Quiz yourself on the 5 Pearls we will be covering! Thank you to Dr. John Martin and Dr. Dan Schatz for their help with the script!
- What is alcohol use disorder (AUD), and how is it different from unhealthy alcohol use? (2:53)
- Who should we screen for unhealthy alcohol use, and which screening tools are preferred? (8:45)
- What are the consequences of unhealthy alcohol use? (14:33)
- Can moderate alcohol be good for patients, and if so, how much is “moderate”? (20:53)
- Pearls Recap (24:29)
- Throwback question: Who, how and how often should patients with chronic hepatitis B infection be screened for hepatocellular carcinoma? (24:29)
- Unhealthy alcohol use is a catch-all term meant to describe a spectrum of drinking ranging from risky use all the way to alcohol use disorder.
- The DSM-IV terms alcohol abuse and dependence have been replaced by the DSM-5 term alcohol use disorder, which is defined as a problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by psychosocial, behavioral, or physiologic features
- According to National Institute on alcohol Abuse and Alcoholism (NIAAA), risk for alcohol use disorder is thought of as daily and weekly alcohol limits:
- For men less than 65 years: more than 4 drinks/day or 14 drinks/week for
- For women and men over 65 years: more than 3 drinks/day or 7 drinks/week
- The United States Preventive Services Task Force (USPSTF) has recommended that all adults in primary care be screened for unhealthy alcohol use
- The AUDIT-C tool is the recommended screening tool for unhealthy alcohol use, and consists of the following questions:
- How often did you have a drink containing alcohol in the last year?
- How many drinks containing alcohol did you have on a typical night when you were drinking?
- How often did you have six or more drinks on one occasion in the past year?
- A single-item screening question has also been validated. It is the most sensitive question for unhealthy alcohol use.
- For men, how many times in the last year, have you had more than four drinks in a day?
- For women, how many times in the last year, have you had more than three drinks in a day?
- The negative health impacts of alcohol include most types of cancer with the exception of thyroid cancer.
- Patients are often diagnosed with comorbid medical conditions that may be reversible if the underlying alcohol use disorder is diagnosed and treated appropriately
- Labs values can be a useful tool for assessing alcohol use and educating patients on end-organ damage; however, they are not recommended for routine diagnosis of the disease
- Population health research has identified a ‘J-curve’ of potentially beneficial alcohol use, leading to a trend in ‘healthy alcohol use.’ Low levels of alcohol are associated with decreased risks for cardiovascular disease and type 2 diabetes.
- Few medical professionals would recommend ‘healthy drinking’ however; the goal remains moderation or minimal intake.
- HCC screening is based on risk factors such as family history of HCC, personal history of cirrhosis, ethnicity and sex of the patient with chronic hepatitis B.
- It starts at the time of diagnosis for African patients, age 40 for Asian men, age 50 for Asian women. Also, all patients w/ cirrhosis or a family hx of liver cancer should get routine screening.
- The AASLD recommends HCC screening with liver US every 6 months with or without serum alpha fetoprotein (AFP).
Pearl 1: What is the definition of alcohol use disorder (AUD), and how is it different from unhealthy alcohol use?
M: I’m really excited we are finally getting a chance to address alcohol use in the primary care setting!
S: Right, most trainees first experiences with it is on the inpatient side with patients who are experiencing withdrawal or with a whole host other inpatient issues
M: And the part I take great umbrage with is that so many people just write ‘E-T-O-H abuse’ in their problem list and just totally forget about it.
K: Yea, Marty I’m so glad you brought up that term “alcohol use”! I feel like Alcohol abuse or quote –unquote etoh abuse is something I see written all over people’s charts – and it’s such a junk term that not only isn’t helpful, but even worse is that it can also be pretty stigmatizing, especially for patients who are honestly looking for help managing their drinking.
M: Ugh, I think the only term that I dislike more than ‘alcohol abuse’ is “patient is a poor historian”… but I’ll save that diatribe for another podcast.
K: Ha thanks Marty.
M: Alright Kate, Alcohol abuse is out. What term should we be using?
K: I like the term unhealthy alcohol use, which is what most organizations are moving towards in their definitions. It’s a catch-all phrase, meant to describe a ‘spectrum of drinking ranging from risky use all the way to alcohol use disorder’. 
M: Unhealthy alcohol use and alcohol use disorder – I can get on board with that! So, no more ‘alcohol abuse’!
S: So Kate, if im thinking of unhealthy alcohol use as a spectrum and that spectrum starts with ‘risky use’ – at what amount of drinks should we start worrying that our patients having risky drinking?
