How Chiropractic Physicians Can Help
Extreme alcohol consumption is a leading cause of premature mortality in the United States, accounting for one in 10 deaths among working-age Americans. In fact, excessive alcohol use is the fourth leading preventable cause of death in the United States1 and costs $223.5 billion annually, or about $1.90 per drink. From 2006 through 2010, an annual average of 87,798 alcohol-attributable deaths and 2.5 million years of potential life lost occurred in the United States.2
The bottom line is that Americans are drinking themselves to death at record rates. And while the recent focus has been on the opioid epidemic sweeping the United States, according to the Centers for Disease Control, in 2014 more people died from alcohol-induced causes (30,722) than from overdoses of prescription painkillers and heroin combined (28,647).3 When adding in the deaths from alcohol related to drunk driving and other accidents, the number of fatalities soars to 90,000. Alcohol abuse is a public health crisis in the United States.
How Much Is Too Much?
Drinking becomes too much when it causes or elevates the risk for alcohol-related problems or complicates the management of other health problems. Research finds that men who drink more than four standard (i.e., 14 grams of pure alcohol found in 12 oz. of beer, 5 oz. of wine or 1.5 oz. of distilled spirits) drinks per day (or more than 14 per week) or women who drink more than three per day (or more than seven per week) are at increased risk for alcohol-related problems.4 But individual responses to alcohol vary. Drinking at lower levels may be problematic and other factors come in to play such as age, medications and co-existing conditions.
STEP 1 Screen the Patient
Karen Konarski-Hart, DC, ACA vice president, former president of the Arkansas State Board of Health and in private practice, points out that SOAP (i.e., subjective, objective, assessment and plan) notes expect the doctor of chiropractic (DC) to write down social history. (See “Keep Your Records Clean With SOAP,” Nov. 2013 ACA News, Page 16.)
“Some people honestly will write down on their history that they drink X amount in a day, or however you grade it on your history intake, that they have a heavy alcohol intake.” But it’s possible that some patients won’t be honest when it comes to alcohol addiction. “Instead the patient comes in and you can smell alcohol, or the patient is impaired in some way,” Dr. Konarski-Hart says. “Sometimes, like when you have a workers’ comp case, before a company will accept liability for a worker, you must determine that a person was not impaired when the accident happened. Chiropractic physicians are asked to figure that out, whether it is by drug or alcohol testing.” Often the DC must do some sleuthing when alcohol is involved. “Sometimes if the injury is alcohol related or potentially alcohol related, while the patient may have fallen, something about the mechanism of injury doesn’t look like a regular accident that a normally conscious person would do,” Dr. Konarski-Hart says.
And often chiropractic physicians pick up on patterns. “Once you have dealt with alcoholics or families of alcoholics, you realize personalities change or the type of behavior that patients exhibit might tip you off,” Dr. Konarski-Hart explains. “Sometimes you find people don’t follow through on tasks you ask them to do, or they miss appointments, or the excuses they use for why they can’t do things may clue you in. Often family members pull you aside and talk to you. So there are many ways that physicians pick up on problems.”
The National Institutes of Health’s (NIH) National Institute on Alcohol Abuse and Alcoholism provides materials for physicians to help patients who drink excessively. Helping Patients Who Drink Too Much: A Clinician’s Guide5 provides two methods for screening: a single question (i.e., about heavy drinking days) to use during a clinical interview and a written self-report instrument called the AUDIT (also provided). The single interview question can be used at any time, either in conjunction with the AUDIT or alone. Some practices may prefer to have patients fill out the AUDIT before they see the clinician. It takes less than five minutes to complete and can be copied or incorporated into a health history.
