergraduate and Postgraduate Education in Addiction Medicine at the Centre for Addiction and Mental Health in Toronto, ON. She also consults at St. Joseph's Health Centre in Toronto.