K: Good question. The generally accepted understanding of risky or unhealthy drinking is ANY amount of drinking behavior that has negative health or social outcomes.
M: So risky behavior could be the college freshman weekend binge drinker or the daily six-pack of beer drinker.
K: Exactly! Alcohol use disorder, on the other hand, which (in the DSM V) replaced the term “alcohol abuse and dependence”, is characterized more specifically by a problematic pattern of alcohol use leading to clinically significant impairment or distress, as manifested by psychosocial, behavioral, or physiologic features.
S: Ugh kind of a mouthful but I get the gist. Basically, alcohol use disorder is drinking that leads to significant impact on one’s life, affecting their relationships, occupation, their health or other parts of their life
K: Exactly. So after I’ve identified unhealthy alcohol use in a patient (we’ll talk about screening in a sec), I rely on open-ended questioning
M: for example, “tell me how alcohol is affecting your life”
K: to determine how alcohol use is affecting their life – the answers can be very enlightening, both for me and my patients!
S: Yesssss. So important to stay as open as possible in these conversations! Sometimes its unclear if they meet criteria for these definitions even after asking a lot of questions
M: Yea, I would love a hard number of drinks but perhaaaaaps I’m just sipping on the wrong juice here….
S: Is there any guidance on how much alcohol use would typically be classified as at risk for alcohol use disorder?
K: Right, the NIAAA (National Institute on alcohol Abuse and Alcoholism) – let’s not even go there about how outdated that acronym is – recommends that men less than 65 yrs drink no more than 14 drinks/week or 4 in a day. For women and men over 65 it’s way less- no more than 7 drinks/week or 3 in a day. 
S: Alright so sounds like theres two buckets of limits – a weekly limit and a daily limits based on sex and age.
M: 14/4 for men less than 65yo and 7/3 women and men over 65. 14/4 and 7/3. For some reason that’s always stuck in my head because 14-4 is 10 and 7+3 is also 10…
S: Honestly I would make fun of you but I also do that, make weird associations to remember things! 14/4 and 7/3, plain and simple!
K: Right, pretty straightforward. I’ve thought to myself where these numbers come from and despite going through a rabbithole of papers, it’s still not very clear and kind of arbitrary! For example, almost every country’s health institute has a slightly different recommendation – for example, the British guidelines don’t even distinguish between men and women.
M: so if anyone has any insight into the genesis of these numbers tweet at us! @COREIMpodcast whoop whoop! 
S: Ok, to recap, the terms alcohol abuse and dependence has been replaced by the by idea of alcohol use disorder, which is a problematic pattern of alcohol use leading to clinically significant impairment or distress. Even more broadly, we have the concept of unhealthy alcohol use, which encompasses a broad spectrum of drinking patterns even beyond alcohol use disorder, and includes things like binge drinking.
M: And, for those of use who like numbers, red flags for high risk drinking translates roughly to more than 4 drinks in a day for men, or more than 3 for women, and 14/week in men and 7/week in women. Just remember 14/4, 7/3
Pearl 2: Who should we screen for unhealthy alcohol use, and which screening tools are preferred?
S: Excellent so now that we have those terms clear and talking the same language. Let’s start with a case! We have relatively healthy 54F who is new to your clinic and wants an annual checkup. No complaints, just wants to get “checked out”.
M: Love these! You’re like colo, mammo pap see you next year! Right?
K: Well not so fast Buster – I wish it was that easy. This is an alcohol use podcast, so you’re not getting away with that! In addition to all those tremendously important things you just mentioned, the United States Preventive Services Task Force (USPSTF) has recommended that all adults in primary care be screened for unhealthy alcohol use.
S: Yah, alcohol is third leading cause of preventable death in the US (pretty big deal) and that’s just one of the reasons we should be screening for alcohol use at ALL intake visit.
M: Yea. the fact is that studies that have looked at targeted screening find that SHOCKER physicians are really pretty bad at predicting which patients have unhealthy alcohol use. This is particularly true for patients with moderate-risk use, who don’t have a lot of obvious symptoms.
K: And moderate-risk drinkers are also the patients who are most likely to change their behavior.
S: So maybe the question is how do you actually go about screening in a clinic visit? Do you just say (slow down)“do you drink?”
K: Or even better – when someone asks “do you smoke, drink or do drugs?” all in one shot! Like word vomit.
S: or the worst – ‘you don’t drink, do you?’
M: UUUUUGH! My goodness! There HAS to be a better way!
