Primary Care Pearls
Primary Care Pearls
"His best friend was Alcohol.. I wanted my best friend back" - Diagnosing Alcohol Use Disorder (Part I)
In this episode, Dr. Barenboim and Dr. Holt explore a couple's journey through a changing relationship to alcohol and when it became an alcohol use disorder.
Share your reactions and questions with us at Speak Pipe . We might feature you on a future episode!
=== Outline ===
Chapter 1: Early Development of a Relationship with Alcohol
Chapter 2: Diagnosing AUD
Chapter 3: Approaching the Conversation
Chapter 4: Motivational Interviewing
=== Learning Points ===
- Someone’s relationship with alcohol is shaped by many factors. Learning more about these elements--such as upbringing, social circles, and if alcohol is used to cope with stressors--will provide a comprehensive biopsychosocial understanding about the role that alcohol plays in a patient’s life.
- Be familiar with and use screening tools for excessive alcohol use. These might include the AUDIT-C or the NIAAA Single Alcohol Screening Question.
- Motivational interviewing not only allows us to understand more about someone’s relationship with alcohol, but provides the guiding framework to explore what they are willing to take on in terms of change and intervention. A key aspect of motivational interviewing in this context is eliciting the patient’s perspectives on what is beneficial and detrimental about their alcohol use, and pointing out the discrepancies in alcohol’s impact on their life.
=== Our Expert(s) ===
Dr. Stephen Holt attended Columbia University’s College of Physicians & Surgeons and subsequently completed his residency training and Chief Residency at Yale's Primary Care Internal Medicine Residency Program before joining the program as an Assistant Professor. He currently serves as the Associate Program Director for Ambulatory Education in the Primary Care Program. His areas of interest include addiction medicine, medical education, and the art and science of physical diagnosis.
=== References ===
- What is a standard drink? https://www.niaaa.nih.gov/alcohols-effects-health/what-standard-drink
- Highlights for the 2022 National Survey on Drug Use and Health: https://www.samhsa.gov/data/sites/default/files/reports/rpt42731/2022-nsduh-main-highlights.pdf
- Facts About U.S. Deaths from Excessive Alcohol Use: https://www.cdc.gov/alcohol/facts-stats/index.html
- AUDIT-C: https://www.mirecc.va.gov/cih-visn2/Documents/Provider_Education_Handouts/AUDIT-C_Version_3.pdf
- AUDIT: https://auditscreen.org/
=== About Us ===
The Primary Care Pearls (PCP) Podcast is created in collaboration with faculty, residents, and students from the Department of Internal Medicine at the Yale School of Medicine. The project aims to create accessible and informative podcasts about core primary care topics centered around real patient stories.
Hosts: Dylan Balter
Producers: Helen Cai, Josh Onyango
Logo and Name: Eva Zimmerman
Theme music and Editing: Helen Cai, Josh Onyango
Other background music: Puddle of Infinity, Adam MacDougall, Density & Time, Jesse Gallagher, Asher Fulero, Astron, Lauren Duski,
Instagram: @pcpearls
Twitter: @PCarePearls
Listen on your favorite podcast platforms: linktr.ee/pcpearls
[00:00:00] Dylan: Hi. Welcome to Primary Care Pearls. A podcast made by learners, for learners.
[00:00:07] James: When I flatlined and, um, I heard her screaming and that kind of clicked in my head. I can't keep doing this. I can't keep doing it. To me, I can't keep doing it to her.
[00:00:20] Dylan: Today, we're talking about alcohol use disorder. In the United States, in the year 2022, nearly 29.5 million people aged 12 and older, were affected by this condition.
The impact of unmitigated excessive alcohol use can be fatal. Approximately 178, 000 people die from excessive drinking each year in the United States. And this has increased by around 29 percent over the last six years. Any effort towards screening, identifying and counseling patients with excessive alcohol use in the primary care setting is not only an important public health service, but also a life changing intervention to the individuals in your office.
