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Brief Summary

GUIDELINE TITLE

Clinical management of alcohol use and abuse in HIV-infected patients.

BIBLIOGRAPHIC SOURCE(S)

  • New York State Department of Health. Clinical management of alcohol use and abuse in HIV-infected patients. New York (NY): New York State Department of Health; 2008 Apr. 15 p. [41 references]

GUIDELINE STATUS

This is the current release of the guideline.

BRIEF SUMMARY CONTENT

 
RECOMMENDATIONS
 EVIDENCE SUPPORTING THE RECOMMENDATIONS
 IDENTIFYING INFORMATION AND AVAILABILITY
 DISCLAIMER

 Go to the Complete Summary

RECOMMENDATIONS

MAJOR RECOMMENDATIONS

 

Key Point:

The role of the primary care clinician in the management of the patient who abuses alcohol or is dependent on alcohol is as follows:
  • Identify the problem
  • Present the diagnosis
  • Work to engage and motivate the patient
  • Participate in the initiation of treatment and continuum of care

Identifying Alcohol Use and Abuse in Human Immunodeficiency Virus (HIV)-Infected Patients

Screening for Alcohol Use

Clinicians should screen all HIV-infected patients for alcohol use at baseline and at least annually. Screening methods should assess quantity and frequency of alcohol use as well as per-occasion amounts to identify binge drinking. If the results are positive, a more detailed screening tool such as the full AUDIT or CAGE should be administered (see Appendix II in the original guideline document).

For at-risk or hazardous drinkers, clinicians should evaluate alcohol use more frequently in order to identify the escalation of present drinking levels or the occurrence of harmful consequences from drinking.

Screening tests should not be performed when patients are under the influence of alcohol.

Clinicians should stress the confidential nature of discussions regarding alcohol use to encourage patients to be open and honest.

Refer to Table 1 in the original guideline document for definitions of terms "at-risk drinking", "hazardous drinking", "alcohol abuse", "alcohol dependence", and "binge drinking" used to describe alcohol misuse.

Clinical Indicators of Alcohol Use

Clinicians should consider alcohol misuse in the differential diagnosis of certain medical disorders that may be alcohol-induced, such as elevated liver enzymes, hypertension, seizures, gastrointestinal bleeding, cognitive impairment, and depression. The presence of clinical indicators should prompt a screen for alcohol use.

Key Point:

Frequent falls or accidents, hypertension that is difficult to treat, and problems at home or at work may be indicative of alcohol-related problems.

Effects of Alcohol Use in HIV-Infected Patients

Alcohol and Adherence

Clinicians should routinely ask about alcohol consumption when assessing adherence to highly active antiretroviral therapy (HAART).

Alcohol and Safer Sex Practices

Clinicians should discuss behavioral risk-reduction measures on a routine and ongoing basis with patients who consume alcohol. These discussions should include use of barrier protection, how to speak with partners about safer sex, and the circumstances under which high-risk sexual behavior might occur.

Alcohol and Hepatitis C Virus (HCV)

Clinicians should educate HIV/HCV co-infected patients regarding the effects of alcohol on the course of HCV infection. Patients who have other underlying liver disease should be advised to abstain from alcohol.

Clinicians should advise patients to abstain from alcohol during HCV antiviral therapy. Patients with alcohol abuse or dependence should be encouraged to enroll in a rehabilitation program and establish abstinence prior to HCV antiviral treatment.

Provider Assistance, Counseling, and Brief Interventions

Clinicians should:

  • Conduct brief interventions with patients who are at-risk drinkers
  • Use brief interventions to help motivate patients who meet diagnostic criteria for an alcohol use disorder (abuse and/or dependence) but decline referral for care
  • Use nonjudgmental language when counseling patients who use alcohol

When brief interventions are not successful in motivating change, the clinician should refer the patient for further assessment and treatment from an addiction specialist.

Referral for Treatment

Clinicians should refer patients:

  • With active alcohol use/abuse problems to treatment programs
  • With alcohol abuse or dependence who are not willing to cut down on their alcohol consumption for further assessment and treatment by professional alcohol treatment services
  • Who require more intensive management for alcohol withdrawal to inpatient treatment or to addiction specialists
Key Point:

Clinicians should be familiar with the resources available in the community for alcohol treatment programs and services. Sources of care can be found on the Office of Alcoholism and Substance Abuse Services website.

Table 3 in the original guideline document shows the various alcohol treatment referral options that are available for patients who abuse or are dependent on alcohol.

Treatment for Alcohol Withdrawal

Clinicians should use nonpharmacologic therapy or benzodiazepines to manage patients with mild or moderate alcohol withdrawal symptoms.

Clinicians should hospitalize patients with a history of severe alcohol withdrawal symptoms for medical management.