S: [groans] Right, only for the patient to answer “not much” or “oh, just socially” and that gets brushed away but if we don’t delve deeper into getting the actual details, we are likely missing a huge opportunity to do some patient education and prevention!
M: Right so let’s go through the validated tools for screening.
S: The trap that most ppl often fall into is ONLY asking the CAGE questions..
M: Oh man I feel guilty just asking those tired old questions…
K: I know. For some reason that’s the only one we all get taught. And I didn’t realize until I was precepting that that’s not actually the best test.
S: Yea! So the CAGE questions…
M: cutting back, annoyed at attention to drinking, guilty about drinking and the classic eye-opener.
K:…are actually geared towards detection of alcohol dependence, which means that it was validated to detect more severe alcohol use, using old DSM definitions..
S: Using the CAGE questions, you will miss a large number of people who don’t have any signs of dependency yet.
K: Exactly, so the preferred tool in the primary care setting (again, not necessarily for psychiatry, or for people who are already known to have Alcohol use disorder), is actually the AUDIT-C tool.
S: Good news, it’s just 3 questions, so it’s even shorter than the CAGE.
K: The AUDIT-C is useful in that, based on the patient’s score, it can help you risk stratify.
S: Alright, break it down for me, what does the C stand for? And for that matter ..what does the A and the U and all the rest of the letters?!?
K: It was adapted from a much longer AUDIT tool – the Alcohol Use Disorders Identification Test – back in the 1980s. The AUDIT-C is the first three questions of the whole tool that refer to “consumption” – hence the “c”.
M: And for the skeptic out there.. It’s been compared to the full AUDIT and CAGE scores and the audit-c found to have favorable test characteristics.
K: And for the super skeptics out there, it’s been validated for white, African American, and Hispanic populations in the US.  
M: So let’s go over the questions, because they’re really simple. I’ll do the first one: How often did you have a drink containing alcohol in the last year?
K: The second one is: how many drinks containing alcohol did you have on a typical night when you were drinking?
S: And the last question: how often did you have six or more drinks on one occasion in the past year?
M: and then you get a score, with 3 or more for women and 4 or more for men as a positive screen for unhealthy use.
K: Exactly. And if that’s hard to remember – like it is for me – the easiest thing to do it just have the calculator open on your computer, so you don’t have to do the math.
M: That all sounds awesome, but it would be pretty awesome to shorten that 3-item screener into a single question screener
S: haha yes!
K:Lucky for you, there is! if you ask the patient if they sometimes drink beer, wine or alcoholic beverages and they say yes, then the most sensitive single item question to ask for detecting unhealthy alcohol use is – Shreya, drum roll please –
S: For men, how many times in the last year, have you had more than four drinks in a day?
K: or if you are a woman, how many times in the last year have you had more than three drinks in a day?
M: Love this! So whats a positive result on that screening question?
K: Basically saying anything greater than 0 days. It has both about ~80% sensitivity and specificity for unhealthy alcohol use.
M: Nice. So to summarize this section. The USPSTF recommends screening all adults for unhealthy alcohol use. And to screen, we have both a single question option – How many times in the last year have you had more than 3 drinks (women) and 4 drinks (men) – as well as the 3-question AUDIT-C.
K: And to reiterate, Audit-C is asking basically a broad gauge of how often do you drink, how many drinks do you drink in a typical night, and how often do you drink 6 or more drinks in one occasion.
Pearl 3: What are the consequences of unhealthy alcohol use?
M: Great, so this is a good opportunity to go back to our patient and discuss why we care about alcohol use – the health implications.
S: So, using our one-question screener, we ask our a relatively healthy 54F in the past year, have you ever had she has had more than 3 drinks in a day? And she says yes….
M: and then we follow that up by asking her how often in the past year has she had more than 3 drinks in an day, she says every day... Wait, Shreya I can’t be reading this script right….
S: In fact she says about a whole bottle of wine a night. It turns out she started running a restaurant and it’s been so stressful that after the restaurant closes at midnight she drinks to relieve that stress. She feels fine, doesn’t have any signs or symptoms of withdrawal and wants to get my input. I start to add “Etoh abuse” to the problem list .. and stop myself!
K: Yay, go Shreya!
S: and change that to unhealthy alcohol use!
M: Love it, so our 54 yo female is drinking 1 bottle of wine a day – which comes out to about 5 glasses of wine right? Even if she sounds put together she is definitely at the risky drinking mark because she is having both more than 3 glasses/day and definitely more than a total of 7 drinks a week!