To better illustrate this, during our discussion, we'll be joined by James and Tanya.
[00:01:15] James: I'm James Streater. Um, I'm a recovered alcoholic. Right now, today I'm 105 days sober
[00:01:24] Tonya: I'm Tonya Robinson Streater. I'm married to James Streater and I'm pretty much here to support him through his journey of recovery.
[00:01:35] Dylan: We'll also be joined by our faculty expert, Dr. Stephen Holt.
[00:01:40] Dr. Holt: Hello, my name is Stephen Holt. I'm a physician. I'm board certified in Internal Medicine and Addiction Medicine and at Yale School of Medicine I direct the Addiction Recovery Clinic within our Primary Care Internal Medicine residency.
[00:01:54] Dylan: The interviews will be facilitated by Dr. Jessica Barenboim.
[00:02:00] Jessica: My name is Jessica Barenboim. I am one of the preventive medicine residents. My interest in the field of substance use disorder has been one that's been brewing for about 20 years.
[00:02:14] Dylan: My name is Dylan. I'm a medical student at Yale, and I will be your host for today's episode.
During this discussion, we'll learn about how excessive alcohol use can develop in an individual, how to initiate the conversation about alcohol use with a patient, and diagnose alcohol use disorder, if present. And finally, we'll explore how to help move patients toward change through motivational interviewing.
Before we get started, please know that this content is meant to be for learning and entertainment purposes only, and should not be used to serve as medical advice. If you or a loved one is suffering from anything discussed in today's episode, please be sure to discuss it with a medical professional.
Okay, with that, let's get started.
Chapter 1: Early Development of Relationship with Alcohol
[00:03:05] Dylan: Alcohol is such a commonplace substance that for many of us, it's a completely normal part of our everyday lives. Our attitudes about alcohol are shaped by many factors, such as our upbringing and the norms we inherited from our families, our friend groups and social spaces, and finally, and perhaps most importantly, the way it makes us feel.
Calming our nerves when we're experiencing social anxiety, or making us light on our feet so we can celebrate more jubilantly. All of these things start to shape a relationship to alcohol. Let's hear about the development of that particular relationship from our patient, James.
[00:03:44] James: My father gave me my first drink when I was like six or seven years old. Started with beer. I didn't started drinking, hard liquor until I, um, I started working at Connecticut Container. Um, I used to, uh, ride share rides with, uh, some of the older guys that drank heavy and I'd have a drink with them after work.
[00:04:05] Jessica: At what point do you think you might have said to yourself, or did someone else say to you, could I potentially have a problem with alcohol? Or, you know, it seems like I'm drinking too much?
[00:04:16] James: I'm a very stubborn person and I didn't think so cuz I couldn't see it. But she had seen it and apparently other people around me could see it.
[00:04:27] Jessica: So your wife was the first one to notice it and then friends or coworkers?
James: Yes.
[00:04:33] Dr. Holt: uh, I've come across so many patients who have that kind of story where, yeah, I I've been drinking since I was 14. But I didn't really start having a problem until six years ago or seven years ago or something.
You know, at what point were you drinking every day? Because that's a good transition point to, you know, in high school, maybe you're drinking at parties every now and then. Maybe in college you drink when you go out with friends, but at what point were you drinking every single day?
And then the next question is, at what point do you feel like you started to lose control of your drinking? And honestly, most patients can articulate that. They can say, yeah, I drank pretty much every day after work, as a way to relax, to cool down, drinking with my significant other or just watching sports, games, whatever, just, I would drink, but it was only like five or six years ago after my divorce or after I lost my job, that's when drinking began to, run away with me.
[00:05:24] James: I had work anywhere from 40 to 70 hours a week. And when I get off work, I may have a cocktail and a beer or two, and that was it. After I got ill, I was labeled with a congestive, congestive heart failure. I got very sick. I had a very strenuous job. I was deemed no longer can do the job anymore and I was, I am forced to retire. And, as part of my retirement, staying home, I started drinking more and more and more. Cocktails for breakfast, cocktails for lunch, cocktails in the evening, cocktails for dinner, cocktails before I went to bed. I mean, it got very, very heavy.
