Substance Abuse Disorder CME/MOC Patient Case

A 38-year-old man is evaluated for a left ankle sprain sustained 5 days ago after falling off of the curb when catching a cab home from a dinner meeting with clients from work. He admits that he may have had too much to drink that night. He states he is under a lot of stress at work, and recently, he and his wife are having marital problems because she thinks he drinks too much. He has not missed work due to drinking or been cited for driving under the influence. On further questioning, he reports drinking about 2 cocktails per evening on weekdays, and on weekends, he has up to 5-6 drinks depending on what he is doing.

Which of the following is the most appropriate next step in the management of this patient?

A. Recommend hospital admission for detoxification
B. Start naltrexone
C. Use CAGE questions to screen for dependence
D. Recommend that he join an Alcoholics Anonymous group

Rationale:

This patient is clearly at risk for alcohol abuse or dependence based on his consumption. According to the National Institute of Alcohol Abuse and Alcoholism, an at-risk drinker has more than 4 drinks in a day and has more than 14 drinks in a week for men, and for women, more than 3 drinks per day and 7 drinks in a week. The patient in this case would qualify as an at-risk drinker. The next step is to assess for abuse and dependence. Alcohol use is classified as abuse if drinking causes or contributes to bodily harm, relationship trouble, role failure, and run-ins with the law. This patient mentions problems. The next step will be to assess for dependence. The CAGE questionnaire is a useful tool and asks patients the following questions:

Have you ever:

1. Felt the need to CUT down your drinking?
2. Felt ANNOYED by others criticizing your drinking?
3. Felt GUILTY about your drinking?
4. Needed a drink first thing in the morning as an EYE-OPENER? With two positive answers, the CAGE questions are sensitive (77-94%) and specific (79-97%) for detecting alcohol abuse or dependence.

In this case, dependence still needs to be established, thus CAGE screening should be performed before pursuing the other measures. Once alcohol abuse and/or dependence are established, then a brief intervention, stating a recommendation to quit drinking should be made. Recommendations for a mutual-help group can also be considered. In patients who have dependence, medications such as naltrexone, disulfram, and acamprosate can be recommended, though the effectiveness of these medications is not definitive. Hospitalization for detoxification can also be recommended depending on the motivation and sense of urgency for the patient to stop drinking.

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