K: Props on calling it unhealthy alcohol use! Without information about biopsychosocial impacts we don’t have enough information to say whether or not she has alcohol use disorder, so I would spend some time discussing mood, sleep, work and the effects on her personal relationships
S: Right, and this is also a time to maybe screen for other health problems she may have that could be related to alcohol use that we might have not picked up on previously.
M: For sure. So let’s talk about health impacts, because that’s what patients, and providers, really want to know.
S: We know that alcohol – maybe second only to cigarette smoking – is the single greatest modifiable risk factors for malignancy.
K: And the data for breast cancer in particular is suuuuuper compelling. I read in a pretty nice meta-analysis published in 2014 in the American Journal of Preventive Medicine that showed for each additional standard drink/day, your breast cancer risk is estimated to increase anywhere from 2% to up to 12%.
S: That’s crazy. And while we’re talking about cancer… all of them are associated with alcohol. Throughout the GI tract – mouth, throat, larynx, esophagus, colon and, more obviously, liver.
M: Wow – that’s ALL the cancers… I feel like all you’re missing on that list is melanoma and thyroid cancer.
S: Well since you mentioned that Marty, Kate and I looked both of those up. Alcohol use is indeed associated with both melanoma and non-melanoma skin cancers.
K: In a dose-dependent relationship…
S: BUT interestingly, alcohol use is actually associated with a DECREASED risk of thyroid cancer! This has been shown in a number of studies, but a 2017 meta-analysis pooled the results and it maintained significance.
K: Yeah, we were actually pretty surprised by this. I’m not sure I would ever recommend alcohol to prevent thyroid cancer, but the association is well described..
M: Hah, right, we’re not recommending smoking to prevent ulcerative colitis!
S: OK so we’ve covered alcohol and cancer. Let’s get a little more primary care. What other health issues might be “brewing” under the surface?
M: Nice Shreya. So yeah, I think the medical complications of alcohol use are relatively well known – cirrhosis, pancreatitis, ulcers – just to rattle off a few.
K: Totally. What I find interesting is that, sometimes, the complications of alcohol use are diagnosed before the alcohol use disorder. So you’ll have patients with uncontrolled hypertension, depression, sleep apnea-
K: – peripheral neuropathies. All of these things, but the alcohol use won’t have been identified! And it’s super important to do that, because a lot of these other medical problems are actually at least partially reversible if you address the alcohol use.
M: Yea, I think it’s so important not to forget the psychosocial and mental health impacts. I think about alcohol use causing or exacerbating depression, suicide,
K: not to mention intimate partner violence, firearm violence
S: AND physician burnout…
M: The other thing to think about as a result from alcohol use is weight gain. Tons of people are trying to lose weight, but few people realize that that bottle of wine is like six, seven hundred empty calories that our patient is consuming nightly!!
S: Yep and that was a great pivot point. I’d like to transition real quick to talk about labs, because to be honest, sometimes it’s lab abnormalities that pop up first that flag possible alcohol use for me.
M: So true. Sometimes I do use abnormal LFTs to open up a conversation about diet and alcohol with my patients. The hard numbers can be an effective teaching points. Alcohol-induced macrocytic anemia is another good example of this.
S: Yah I like to turn my screen around in clinic and have my patients see their lab abnormalities. Often these patients feel okay but when they see its actually affecting their body in terms objective labs that can often be a motivating factor.
K: Yea Shreya I agree, although I think it’s important to point out that most major medical organizations don’t recommend using labs for diagnostic purposes, but I agree they can be helpful in educating your patients, and maybe moving your precontemplative patients forward!
M: Love it. So, in summary, alcohol causes serious damage – which might be the understatement of the century. Alcohol use is associated with tons of malignancies – with the possible exception of thyroid – as well as medical problems literally from head – like memory impairment – to toe – like peripheral neuropathy. Don’t forget about psychosocial and mental health issues like depression and intimate partner violence. And lab tests can be useful motivators for behavior change but they’re not recommended for routine diagnosis.
Pearl 4: Can moderate alcohol be good for patients, and if so, how much?
S: So, back to our case. After we talk about health implication for her alcohol use, and she tells me that she only drinks red wine because I’ve heard it’s good for you! Which is true, to a certain extent, right?
M: I have definitely heard about the red wine for hyperlipidemia, but I guess her confusion begs the question is there a healthy amount of alcohol a person can drink?
K: So this is the famous ‘J curve’ conversation….
M: The J curve?