[00:06:09] Tonya: And then before you know it, he’d buy half gallon bottles. First it would be maybe, one once a week. Then it became twice a week. Three times a week. He would stop eating, would just sleep and drink. And it started to consume him till it taxed his heart even more.
[00:06:32] James: Until I got very, very sick.
[00:06:34] Tonya: When he went into the hospital. He was in ICU, when he, when it all fell apart. He flatlined. It was the most horrific experience in my life waiting for the phone to ring.
And the next thing I know, they're screaming his name, James. James wake up and they hang up the phone. And I think at that point, for me, that was when I think I flatlined emotionally, because that was literally the line that was crossed in the sand that either, either he's gonna die. From this or when he gets past this, we have to find the right path for him to stop drinking. Cuz it can't be from me. I can want anything I want. His doctors can want anything that they want, but if he can't see it, if he can't feel it, touch it or want it, it's not gonna matter.
He's going to die. And I started wrapping around my mind, I'm going to lose my husband. I didn't know when, didn't, didn't know the date, but I knew it. I was going to lose my husband. And it was literally the hardest thing every day to wake up every morning next to the person that you love, going to work, coming home and not knowing was he going to have a massive heart attack and he wasn't going to be here.
There really wasn't any great conversations anymore, um, or outings anymore. It was just, he was in his world, but he was never abusive to me. It was just, I didn't have my best friend anymore, because his best friend was alcohol and I wanted my best friend back.
[00:08:31] James: I've had four other family members that passed away from drinking. My father, my great-uncle, one of my other cousins and my sister, just recently all with cirrhosis of the liver from drinking too much. When I flatlined I heard her screaming and that kind of, that kind of clicked in my head. I can't keep doing this. I can't keep doing it to me, I can't keep doing it to her. You know, it's time, it's time, time to step back and refocus and get rid of this.
[00:09:09] Dylan: This was clearly an incredibly traumatizing experience for both James and Tanya. Although James' relationship to alcohol started out as benign, it began to evolve and snowball into a disease that almost took his life. James and Dr. Holt identified some of the triggers, or accelerants, to that evolution, which in this case involved losing a job, leading to idleness, a common trigger for many forms of addiction.
And for many individuals struggling with addiction, they may not be able to recognize the disease until they experience a major crisis involving their health, relationships, or work. We often colloquially refer to these crises as rock bottom. But does this mean that an individual's relationship to alcohol has to be associated with a crisis for us to diagnose them with an alcohol use disorder?
Let's hear from Dr. Holt.
Chapter 2: Diagnosing AUD
[00:10:04] Dr. Holt: So just some definitions. When we think about alcohol use disorder it uses the same diagnostic criteria as we use for any substance use disorder. And maybe from prior episodes of this podcast, you guys have talked about 11 criteria that distinguish a substance use disorder from just maybe unhealthy alcohol use or at risk alcohol use.
Without going through those 11 criteria, we sometimes just boil them down into the three Cs: Evidence of cravings. You find yourself thinking about alcohol consumption, all the time. It's just something that you're ruminating about all the time. So that's cravings.
Then consequences, that is you're continuing to use alcohol. We're starting to see some consequences of your use. Maybe it's physical consequences, like you simply have some, higher blood pressure or insomnia or maybe peptic ulcer disease or maybe more really very advanced physical consequences like cirrhosis or even heart failure, things like that. Or social consequences, stress in your relationships. Failure to meet other role obligations at work, things like that.
