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
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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.
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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
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.
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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