How To Treat An Alcoholic – K: Ok Marty, how about reversing the order of the podcast – I thought we did well with 4 new gems followed by one from the previous episode. what gives
M: Yes, and I am completely open to criticism. But listen to me. About the unhealthy use of alcohol – part 1 We discussed the definition of disease at the macro level, survey, risks and benefits of alcohol use. We will now approach specific treatment options. And since the interventions usually start with screening, which is the first part of the acronym for the *super suite* – SBIRT – I thought we should go there.
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S: Remember that SBIRT is an acronym that stands for Screening, Brief Intervention and Referral to Treatment. This framework helps to diagnose unhealthy alcohol use and start treatment quickly. We’ll go over the rest of SBIRT’s BIRT in our next gem.
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M: Well, unhealthy alcohol use is a phrase that covers hazardous use – think heavy drinking in college – in alcohol use disorder – which is really any amount of alcohol consumption that has negative health or social consequences.
K: In terms of screening, for those who like hard numbers, what are the red flags for high-risk drinking?
S: Yes Marty! To translate these numbers: Hazardous drinking for women of any age or for men over 65 is defined as more than 3 drinks in one sitting or more than 7 per week. For men under 65, it’s a bit more extreme – more than 4 drinks a day or 14 drinks a week means they’re using alcohol in an unhealthy way and have health or social problems afterwards. The effects must be assessed.
K: Great, thanks Sharia. And do you remember approved means of screening for unhealthy alcohol use?
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M: I stick with the AUDIT-C, mostly because I remember it’s a three-item questionnaire and I open it in my EMR instead of memorizing specific questions.
A: Well, and those questions are basically (1) how often do you drink an alcoholic beverage, (2) how many drinks do you have on a typical day that you drink, and 3) how often do you drink? 6 or more drinks?
K: So any connection to a C audit calculator would risk layering for you. And if you want, you can abbreviate to the product screening program. Beverage bar
M: Great – this is how SBIRT covers the S – this is the screening – and our gem. Let’s move on to our first gem and the rest of the acronyms!
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You see an important “new patient” at the clinic. He is a 46-year-old man who received an emergency appointment for abdominal pain that went away with Mylanta and PPI and is now here for treatment. He has high blood pressure but no other medical problems.
M: Okay. So we talked about screening all patients for unhealthy alcohol use, but my paranoia about alcohol in this patient is really explosive because (a) it’s an alcohol podcast and (b) he has two alcohol-related medical problems that we know about.
A: Yes, and he tested positive using a single-item screen, meaning he drinks more than 4 beers at least once a week. It is about 16 beers a week and when asked about his alcohol consumption it seems that his drinking does not affect his work or his social life and therefore it is considered unhealthy alcohol consumption.
K: I have to say that in real life it’s not often an opportunity to intervene – as we all know – but when the stars align like this, I find myself doing a silent internal ‘fist pump’.’ and moves on to the next step. section. of SBIRT, which is a brief intervention.
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K: Okay, easy, Marty. Let’s not kill the poor thing. Think of the brief intervention as a type of focused motivational counseling intervention in which the provider spends about 5 minutes after the screening doing the following: 1) raising the problem, 2) providing feedback about the level of risk, 3) motivating the patient to change, and 4) setting goals or planning Implementation of this change.
Q: Kate that sounds great and besides, my question is why waste 5 minutes of my 20 minute visit on her? What is the level of evidence supporting the SBIRT protocol? I mean, are we talking like statins in water which is almost a proven benefit or are we like vitamin D – maybe it works but it doesn’t really cause problems, so why not??
M: That’s a great question, Sherry! I actually watched it because I had that healthy skepticism (no offense to Kate).
M: A 2006 article in the American Journal of Preventive Medicine did a large-scale systematic review of many different preventive health services, from tetanus shots to mammograms, and ranked them by effectiveness. SBIRT was at the top of the list with a score equal to colon cancer screening – above both Pap smear cervical cancer screening and routine lipid screening. We will add the paper to the program notes for those who want to go deeper.
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K: Wow that’s great. Makes you think about the time we spend on pop and fats in relation to alcohol control.
Q: My right ear is tired! Let’s break each item down a little more. How can such a discussion progress?
M: The caveat is that we have to say that everyone has their own interview style, so we’re going to give you some examples that we’ve found to be helpful and you can try them out and see if they work. right.
K: Okay. So in this scenario we would maybe raise the issue, which is step 1, look into it, but then it helps to open the conversation something like, “Do you care? If we talk about it a little bit more, its effects? Alcohol on your health?” and understand his thoughts a little better.
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A: So giving feedback is often as simple as saying, “I’m concerned about your drinking and how it may be affecting your health. Do you know the recommended limits of alcohol consumption?”
M: I would argue that pointing out the connection between the drink and his hypertension or GERD and then asking if he thought about it would also provide feedback.
A: And regarding the third part, I would imagine that the motivation for change is the old 1=10 scale of motivational interviewing?
A: So the next question is the most important – once you commit to how much they are willing to change, you ask the patient why they didn’t choose a lower number.
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M: For example, if our patient says “I’m not really interested, maybe 5”, you answer “I understand, tell me why you didn’t say 3 or 4”.
A: It allows the patient to talk about any motivation they have instead of focusing on motivation they may lack.
K: Definitely Shrey. And the last part of the brief intervention is setting goals and planning for the end of the session. And here I want to say don’t get too excited – short-term and achievable goals (even if it’s like cutting back on an extra drink or two a day) are more effective than big, idealistic goals. Goals may also focus on starting counseling or referral to an addiction treatment program or peer support group.
K: Yes, this is an example. AA, or Alcoholics Anonymous, is one of the only 12-step support groups that is quite popular. There are also groups for people who use opioids – Narcotics Anonymous, or NA – marijuana, cocaine groups, all kinds of things. The common theme in these groups is that altruism is achieved through personal inquiry and acceptance, and there is also an emphasis on belief in some spiritual higher power. Which may not be to everyone’s liking.
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M: An alternative to these 12-step programs is a method called SMART Recovery – SMART stands for Self-Management and Recovery Training. SMART is a trademark process that replaces the intellectual basis of AA with a more flexible cognitive-behavioral framework. It is new and the meetings are significantly smaller than AA.
K: If it’s a trademark, Marty, does that mean we’re allowed to mention it on the show? What kicks do you get?
K: Well, SMART Recovery can be good for points that are interested in groups, but for whom AA is not suitable.
A: To summarize this section: After a positive test, a simple “brief intervention” in the office followed by a referral to treatment tailored to the patient’s specific goals and beliefs is effective.
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M: And remember brief interventions for people with uncomplicated unhealthy alcohol use. It consists of four parts – set the topic, give feedback, assess the motivation and finally set the goals.
K: Let’s look at our case again. Although a