And then beyond cravings and consequences, the third C is basically control. So issues with: you're no longer able to restrain yourself like you're trying to cut back. You've acknowledged that there are consequences of your use and you're trying to abstain or even just cut back a little bit in your use and you're unable to do so. You've basically lost the reins. And this substance has taken over and so that's the third C. And when you've got evidence of all three of those things, along with perhaps some tolerance evidence of withdrawal symptoms, that's a point where we say you have either mild, moderate, or severe alcohol use disorder, depending upon how many of these specific 11 criteria that you might meet.
[00:11:45] Dylan: Okay, so a quick summary.
Alcohol use disorder falls under the umbrella of substance use disorders and shares the same diagnostic criteria. While there are 11 specific criteria in the DSM 5, we can simplify them to the three C's.
First is cravings: that persistent, nagging desire for alcohol.
Second: we have consequences. The negative impacts on one's physical health, relationships or job.
Third is control: that feeling of being unable to cut back or stop even when you want to.
And finally, we consider additional factors like tolerance and withdrawal symptoms. The presence of these factors and the number of specific criteria met determine the severity of alcohol use disorder, whether it's mild, moderate, or severe.
It's important to realize that these dynamics are not simply a moral failing or weakness of willpower on the part of the individual, but rather they are a result of the changes occurring in their brain
[00:12:51] Dr. Holt: When we think about the neurobiology of alcohol use disorder, all addictive substances ultimately have effects on the dopaminergic pathways in your brain, that is the reward pathways in your brain. We often think about alcohol. We're so focused on the GABA system, cuz that's what causes us to feel disinhibited, a little bit drowsy, potentially. Loss of coordination, that's all GABA.
But the reason that people who drink alcohol keep doing it is because it feels good. When you drink alcohol, your body releases some endorphins. The endorphins drive dopamine release. And the combination of endorphins, your body's natural feel-good hormone and dopamine, your body's natural feel-good neurotransmitter makes you want to do it again.
And so that's the reinforcing property that really drives the cycle of binge, intoxication, withdrawal, rumination, binge, intoxication, withdrawal, rumination. That's the sort of cycle that gets set up.
[00:13:48] Jessica: James did mention, it was difficult to identify, quote as an alcoholic. I think many patients probably have difficulty with the consideration that they may have a label of some kind that otherwise may have a negative connotation.
So in that regard, what might you say to a patient who says: but Doc, I'm not an alcoholic. My family just drank a few when we were growing up.
[00:14:14] Dr. Holt: It's not our job to police people's words.
For me, it's just, regardless of what you call yourself or don't call yourself, how interested are you in trying to cut back? Or how interested are you in trying to make a change from drinking X to drinking X minus Y? And we don't have to get too bogged down with the terminology of what you want to call yourself.
We can agree that in some sense it looks like alcohol has negatively affected your life. Whatever you wanna call that.
But I do think it is important to help people to escape from the trap of self-blame, self-deprecation, where you literally just say, I am an addict. You know, you think about all the other chronic medical diseases that are out there, and there aren't many where a person reduces themselves to a walking, talking pathology. But somehow we're really comfortable doing that in the addiction arena. Again, I don't get too bogged down with it, if a patient repeatedly says I'm an addict, what can I do? I'm just an addict. I, I will at times just bring up: well, you know, you're a person first. And you're a person who has a particular chronic medical disease that can have real consequences. And that ultimately is seated in your brain. And so we're gonna work on strategies to try to overcome that. Maybe using medications, maybe using behavioral approaches. But you are a person first, and we're gonna try to do our best to separate your personhood from this relapsing, remitting chronic medical disease.
[00:15:44] Dylan: Now that we better understand how to identify and diagnose alcohol use disorder, let's hear about how to discuss this sensitive and often stigmatized subject with a patient in your clinic room.
Chapter 3: Approaching the Conversation
[00:15:54] Jessica: Did you ever discuss your drinking habits with any of your providers?
[00:15:59] James: Yes, I, yes I did. My primary care doctor, he's older and he's a little more direct. and he would just tell me: James, stop drinking .
