ALCOHOLISM

Required Video: Alcoholism

Required Reading: Screening Tools for Unhealthy Alcohol Use

Required Reading: Pharmacotherapy for Adults with Alcohol Use Disorder

Resource: Alcoholics Anonymous

Resource: SmartRecovery

Video: Alcoholism
Poul LaPlante MD 3/14/17

Underdiagnosis

• In primary care and hospitalized patients ETOH problem only diagnosed in about 40% of those suffering from it 1

Reasons for Underdiagnosis

• Lack of organized approach to diagnosis and treatment
• Denial prominent in alcohol problems, especially minimizing use
• Potential for conflict in confrontation with patients
• Feeling that this is not a medical problem 2

Diagnostic Tools (over 200)

• CAGE (1964): 4 questions; simple; best for severe disease
• MAST and others: 10-30 questions; sensitive; time-consuming
• AUDIT: current gold standard; 10 questions; Sensitive; somewhat time-consuming

Drinkers When Quitting Complain Most

• Do you drink? If no, why not (US 60% adults drink alcohol)
• When was your last drink? (default 1-2 days )
• Ever cut down or quit? Normal drinkers don’t have to cut down or quit except in pregnancy or weight loss. Very high sensitivity for alcohol use disorder
• Has anyone complained about your drinking? Highest sensitivity
• Largest amount consumed in 1 sitting? Past year? + is ≥ 7 drinks for men, 5 for women

Associated Points of History

• Legal: 2 DUI arrests has extremely high sensitivity for presence of an alcohol use disorder
• Family History: 60% of alcoholics in detox have 1st degree relative with the disease
• Blackouts, injuries, morning drinking, drinking alone, unable to stop, previous treatment or AA, drink every day, drinking when unplanned or will affect responsibility, other drug use, tobacco use

Communicating Diagnosis

• Refer to “problems with alcohol” or “alcohol use disorder” rather than alcoholism
• Remain factual and neutral
• State why you are concerned (factual evidence)
• Talk about denial
• Outline natural history of alcohol misuse

Helping Patient Accept Diagnosis

• Get patients definition of alcohol problem
• Offer alternatives for definition
• “If drinking causes problems and you keep drinking, you have a drinking problem”
• “Inconsistent Inability to control Intake”

Treatment

• Evaluate for need of withdrawal management
• Suggest abstinence, if patient insists on moderating drinking
• Alcohol challenge test
• Suggest “Open” AA meeting; frame it in terms of learning more
• Deal with objections which may arise such as: God, bad with groups, will power, shy, afraid they will see people they know

Other Resources

• Smart recovery: good program, not many meetings
• Rational Recovery: online only
• LICSW, psychiatrists, and others who have experience with addictions

Follow Up

• Inquire as to drinking status each visit; If someone is not receptive to talking about it today, they may be more open in the future.
• Avoid Benzodiazepines. If patient is unable to stay sober and is depressed, consider SSRI
• Adjunctive medications such as naltrexone, acamprosate, disulfiram of limited utility

References

1. Moore, Richard. “Underdiagnosis” Journal of Medical Education (1987) 46-52
2. Clark, William. “Primary Care Physician and the Patient with Alcoholism” American Journal of Medicine (1981) 275-286

Visnuth Keo: Smoking Cessation

Required Reading: Promoting Smoking Cessation

Handout: Smoking Cessation Therapy

Resource: Smoking Cessation Worksheet/Contract

Example of how a patient completed this worksheet:

Health Systems

Required Reading: From Triple to Quadruple Aim

Required Reading: The Developing Vision of Primary Care

Required Reading: Overkill

Optional Reading: The 10 Building Blocks of High Functioning Primary Care

Optional Reading: 100 Million Healthier Lives Concept Paper

Motivational Interviewing

Motivational Interviewing

“Motivational interviewing is a directive, patient-centered counseling style for eliciting behavior change by helping patients explore and resolve ambivalence” – Stephen Rollnick & William R. Miller

Think of a time in your life when someone inspired or motivated you to make a big change – how did they do that?

To begin, assess patient’s readiness to change: Pre-contemplative/Contemplative/Preparation/Action/Maintenance/Relapse

4 Principles of Motivational Interviewing – “REAL”

1. R – Righting reflex

Doctors are trained to make things right, and do this with our “righting reflex”.  We want to tell patients what to do in order to fix them.  Techniques often used are: suggesting, advising, persuading and giving speeches.   These techniques usually shut patients down.

