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January 2019

Unhealthy Alcohol Use in Primary Care—The Elephant in the Examination Room

Author Affiliations
  • 1Yale School of Medicine, New Haven, Connecticut
  • 2Yale School of Public Health, New Haven, Connecticut
JAMA Intern Med. 2019;179(1):9-10. doi:10.1001/jamainternmed.2018.6125
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    3 Comments for this article
    Need to always ask about alcohol use
    Phillip Shepard, MD | Retired Family Physician
    During years of practice hardly a day went by when I didn't see a patient with an alcohol related problem or a family member affected by alcoholism in the home. Once I delivered a small baby with the abnormal physical features. He had Fetal Alcohol Syndrome. When questioned the mother gave a history of significant alcohol use during pregnancy. Many women are "hidden alcoholics". I worked in the Pathology Department as a student. The pathologist diagnosed a case of alcoholic liver disease as cause of death at autopsy of a woman who denied drinking. Only after our post mortem diagnosis did the family members admit that "Mom drank a lot". Drinking patterns vary. Some problem drinkers can go for months without drinking but then go on a "bender" and end up losing their job or dying in an auto accident. Some young males have the hereditary form of "the violent alcoholic": rapid addiction, blackouts, violent behavior as described by Jellinek. The middle-aged woman with rash on her legs and abnormal liver functions due to a diet heavy on wine, low on vitamins. In addition to seeking out the correct diagnosis the long-term management always looms over us. All areas of medicine are affected and all doctors need to adopt the USPSTF recommendations.
    A single question about drinking that is empirically validated as a screening
    Reid Hester, Research Division | CheckUp & Choices
    How many times in the last 12 months have you had 5 or more (4 or more for women) drinks on one occasion. An answer of 1 or more is a positive screen. This screening question can easily be embedded into a lifestyle screening that also asks about diet, exercise, smoking, sleeping, etc.

    Physicians, PAs or Medical Assistants can then give brief feedback and recommend the patient get a more detailed assessment like our alcohol CheckUp on www.checkupandchoices.com.
    CONFLICT OF INTEREST: I am a co-founder of CheckUp & Choices that disseminates digital tools for people with alcohol and drug misuse.
    Undiagnosed alcohol withdrawal consequences
    Patricia Murphy, MSN, ANP | Crestview Recovery
    Screening is great but the missing conversation is the one about what happens to these heavy drinkers when they are unable to drink for 2-3 days. If the CDC ever looked into the incidence of stroke, MI and seizures post op and during acute hospitalizations, they would see the real dangers. I believe based on my 10 plus years in addiction medicine, this could be prevented with a more serious discussion with patients about the effect of stopping their use abruptly. This includes stopping for "the month cleanse, new years resolution" etc. We all know what holiday heart syndrome is, and have the responsibility to inform our patients that they should stop drinking, but taper or get help with detoxification. We always tell or clients when entering treatment not to stop until they get to detox.