[00:16:11] Dr. Holt: The history of the healthcare system interfacing with folks with substance use disorders has been almost uniformly confrontational, right? It's always been paternalistic. You know, you keep drinking, you're gonna kill yourself. Why do you keep using, using drugs? Are you stupid? Are you, do you just have no willpower? Are you trying to kill yourself? That's how the history of the healthcare system has approached substance use disorder.
[00:16:36] James: Versus my cardiologist, we talk sports. You know, I feel very comfortable with him and he'd tell me, you know, it's time for you to start slowing down and eventually stop.
You know, you have a wonderful wife. You guys are great together. But if you continue to drink the way you are, you're not gonna be together though long because you're not gonna be here.
[00:16:59] Dr. Holt: When a patient realizes that they are understood, that they are seen by you, and that they're not going to be judged or viewed as culpable, it changes the entire conversation. A patient has to know that you see them. That you have heard their concerns, you've heard their values. They need to hear that you trust them when they tell you how much they're drinking and that they can trust you to not be judgmental, to kick them outta the practice because they're not following through on all the obligations. I think it's important for folks to know that the threshold to kick somebody out of a practice is fantastically high. And so our role really is to meet folks where they are.
Whatever their goals are. Again, I will indulge a patient with any goal they have. And I've heard some pretty not good goals, but I will indulge them for now and we'll give you a chance, if you wanna cut back from drinking two pints a day to one and a half pints a day.
Great. Let's see how that goes. I don't think it's gonna go well, but let's give it a try and that's okay. I just think it's, the relationship is so much more important than the treatment oftentimes because the relationship ensures they'll keep coming back. And if they keep coming back and you trust each other, then you're just working through a problem.
A complex, difficult problem, but you're working through it together.
[00:18:22] Jessica: What do you think are important questions to ask in a person's history?
[00:18:27] Dr. Holt: Yeah. Quantity is important. You'll note that when I talked about the three Cs, quantity is not in there. But it is important to tease apart quantity, even if it's not part of the diagnostic criteria. And there are some really effective little tricks to get at how much alcohol a person consumes.
Oftentimes when I'm watching less trained students or residents taking a history from a patient, they'll just say, do you drink alcohol? And how much alcohol do you drink? A couple beers? Or what do you drink? And while that sounds straight, straightforward enough, it turns out that if, let's say a patient drinks a six pack of beer a day, six pack of beer a day, if you say, do you drink a few beers?
They're gonna say yes, and then you're gonna put in your history "they're drinking a few beers". For me, when I hear a few beers, I think two or three. If in contrast, you find out the person drinks beer and you say to them, so you know, how much beer would you say you drink? Two or three, six packs. That may sound like a laughable quantity to ask somebody if they drink two or three six packs of beer.
But that person who drinks one six pack of beer is gonna be completely forthcoming because it's much easier to shoot under what somebody says than to shoot over it just because of all the shame and stigma that goes into the consumption of substances. That's just a little trick, but always dramatically overshoot what you think this person might be consuming and you'll get a better answer.
And it's good to clarify what kind of beverage they're drinking as well.
[00:19:55] Jessica: At your peak when you became most ill, how much would you say you were drinking per day?
[00:20:03] James: It would vary. It would go from anywhere to like a half a 30 pack of Budweiser or more and a half a gallon and a pint of Seagram's gin a day at times. And it went fast because I was mixing in these big cocktail glasses, you know, with, uh, cranberry juice.
So once I busted down one, I'd be ready for another and it just didn't phase me.
[00:20:33] Jessica: So, uh, pint and a liter of hard liquor and about 15 plus cans of beer a day.
[00:20:42] Dr. Holt: So if somebody says they drink, they tend to drink vodka or they tend to drink bourbon, I always say, so how much bourbon are we talking? Like you typically drink one or two pints a day? And when you ask with that totally flat, monotone, non-judgmental sort of tone you're gonna get, you're gonna get the correct answer. So that's consumption.