Avoid the righting reflex.  Avoid arguing, ordering, directing, commanding, warning, threatening, telling patients what they should do, advising, suggesting solutions, persuading with logic, disagreeing, judging, criticizing, probing, interrogating.

In order to help patients, try to listen and engage them.  Dance-don’t wrestle- with resistance (Rolling with resistance example: sounds like quitting smoking will never happen for you, I didn’t say never).  Allow patients to explore barriers in a nonjudgmental, supportive manner to help them to change.

2. E – Empathy

Express empathy.  This helps to build trust and collaboration, legitimizes patient’s struggle, and communicates respect.

Techniques include:

• Ask for permission: “Would you be willing to discuss your smoking?”
• Reflective listening: “What I hear you saying is that drinking helps you manage your stress”
• Open ended questions: “What do you think it would be like to take your insulin?

3. A – Ambivalence

Explore ambivalence and uncover discrepancy through active listening.  This helps patients figure out what they are doing vs. what they want to be doing (uncover discrepancies between the patient’s behavior and values).

Techniques include:

• Open ended questions about specific concerns: “What concerns you most about your smoking?”
• Facilitating recall about times before the behavior was a problem: “What was it like for you before your drinking started affecting your work?”
• Facilitating patient imagination of future both with/without behavior: “What do you think your life will be like in five years if you don’t change the way you are eating?”
• Connecting patient’s values with behaviors/Explore ambivalence: “What do you like about smoking?  What do you not like about smoking?”
• Use scaling questions: “How important is it for you to do this on a scale of 1-10- 10 being most important.  Why did you pick a 6 instead of a 3?  What would it take for you to be a 9?”

4. L- Listen in order to Understand and Empower

Listen to what your patients are really saying, listen to the changes they are willing to make, and support their self-efficacy  Use active listening techniques, open ended questions, and reflect and clarify what you hear.

• Support your patient’s strengths, successes and provide encouragement.
• Communicate to patients that they are in control of decisions, and that you are there to provide support and guidance.
• Help patients in make self-generated action plans. When the patient “owns” the plan they’re more likely to execute it.
• Facilitate follow-up on the plan.

Analogy: Car with emergency brake half on…Grind forward as fast as you can and wonder why it feels so hard or, recognize that the patient is the driver and motivate him/her to turn the emergency brake off.

Evidence to support Motivational Interviewing: 

A meta-analysis done by Vasilaki in 2006 reviewed 9 studies comparing brief motivational interviewing with other interventions for treatment of excessive alcohol use and found that it was more effective than the traditional approaches.

Motivational interviewing was also found to be effective in studies looking at behavioral interventions in teens with type 1 diabetes (Channon et al 2007) and obese women with type 2 diabetes (West et al 2007).  In a study of a behavioral weight loss modification program, adding motivational interviewing led to increased weight loss, improved physical fitness, and improved dietary intake as compared to the group without motivational interviewing (Carels et al 2007).  

References:

Using motivational interviewing as a supplement to obesity treatment: a stepped-care approach. Health psychology: official journal of the Division of Health Psychology, American Psychological Association 26(3):369-74

Motivational Interviewing In Teenagers with Diabetes

Motivational Interviewing Course: Arizona Center for Integrative Medicine; Integrative Medicine in Residency 2013

Behavioural and Cognitive Psychotherapy

Motivational interviewing improves weight loss in women with type 2 diabetes

The efficacy of motivational interviewing as a brief intervention for excessive drinking: a meta-analytic review

_{Created by Wayne Altman, MD, FAAFP}

Nutrition/Obesity

Required Reading: Diets for Health: Goals and Guidelines

Optional:

Handout: Nutrition Truth

Handout: Altman Rule

Christine McHale: Pregnancy Options

Required Reading: Fact Sheet on Induced Abortion in the United States
Required Reading: Emergency Contraception and Medication Abortion: What’s the Difference?
Required Reading: Comparison of Early Abortion Options – A Resource for Patients
Required Reading: BMJ Clinical Review: Abortion

Resources:

Pregnancy Options Info: A Workbook of Options including Abortion, Adoption, and Birth
Fact sheet for families from the Department of Health and Human Services: “Are you pregnant and thinking about adoption?”
Reproductive Health Access Project. Resources to help primary care physicians provide contraception and abortion care.
ACOG Committee Opinion: The Limits of Conscientious Refusal in Reproductive Medicine
ANSIRH Early Abortion Training Workbook

Sports Medicine Workshop

Required Reading: Patellofemoral Pain Syndrome

Required reading: Shoulder Pain

Technique to examine joint: “IPASS”

• Inspection
• Palpation
• Active Range of Motion
• Strength
• Special Tests