The Clinician’s Guide recommends physicians think about clinical indications for screening for excessive alcohol use6 and key opportunities, including:
• As part of a routine examination;
• Before prescribing a medication that interacts with alcohol;
• In the emergency department or urgent care center; and
• When seeing patients who are (1) pregnant or trying to conceive; (2) are likely to drink heavily, such as smokers, adolescents and young adults; (3) have health problems that might be alcohol induced, such as cardiac arrhythmia, dyspepsia, liver disease, depression, anxiety, insomnia and trauma; or (4) have a chronic illness that isn’t responding to treatment as expected, such as chronic pain, diabetes gastrointestinal disorders, depression, heart disease and hypertension.
STEP 2 Assess for Alcohol Use Disorders
The NIH Clinician’s Guide next says to determine whether there is a maladaptive pattern of alcohol use, causing clinically significant impairment or distress. It is important to assess the severity and extent of all alcohol-related symptoms to inform your decisions about management.
Determine whether in the last 12 months your patient’s drinking has repeatedly caused or contributed to:
• Risk of bodily harm;
• Relationship trouble;
• Role failure at home, work or school;
• Run-ins with the law.
If the answer to one or more of the above is yes, your patient has alcohol abuse. No matter the answers, screen for alcohol dependence by determining whether in the last 12 months your patient has:
• Not been able to stick to drinking limits; • Not been able to cut down or stop; • Shown tolerance; • Shown signs of withdrawal; • Kept drinking despite problems; • Spent a lot of time drinking; • Spent less time on other matters.
If the answer is yes to three or more of these areas, your patient has alcohol dependence.
STEP 3 Advise and Assist (Brief Intervention)
Advising a patient with an alcohol problem is as individual as the doctor and the person, according to Dr. Konarski-Hart. The situation changes when another party is involved, such as during the investigation for an auto accident or workers’ compensation case, because you are bound to report back. “Sometimes — depending on how serious you think the problem is or what the potential is for it escalating badly — you may need to be more direct, or you can ask if there are problems at home and ease into the questions,” she says. “There are some people you need to look at and ask if they have a problem with alcohol; simply, are you drinking too much?”
Alcohol abuse usually affects family, friends and other relationships. “If there is a family member involved in the person’s care, ask the patient if it is OK to talk to his or her spouse, significant other, son or daughter, and see if that person can help,” says Dr. Konarski-Hart. “You don’t have to fight the battle alone. Most DCs are not particularly well trained in how to assess, manage and follow up on alcohol abuse.” It helps to take advantage of available resources.
The NIH Clinician’s Guide advises stating to the patient, “You’re drinking more than is medically safe.” Relate to the patient’s concerns and medical findings if present. Further, tell the patient, “I strongly recommend that you cut down (or quit), and I’m willing to help.” At this point, the physician must gauge the readiness of the patient to change drinking habits and ask, “Are you willing to consider making changes in your drinking?”
STEP 4 Follow Up and Continue Support
The chiropractic physician must document alcohol use and review goals at each visit. Depending on whether the patient is able to meet and sustain drinking goals will decide your next recommendations. When negotiating drinking goals, understand that abstaining from drinking is often the best course for most patients with alcohol use disorders. Patients with milder forms of abuse or dependence who are unwilling to abstain may be successful at cutting down.
Consider referring for further evaluation by an addiction specialist, especially if the patient is alcohol dependent. Consider recommending a mutual help group. For patients with dependence on alcohol, consider the need for medically managed withdrawal (e.g., detoxification) and referring the patient to a provider for the prescription of a medication for alcohol dependence for those who endorse abstinence as a goal. Always follow up.
Alcoholics Anonymous (AA) is well known for a reason. “Most people I know of with alcohol abuse problems do well in a group dynamic like AA or similar programs where they are held accountable,” says Dr. Konarski-Hart. She gives a nod to the saying that people often have to hit bottom. “They may go in to AA, commit, quit, fall off the wagon and having that group support really does seem to be a way that these people can help stay on track and do well, and they usually become strong advocates of these programs.” (For more on Alcoholics Anonymous, go to www.aa.org.)