[00:21:03] Dylan: I love that trick. When asking about quantity of use, many of your patients may already be feeling judged and self conscious about their consumption. So, to create a non judgmental environment, offering very high examples can signal to the patient that whatever amount you actually drink won't faze me, hopefully freeing them up to share more openly about their true drinking habits.
For reference, the American Heart Association and American College of Cardiology recommend one drink per day, or less than seven drinks per week for women, and two drinks per day, or less than 14 drinks per week for men. We'll leave a chart in the show notes to demonstrate what is considered a standard drink.
In addition to the three C's, there are a few other ways to screen for problematic alcohol use, which may signal a substance use disorder. In addition to the three C's, there are a few other ways to screen for problematic alcohol use.
One is by asking a simple question, such as how many times in the past year have you had five for men, or four for women, or more drinks in a day, with any answer other than zero, suggesting it may be worth digging deeper. A second tool recommended by the U. S. Preventive Services Task Force is the Alcohol Use Disorders Identification Test, AUDIT, a 10 item survey, or the shorter 3 item variant, called the AUDIT-C.
Both of these tools assess alcohol consumption, dependent symptoms, and alcohol related problems. Dr. Holt goes on to describe a framework for understanding the problems that can arise from excessive alcohol use.
[00:22:53] Dr. Holt: In terms of other things that you wanna ask about I always like to go through the medical complications, the social complications and then legal complications.
And I really like to make sure I go through each of those because you'll miss stuff if you don't. So, for medical complications, had you ever been admitted to the hospital for alcohol? Have you ever had any times where you were intoxicated and ended up in the emergency room?Have you had any of these, and then I go through all the different systems in your body that are affected by alcohol, many of which patients have, just don't even realize, like people don't even attach alcohol to hypertension, but it's very well established. Or insomnia or peptic ulcer disease or osteoporosis in women, breast cancer, head and neck cancer.The list goes on and on for all the potential medical consequences that you can attach to this person's alcohol consumption.
Then social consequences, you're looking at. Do you have folks in your family who don't like how much you drink or give you a hard time about it? Your spouse, your kids, whatever. Have you had trouble getting to work on time or have you ever been laid off because of your drinking or had trouble at school? Whatever it is. So those are looking at kind of social consequences.
And you'd be surprised when you ask about legal stuff. How many folks will say, yeah, I've never really had any problems with alcohol, but I did have a DW like two years ago. But, that's in the past. But those are the kinds of things that I always screen for when trying to assess the extent to which alcohol has negatively impacted a person's life.
[00:24:21] Dylan: Let me take a second to introduce you to SBIRT, which stands for Screening, Brief Intervention, and Referral to Treatment. Although Dr. Holt describes here a pretty comprehensive framework for obtaining a substance use history, you may not have time to do this among other concerns and priorities in a primary care visit.
So, SBIRT is a tool that can be used to quickly identify any potential unhealthy alcohol use through screening methods such as AUDIT-C, or the simple one liner regarding quantity of use that we just talked about a few seconds ago. So what do you do once you've identified someone that may have either unhealthy alcohol use or an alcohol use disorder?
Chapter 4: Motivational Interviewing
[00:25:06] James: Well, they'd always ask me, did I drink and ask how much? And a couple of times, I did samples for them and they noticed the impact of what I was drinking and they told me I should cut it, cut it down some, eventually stop cuz they were concerned about my liver and everything. And I tried and then I just said, yeah, whatever. And I just went back to doing what I was doing.
[00:25:33] Dylan: Okay, so it looks like James's providers went to the second step of providing a brief intervention by simply telling James to cut down and stop his use. But it seems this wasn't very effective. How can we improve the efficacy of our brief intervention?
[00:25:49] Tonya: His cardiologist, who's fantastic, would have all these private conversations with him. And at the time, um, he just wanted him to give up beer because beer is very taxing on the heart and he wouldn't do it. And then finally, Dr. Posik called me, he wanted me at this doctor's appointment, and my husband was just furious.
