A 44-year-old man comes to the office for an annual physical examination. The patient's history includes hypertension and gastroesophageal reflux disease, for which he takes enalapril and ranitidine. The patient also has a history of depression in his early 20s that responded well to sertraline. He currently has no depressive symptoms. The patient works as a real estate agent and has been employed at the same company for many years. He is married with two children ages 17 and 15. He says, "Things are okay at work and at home, but I'm a little worried about paying for college." The patient has a 15-pack-year smoking history and drinks socially but does not use illicit drugs. There is a family history of hypertension and coronary artery disease, and the patient describes both his father and brother as recovering alcoholics. Blood pressure is 130/80 mm Hg, pulse is 72/min, and respirations are 16/min. Examination shows no abnormalities. Which of the following questions is most appropriate to screen this patient for unhealthy alcohol use?

Question

A 44-year-old man comes to the office for an annual physical examination.  The patient's history includes hypertension and gastroesophageal reflux disease, for which he takes enalapril and ranitidine.  The patient also has a history of depression in his early 20s that responded well to sertraline.  He currently has no depressive symptoms.  The patient works as a real estate agent and has been employed at the same company for many years.  He is married with two children ages 17 and 15.  He says, "Things are okay at work and at home, but I'm a little worried about paying for college."  The patient has a 15-pack-year smoking history and drinks socially but does not use illicit drugs.  There is a family history of hypertension and coronary artery disease, and the patient describes both his father and brother as recovering alcoholics.  Blood pressure is 130/80 mm Hg, pulse is 72/min, and respirations are 16/min.  Examination shows no abnormalities.  Which of the following questions is most appropriate to screen this patient for unhealthy alcohol use?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c19f_5da9_8f63_a370fd119a76_MD0005_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 to heavy drinking. All adult primary care patients should be screened for unhealthy alcohol use. Studies support the use of single-item screening. The single-item screening question, "How many times in the past year have you had 5 (4 for women) or more drinks in a day?" efficiently identifies unhealthy use. A response >1 is considered positive. Patients who are positive on the single-item screen should subsequently be assessed further for symptoms of DSM-5 substance use disorder (eg, evidence of withdrawal, tolerance, craving, functional impairment). Other screening tests to identify unhealthy use in primary care include the 10-item Alcohol Use Disorders Identification Test (AUDIT) and the 3-item AUDIT-C, which are widely validated but more time-intensive (appropriate for settings with additional staff and time). Both the AUDIT-C and AUDIT require scoring, with specific cutoffs screening positive for unhealthy drinking and 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. (Choices A, C, and D) Questions from the 4-item CAGE questionnaire are no longer recommended as an initial screen because they fail to identify the full spectrum of unhealthy use (ie, patients with a mild alcohol use disorder may respond negatively to all CAGE questions). CAGE questions can be used to quickly detect more severe alcohol problems indicative of a moderate to severe DSM-5 alcohol use disorder. For example, a positive response to drinking in the morning to steady one's nerves suggests the presence of alcohol withdrawal. (Choice B) Although psychiatric conditions are commonly comorbid with alcohol use disorders, and this patient has a previous diagnosis of depression, the first step is to identify the extent of his alcohol use. Questions to assess the relationship of his alcohol use to depression would be indicated if the patient were currently having depressive symptoms. Educational objective: Asking how many times in the past year a patient has had 5 (4 for women) or more drinks in a day is an effective screening tool to identify unhealthy alcohol use. The Alcohol Use Disorders Identification Test-C is also a widely validated instrument that can be used for assessment. References: Validation of self-administered single-item screening questions (SISQs) for unhealthy alcohol and drug use in primary care patients. (http://www.ncbi.nlm.nih.gov/pubmed/25986138) 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