The Defining Moments
Dr. Konarski-Hart advises simply being available to your patients when they need you. If your patients need to talk, you need to pay attention and be there. “You may not have all the answers, but sometimes it is in that moment when they have made a connection and want to talk that may make a real difference as far as starting the commitment to stopping drinking,” she says. “You have to always be sensitive to that. Just listen and offer to help make a call or give advice and help find an expert.”
Finally, be aware of the opportunities to confront alcohol abuse not necessarily with patients, but with colleagues and friends in social situations. You have the opportunity to perhaps make a difference to someone. “I’ve seen people ruin a career or relationship because of drinking and what happens as a result and that is unfortunate to see a person lose a lot because no one ever said anything,” Dr. Konarski-Hart concludes.
1) Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000. [Published erratum in: JAMA. 2005;293(3):293-4, 298]. JAMA. 2004;291(10):1238–45.
2) Stahre M, Roeber J, Kanny D, Brewer RD, Zhang X. Contribution of excessive alcohol consumption to deaths and years of potential life lost in the United States. Prev Chronic Dis. 2014;11:130293. DOI: http://dx.doi.org/10.5888/pcd11.130293.
3) Rudd RA, Aleshire N, Zibbell JE, Gladden M. Increases in drug and opioid overdose deaths — United States, 2000– 2014. Morbidity and Mortality Weekly Report (MMWR); Dec. 18, 2015/64(Early Release);1-5.
4) Dawson DA, Grant BF, Li TK. Quantifying the risks associated with exceeding recommended drinking limits. Alcohol Clin Exp Res. 29(5):902-908, 2005.
5) Helping Patients Who Drink Too Much: A Clinician’s Guide, U.S. Department of Health and Human Services, National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism. http://pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/guide.pdf.
6) Diagnostic and Statistical Manual of Mental Disorders, 4th Ed. (DSM-IV), Revised.
WHO HEALTH FACTS Did You Know?
According to the “Global Status Report on Alcohol and Health 2014” issued by the World Health Organization:
• The harmful use of alcohol is a component cause of more than 200 disease and injury conditions in individuals, most notably alcohol dependence, liver cirrhosis, cancers and injuries.
• The latest causal relationships suggested by research are those between harmful use of alcohol and infectious diseases, such as tuberculosis and HIV/AIDS.
• Worldwide consumption in 2010 was equal to 6.2 liters of pure alcohol consumed per person aged 15 years or older, which translates into 13.5 grams of pure alcohol per day.
• Worldwide, about 16 percent of drinkers aged 15 years or older engage in heavy episodic drinking.
• In 2012, about 3.3 million deaths, or 5.9 percent of all global deaths, were attributable to alcohol consumption.
• In 2012, 139 million disability-adjusted life years, or 5.1 percent of the global burden of disease and injury, were attributable to alcohol consumption.
• Many WHO member states have demonstrated increased leadership and commitment to reducing harmful use of alcohol in recent years. A higher percentage of the reporting countries indicated having written national alcohol policies and imposing stricter blood alcohol concentration limits in 2012 than in 2008.
To download the 365-page report, go to http://apps.who.int/iris/bitstream/10665/112736/1/9789240692763_eng.pdf .
FEDERAL PUBLIC HEALTH RESOURCES for Alcohol Addiction Treatment
A. Carlo Guadagno, DC, chair of ACA’s public health committee and clinical sciences instructor at National University of Health Sciences Florida Campus, recommends the following online alcohol screening guidelines for chiropractic physicians to use with their patients:
• www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/alcohol-misuse-screening-and-behavioral-counselinginterventions- in-primary-care
In order to treat a patient with an alcohol problem, Dr. Guadagno recommends the treatment center locator help from the Substance Abuse and Mental Health Services Administration (SAMHSA):
Publications from SAMHSA for Alternative Therapies:
Easy Statistics and Facts:
ACA’s Preventive Services Toolkit
ACA publishes an online toolkit to help the chiropractic physician with billing and coding for alcohol counseling and many other types of wellness counseling. You can find it at www.acatoday.org/prevservices.
Lori A. Burkhart, J.D., is editor of ACA News.