He did not want me in that room. His cardiologist called me in the room and he wanted me to know every step, every piece of information that he told you. James, remember that? Yes, I do. Um, he wanted me to understand. What was going on with his health, how it was impacting and how beer itself, not at this point, liquor, um, alcohol, but just beer itself was destroying, weakening his heart. That's when I got on board to try and get him to see he had to reverse it.
[00:26:48] Dylan: Interesting. So it seems after James's cardiologist detected his patient's apathy, his strategy was to directly involve a loved one, who might provide more accountability. Although this can be an effective route to take, I wonder if there’s a way to dig a little deeper and motivate James himself away from apathy and toward change.
[00:27:11] Dr. Holt: Motivational interviewing 101, ask permission- so is it okay if we talk a little bit more about your alcohol use? Okay. They generally always give permission. It's rare that they would say no, but it's still a good step. And then rather than starting off with, why haven't you quit? Start off with saying, what do you like about drinking?
What does drinking do for you? Because there's no one, no patient I've ever met who drinks a pint of vodka because they like being enslaved to a substance. It's a consequence of something else that got them to that point. And I can certainly say that about somebody who's using 30 bags of heroin a day.
No one wanted to get there, something got them there. And it's still doing something for them now. If I was to think about our gentleman for this episode, I would say, what is it that you like about drinking? What does it do for you?
And he would say something along the lines of it helped me with loneliness. Helped me with feeling a little bit anxious around people or helped me to cope with not having a job. Whatever it is. So, I think it's important to ask that kind of question because it gives the patient the opportunity to explain themselves, if you will. To be able to say that, yes, I have an underlying problem, alcohol serves to alleviate that problem.
Once you've done that and you've talked about what they do like about drinking or smoking cigarettes or using cocaine or whatever it is. Then the next question is, all right, so if I hear that in what ways has alcohol negatively affected you?
And this is where, again, we go back to like medical consequences, social consequences, legal consequences. This is where I get into the weeds with those things. So what are the things about it that, that, that have affected you in a negative way? And then I say to the patient, so putting those two things together, on the one hand, alcohol helps you to relax at night. It helps you to bond with friends or with your significant other, what have you. On the other hand, boy, it sounds like it's really had some negative consequences for you over time, particularly in this past year or so. How do you reconcile those two things?
It sounds like you're of two minds. And it's really important to put that out there because patients really are of two minds about a substance and helping them to realize this discrepancy in how they think about alcohol. And then from there it's: okay, so seeing that there's some discrepancy there, what do you wanna do about it?
What do you think? Are you interested in trying to cut back? Have you tried to do so before? And again, this is heading down--I don't think we're gonna do a whole section on how to do motivational interviewing, but this is where those kinds of skills come to bear.
[00:29:44] Dylan: That was a brief but master class on motivational interviewing from Dr. Holt. Now, you can learn and practice how to do this on your own. But if you feel you don't have enough time or interest in doing so, this is when we get to the third part of SBIRT, referral to treatment. An addiction specialist like Dr. Holt can be a way to get assistance with motivating your patient towards change, and also provide them with other resources such as medications and support, which we'll talk about in our next episode. As you're discussing a change in drinking habits with your patients, What should you be guiding them towards? Cutting down or abstinence? Let's hear Dr. Holt's perspective on this.
[00:30:29] Dr. Holt: Harm reduction is certainly such an important component of addiction care when it comes to folks with alcohol use disorder. There's as you might expect, there's many folks who don't want to abstain. They just wanna figure out a way to drink in moderation and drink in a controlled fashion. And we support that. We're behind helping folks to just reign it in, so to speak. And naltrexone is, I think, a great medication in particular for that because it, it really does seem to do a pretty good job of just helping people to not get out of control with their drinking.
On the flip side, I of course always support patients desire to, drink or use in, in, in moderation, my experience is that once a person's come to my office and has been diagnosed with an alcohol use disorder, moderation rarely works.
