A 44-year-old man comes to the office for an annual physical examination. He has no significant medical history and takes no medications. The patient has a history of depression in his early 20s that responded well to sertraline. He currently has no depressive symptoms. He is married, has 2 school-age children, and works as a landscaping contractor. The patient drinks socially and does not use recreational drugs. He has a 25 pack-year smoking history. He says that his mother and brother are recovering alcoholics. Physical examination is unremarkable. Routine laboratory blood tests are obtained.
Which of the following is the best next step in assessing this patient for unhealthy alcohol use?

Question

A 44-year-old man comes to the office for an annual physical examination.  He has no significant medical history and takes no medications.  The patient has a history of depression in his early 20s that responded well to sertraline.  He currently has no depressive symptoms.  He is married, has 2 school-age children, and works as a landscaping contractor.  The patient drinks socially and does not use recreational drugs.  He has a 25 pack-year smoking history.  He says that his mother and brother are recovering alcoholics.  Physical examination is unremarkable.  Routine laboratory blood tests are obtained.
Which of the following is the best next step in assessing this patient for unhealthy alcohol use?

Quizplus · Accepted Answer

11ec193a_98b0_6f9f_853d_f5052eb70313_MD0002_00 Unhealthy alcohol use (that can result in medical consequences and/or features of DSM-5 substance use disorder) is prevalent and under-recognized in primary care. This patient admits to "social" drinking, but this is a nonspecific term that could indicate anything from infrequent consumption of small amounts of alcohol to heavy drinking. All adult primary care patients should be screened for unhealthy alcohol use. Studies support the use of either a single-item screening test or the AUDIT-C (Alcohol Use Disorders Identification Test-C) screen. A single-item screen (uses the lower threshold of 5 drinks) efficiently identifies unhealthy use (any positive response is considered abnormal). The AUDIT-C contains 3 items from the AUDIT, which is a widely validated but more time-intensive test (appropriate for settings with additional staff and time). Both the AUDIT-C and AUDIT require scoring and have specific cutoffs that indicate unhealthy drinking, with higher scores suggestive of alcohol dependence. A brief counseling intervention is recommended for patients identified as having unhealthy alcohol use. This consists of a nonjudgmental, empathic discussion about the patient's personal risks of continued alcohol use with the goal of decreasing consumption or achieving abstinence. (Choice A) The 4-item CAGE screening questionnaire is no longer recommended as an initial screen because it emphasizes complications of heavy use and fails to identify the full spectrum of unhealthy use. It can be used to quickly detect a more severe alcohol problem in a patient who tests positive on single-item screening. (Choice C) Abnormal liver function tests and mean corpuscular volume level can support the diagnosis of alcohol use disorder, but they are nonspecific and costly. (Choice D) A quickly and efficiently administered screen would be the best next step in this case. A full substance use history to further assess the patient's use of alcohol and other drugs should be performed if the patient tests positive on the single-item or AUDIT-C screen or reports using illicit drugs. (Choice E) Urine toxicology can detect recent alcohol use but does not give information about pattern or amount of use, making the single-item screening more useful. Educational objective: A single-item screening that asks patients how many times in the past year they have had 5 (4 for women) or more drinks in a day is an effective tool to identify unhealthy alcohol use prior to asking further questions. The AUDIT-C is another widely validated instrument for assessment of alcohol use. __________ References: The ability of single screening questions for unhealthy alcohol and other drug use to identify substance dependence in primary care. (http://www.ncbi.nlm.nih.gov/pubmed/24411807) Primary care validation of a single-question alcohol screening test. (http://www.ncbi.nlm.nih.gov/pubmed/19247718)

A 44-Year-Old Man Comes to the Office for an Annual