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.

Most people are able to reach this goal by the end of the day if they started in the early morning. But in cases where the scores won't go down, you need to transfer the individual to the hospital or have them monitored in an ED for the duration of the detoxification. Those with a prior history of withdrawal seizures or delirium tremens should initially receive 3 doses of oral diazepam 20 mg in hourly intervals -- no matter what their CIWA-A score -- and then continue with hourly monitoring. All patients also ought to receive oral thiamine 100 mg once daily for 7 days to prevent Wernicke's encephalopathy.

It's recommended to offer a follow-up the next day to assess continued withdrawal, but it's usually not necessary to go on with the diazepam. If at any point during the detoxification the patient develops delirium or a new symptom not typically associated with withdrawal, transfer them immediately to the ED.

Do medications have a role to play?
There are several pharmacologic options to help people with alcohol use disorders. These vary depending on the goal of therapy -- whether it's abstinence or a reduction in consumption. Either way, patients should stay on a medication for 3-6 months if they feel it's working for them.

If the individual is not committed to abstinence, naltrexone may be helpful in reducing cravings and -- in effect -- the over-all alcohol consumption. The starting dosage is 25 mg orally once daily for 4 days, followed by a daily dose of 50 mg. You may increase the dose to 150 mg daily if there's a partial treatment response at a lower dosage. An intramuscular formulation of this drug exists, but right now it's only available in the U.S. Naltrexone is contraindicated in patients taking opioids as it's an opioid antagonist and may precipitate withdrawal.

Those with acute hepatitis and liver failure should also not take this drug, as serious side effects include hepatotoxicity. It's recommended that you do a liver function test (LFT) before initiating treatment and monthly thereafter. Enzyme elevations of up to 3 times the upper limit of what's considered "normal" are acceptable -- both before and during treatment -- as this will likely improve once the person cuts down on drinking. Other common side effects that often resolve within the first few weeks include nausea, vomiting, decreased appetite, headache, dizziness, fatigue, somnolence and anxiety.

Recently, topiramate has made the news as a potential new drug to treat alcohol use disorders. A multi-site double-blind placebo-controlled trial showed promise for this medication in reducing the percentage of heavy drinking days. This is but one of several new treatments that are currently being studied. It's too early, however, to make recommendations for its use.

What about those who are ready to quit?
If the patient is willing to commit to abstinence, naltrexone is still an appropriate choice, but there are two additional options -- acamprosate and disulfiram. The latter was previously marketed as Antabuse; now it's obtainable only through pharmacies that will compound it. Acamprosate is available at the wholesalers, and individual pharmacies should be ordering it soon. The drug decreases alcohol cravings but is different from naltrexone in that it's metabolized by the kidneys. Once the patient has been abstinent for a few days, acamprosate may be started and maintained at 666 mg by mouth 3 times daily. In patients with risk factors for renal disease, be sure to measure creatinine clearance before starting therapy and adjust the dose accordingly (see product monograph). If the creatinine clearance is < 30 mL/min, this drug is contraindicated. Side effects include rare instances of increased suicidality and -- more commonly -- diarrhea and somnolence, which often resolve in the first few weeks of therapy.

The second drug, disulfiram, isn't used very often. It acts as a deterrent -- making people feel ill if they drink while taking it. A person has to be abstinent for a few days before starting the medication and must avoid all food and toiletries that contain alcohol. In fact, consuming alcohol while taking disulfiram may result in a potentially fatal reaction, so you have to give out a warning. The daily dose is 125-250 mg by mouth, and it's more effective if dispensed by the patient's spouse/partner, caregiver, friend or relative. Contraindications include coronary artery disease, pregnancy and hypersensitivity to rubber (thiuram) derivatives. Caution is advised in patients with hepatic insufficiency, cerebrovascular disease, psychosis, diabetes, epilepsy, hypothyroidism and renal impairment.

There's no role for low-dose benzodiazepines in the treatment of alcohol use disorders. It would be dangerous to prescribe such a medication to a patient who wants to quit because of the risk of overdose in the case of a relapse. The threshold for treatment with antidepressants should be lowered, though, as alcohol can cause an organic depression, which will resolve when the person quits drinking. Antidepressants can indeed speed up recovery and reduce the probability of relapse.

Which other forms of support are useful?
In addition to medical therapy, you should offer relapse prevention counselling -- either with an addiction therapist or with a physician like yourself. Initially, I ask my patients to visit the clinic weekly, but this frequency may be decreased to monthly or bi-monthly as the individual stabilizes. Mutual aid or peer support groups such as Alcoholics Anonymous (AA) can also be very helpful. These provide a unique type of reassurance and are readily available in most communities. Some people, however, may say that they don't like AA because of its religious aspect or because they can't identify with the other members of their group. I encourage patients to "shop around" until they find a group they like -- there are also meetings associated with different organizations. It's quite possible, though, that those with more severe and treatment-resistant alcohol use disorders may need to attend a day or residential treatment program.

How do you deal with relapse?
Alcohol use disorders follow a relapsing/remitting pattern that is difficult to predict. Relapse is to be expected and it's crucial that it be managed correctly, so that neither the clinician nor the patient will give up on treatment. The key is to make sure that the individual feels comfortable enough with their doctor to ask for help early. You should stress that relapsing is a normal part of quitting -- this will prevent the person from feeling like a failure and giving up. The sooner that a new treatment plan with additional supports is put in place, the more likely the patient will re-gain control of his or her alcohol use.

What's the upshot of the case of Mr. X.?
Mr. X. meets the DSM-IV criteria for alcohol dependence. In this kind of case, abstinence is recommended, but Mr. X. insists on trying to reduce his consumption first. I'd encourage him to follow the Low-Risk Drinking Guidelines and consider this a "trial of reduced drinking." I might also get him started on 50 mg naltrexone per day to help manage cravings -- that is, after reviewing his LFTs.

After one month, however, Mr. X. returns to the office and is now consuming 6 beers per day. While he has reduced his consumption, he's still drinking above the Low-Risk Drinking Guidelines and therefore I'd strongly recommend that he try a period of abstinence. Given that Mr. X. is currently consuming 6 standard drinks daily and suffers from morning withdrawal symptoms, he'll need medically supervised detoxification. His naltrexone dose may also need to be increased to 75-100 mg per day, but only after evaluation of his LFTs. Acamprosate -- soon to be available in Canada -- may also be helpful if he plans to be abstinent.

Mr. X.'s depression is likely worsening with his alcohol consumption, and may in fact be an organic mood disorder caused solely by the alcohol. It merits being treated, however, while he's trying to address his alcohol dependence. I would continue his citalopram for the time being. We now know that it's important to treat addictions and mental health problems concurrently. Mr. X.'s hypertension may also be caused or worsened by his alcohol consumption -- he might become normotensive with abstinence and no longer need his hydrochlorothiazide.