So on the one hand I'm catering to the patient's goals cause I want to, and if that's what they say they wanna do, I'm fine. But I also know, in my heart, that a month from now we've set this goal to cut back on your drinking and only drink four drinks a week, but you're not gonna be successful.
And sometimes it's good for them to see that. It's good for us to say, okay, it sounds like your goal is to cut back from drinking, a pint of tequila a day to drinking a half a pint. That sounds great. Let's put this goal on the table. We're gonna see in a week and we'll talk about whether you were successful in doing that or not.
And then when they come back in a week and they say, I tried, but I just found, one day I was able to do it, but then the other days I was drinking a pint of tequila again each day. And then that's a great conversation. It's like, all right, it sounds like: On the one hand you wanted to run the ship, you created some goals, you set these very clear, SMART goals, objective sort of criteria that were time bound and had a very specific amount.
But on the other hand, it looks like you're not actually at the wheel. It looks like alcohol is driving this ship. What do you think about that? What do you think about this idea that even with medications on board it looks like alcohol has a little bit too much power in this equation.
So maybe we need to take alcohol off the table. Maybe we've gotta get alcohol out of the room cuz I don't know that you can take the reins in this way. So that helps to get the patient to start thinking about, maybe abstinence really is at least my short term goal. If we really want to make any change.
[00:32:46] Jessica: So have you had any conversations with Dr. Holt that have stood out to you? That made you feel particularly supported or helped along in this process?
[00:32:58] James: Once a month, now we have these, um, one-on-one interventions and, uh, he wants to know my, my, my recovery, how I'm doing. Asking questions about, have I drank?
Did you have a desire to drink? How are you feeling? And you know, he's a very nice guy as well. I feel comfortable with him and I like that.
[00:33:26] Dylan: We started the episode by observing James' relationship with alcohol, starting as a normal part of his life, but later becoming an intrusion and a danger to his well being. I can't help but remember all the times someone has told me, "hey Dylan, we should grab a beer sometime". In our society, alcohol can be a symbol of social connection, of celebration, of self care, and can be a healthy part of the way we interact with colleagues and loved ones. But as we learn from James' story, it's important to pay attention to the way that our patients, and frankly our own relationship with alcohol, may change, and whether it's beginning to cause more harm than good.
So here are some notes I took away from the episode, and I hope you did too. First, our patient's relationship to alcohol is shaped by many factors, such as upbringing, social circles, and whether drinking is being used to cope with other life challenges. Eliciting these elements can provide us a more comprehensive biopsychosocial understanding of our patients drinking patterns.
Second, it's important to screen for excessive alcohol use, which you can do quickly by using AUDIT-C or asking, how many times in the past year have you had five for men or four for women or more drinks in a day.? Third, once someone has screened positive, there are 11 criteria from the DSM 5 used to diagnose alcohol use disorder, which are similar to other substance use disorders.
A simpler framework to remember is the three C's, cravings, consequences, and loss of control. Consequences of excessive use can include medical, social, employment, or legal issues. And lastly, motivational interviewing can be a very effective tool for shifting patients towards change. The key elements include asking permission, eliciting both positive and negative effects of alcohol, using open ended questions to help encourage reflections on discrepancies, and being validating and supporting your patient's autonomy.
Be sure to tune in next time to catch episode two, where we'll be discussing managing alcohol withdrawal, medications for alcohol use disorder, and mutual support groups.
And that concludes our episode for today. We hope you enjoyed this episode, which was made possible by contributions from our patient and his wife, James and Tonya, Dr. Jessica Barenboim, who served as our interviewer and Dr. Stephen Holt, who served as our faculty expert and provided peer review for this series. Special thanks to our producers, Helen Cai, Daniel Wang, and Dylan Balter, myself, as well as our faculty advisors, Dr. Joshua Onyango and Dr. Katie Gielissen.
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We'll catch you in the next one.