Pharmacologic Management of Alcohol Abuse

Clinicians should determine the benefit of pharmacotherapy with naltrexone, disulfiram, or acamprosate for the treatment of alcohol use disorders on a case-by-case basis. Pharmacotherapy should be used as an adjunct to behavioral therapy.

Clinicians should avoid naltrexone in patients with acute hepatitis or liver failure.

Refer to Table 4 in the original guideline document for information on adjunctive pharmacological agents such as disulfiram, naltrexone, and acamprosate for the treatment of alcohol misuse.

Follow-Up

At-Risk or Hazardous Drinkers

Clinicians should:

  • Review goals, progress, and laboratory results (when applicable) with the patient during each follow-up appointment
  • Assess the patient's motivation for change
  • Reinforce safe drinking levels
  • Actively support patient efforts to reduce alcohol use

Patients Receiving Treatment for Alcohol Use

Clinicians should:

  • Arrange follow-up appointments to monitor the patient's alcohol consumption and progress
  • Provide supportive feedback to patients who are engaged in a recovery program
  • Ask patients about the date of last use of alcohol at every monitoring visit to identify relapses
  • Inform patients that relapse is common and part of the therapeutic process
  • Assess the patient's continued motivation for further change, when applicable
Key Point:

Sustained behavior change is often accomplished gradually. Relapse should be recognized as part of the usual clinical course of alcohol abuse.

Relapse of Alcohol Use

Clinicians should:

  • Anticipate relapses
  • Adopt a nonjudgmental attitude toward the patient's resumption of alcohol use when/if it occurs
  • Encourage participation in treatment

CLINICAL ALGORITHM(S)

None provided

EVIDENCE SUPPORTING THE RECOMMENDATIONS

TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of evidence supporting the recommendations is not specifically stated.

IDENTIFYING INFORMATION AND AVAILABILITY

BIBLIOGRAPHIC SOURCE(S)

  • New York State Department of Health. Clinical management of alcohol use and abuse in HIV-infected patients. New York (NY): New York State Department of Health; 2008 Apr. 15 p. [41 references]

ADAPTATION

Not applicable: The guideline was not adapted from another source.

DATE RELEASED

2008 Apr

GUIDELINE DEVELOPER(S)

New York State Department of Health - State/Local Government Agency [U.S.]

SOURCE(S) OF FUNDING

New York State Department of Health

GUIDELINE COMMITTEE

Substance Abuse Committee

COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

Chair: Marc N Gourevitch, MD, MPH, New York, University School of Medicine, New York, New York

Committee Members: Bruce D Agins, MD, MPH, New York State Department of Health AIDS Institute, New York, New York; Julia H Arnsten, MD, MPH, Montefiore Medical Center, Bronx, New York; Lawrence S Brown, Jr, MD, MPH, FASAM, Addiction Research and Treatment Corporation, Brooklyn, New York; Brenda Chabon, PhD, Montefiore Medical Center, Bronx, New York; Barbara H Chaffee, MD, MPH, Binghamton Family Care Center, Binghamton, New York; Michael L Christie, MD, AIDS Community Health Center, Rochester, New York; Chinazo O Cunningham, MD, Montefiore Medical Center, Bronx, New York; Nereida L Ferran-Hansard, MD, Jacobi Medical Center, Bronx, New York; Steven S Kipnis, MD, FACP, FASAM, New York State Office of Alcoholism and Substance Abuse Services, Orangeburg, New York; Joseph P Merlino, MD, MPA, Mount Sinai School of Medicine, New York, New York; Nancy Murphy, NP, St. Luke's Roosevelt Hospital Center, New York, New York; Edward Nunes, MD, New York State Psychiatric Institute, New York, New York; David C Perlman, MD, Beth Israel Medical Center, New York, New York; Sharon L Stancliff, MD, Harm Reduction Coalition, New York, New York; Robert Whitney, MD, Erie County Medical Center, Buffalo, New York

Liaisons: Daliah I Heller, MPH, Liaison to the New York City Department of Health and Mental Hygiene, New York, New York

AIDS Institute Staff Liaisons: Diane M Rudnick, MEd, Liaison to the New York State Department of Health AIDS Institute, New York, New York

AIDS Institute Staff Physician: Eunmee H Chun, MD, New York State Department of Health AIDS Institute, New York, New York

Principal Contributor: Joseph Conigliaro, MD, MPH, VA Pittsburgh Healthcare System, and the University of Pittsburgh School of Medicine, Pittsburgh

FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

GUIDELINE STATUS

This is the current release of the guideline.

GUIDELINE AVAILABILITY

AVAILABILITY OF COMPANION DOCUMENTS

PATIENT RESOURCES

None available

NGC STATUS

This NGC summary was completed by ECRI Institute on July 3, 2008.

COPYRIGHT STATEMENT

DISCLAIMER

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