K: Right, the J curve – so you have burden of disease on y-axis and amount of alcohol on x-axis, and there’s actually a point when drinking more is associated with better health outcomes than drinking less.
S: a little sweet spot.
K: Right. So alcohol in quote “moderate” amounts – which is around a drink a day –  has been shown to have potential cardioprotective effects as well as protection against the development of type 2 diabetes. Studies have repeatedly shown inverse relationships between this level of drinking and risk of cardiovascular morbidity and mortality. The Nurses Health Study – that enormous cohort study on health risks for women – is a great example of this. 
M: There’s a 2015 JAMA meta-analysis of alcohol use that also showed this relationship basically set the bottom of the curve 2 drinks per day in women and 4 drinks per day in men. At this level there was an overall lower mortality compared with zero consumption. 
K: Yea I read that article. It’s actually the J curve that explains why the recommendations for alcohol use are different for men and women.
S: What! Mind blown! I’ve always wondered why the recs were different from women and men!
K: Yea, so for women, the benefits of alcohol seem to disappear at lower quantities of consumption – basically, the J curve is left shifted. There have been a number of theories put forward about the physiologic mechanisms behind the male-female difference – fat distribution in the body, the amount of digestive enzymes women make, even the role of the menstrual cycle – but none have been definitively proven. 
S: Marty, Kate, while all those studies sounds great this can be confusing for our patients, we do have to take them with a grain of salt. Most of these studies were observational, and based on population health data.
K: That’s a great point Shreya. It’s so important to differentiate between population level and individual level data. While on a population level, sure these studies show associations but in no way on an individual level, would I think to counsel my patients to go drink alcohol based on this.
S: Right. I have not yet seen anyone “routinely recommend counseling patient to engage in quote-unquote healthy alcohol use”]
M: Right? And, like where is the RCT that compares a drink a day with a jog a day? Or, like, a salad a day?
S: So, I’m hearing maybe moderation isn’t always the best advice. wait, but is the goal here really abstinence?
K: So for some patients, the answer may be yes. But in general I find that it’s most worthwhile to reiterate moderation to patients, because there’s a fine line between moderate ‘healthy’ drinking and unhealthy alcohol use – for women, it’s a one-drink difference!
M: I’m also a big fan of harm reduction here when the situation calls. If I have a patient who I know is going to drink I spend time encouraging them to do so moderately, rather than cutting out completely which I know isn’t going to work. And then setting some goals around moderation.
S: We’re going to have another podcast on actually treating and counseling people who have alcohol use disorder which will discuss this more explicitly.
K: Right. And it is also important to say here that my counseling for patients with AUD is different from my educating patients on unhealthy alcohol use. And, just a pitch for the next section, there have been some positive developments in counseling around risky alcohol use and alcohol use disorder – call brief interventions, which we will save for our next podcast!!
M: So in summary, large observational studies do show a J-curve relationship with alcohol consumption that shows low levels of alcohol MAY have beneficial cardiovascular outcomes. However, most professionals don’t recommend counseling around the J-curve in favor of moderation in drinking.
S: And with that i’d like to introduce Dr. Jennifer McNeely who is an an Associate Professor at NYU School of Medicine who specializes in addiction medicine
Pearl 5: Throwback from HBV Screening
S: Alright great job guys. Let’s finish up this episode with a throwback pearl from one of our most popular episodes – Episodes 7 and 8 on Chronic Hep B!
M: Yeah these were really fun to do with Dr. Amy Shen Tang – who has since give a talk at the 2018 National ACP meeting on Hepatitis B!
S: So happy to see Amy doing great things! So let’s focus this throwback on screening for hepatocellular carcinoma – or HCC – in patients with chronic hepatitis B infection.
K: Yes! Great topic! So to start we need to figure out which patient groups with chronic Hep B get screened for HCC.
M: Right this part is a little tricky because the answer depends on the patient’s ethnicity and age and sex. African patients with Hep B are at a higher risk for HCC so they get screened at diagnosis. Asian men start screening at 40 and women at age 50.
K: Anyone with a personal or family history of HCC gets screened as well.
S: And unless they have that history of HCC , there are currently NO recommendations to screen white patients.
M: Great, so next question is how do we screen?
S: We screen with US +/- serum alpha fetoprotein, or AFP,. AFP is not a good test alone, but there is some data that US + AFP is better than US alone.
K: And how often?
S: Every 6 months.
M: Perfect. That concludes our podcast for the month. Thanks for listening!
S: Thanks! See you next time!
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Tags: alcohol, audit, binge drinking, moderation, screening, side effects, unhealthy alcohol use