This 'Will Change My Practice' on Alcohol Use Disorder

Matthew F. Watto, MD; Paul N. Williams, MD; Stuart K. Brigham, MD


March 09, 2020

This transcript has been edited for clarity.

Matthew F. Watto, MD: Welcome back to the Curbsiders. I am Matt Watto. Stuart's here, and so is the great Dr Paul Williams.

Stuart K. Brigham, MD: Tonight we talked with Dr Marlene Martin from the University of California at San Francisco about alcohol use disorder (AUD). We are each going to talk about our favorite practice-changing pearl from that conversation, and to start off, we have Paul's pearl.

CAGE Is Dead

Paul N. Williams, MD: For me, the thing that was most useful and surprising is that CAGE is dead. We all heard about the CAGE questionnaire. We learned about it in medical school; my residents still talk to me about it. I still teach it, and it turns out that it's no longer recommended as a first-line screening tool for AUD.

Brigham: I don't think it ever was.

Williams: It was just kind of out there; "CAGE" is catchy.

Watto: Someone taught it to me.

Williams: Unfortunately it's not terrifically useful or well validated. There are better tools. One that we talked about a little is the single-item screening question, which is not diagnostic but it can tell you whether you need to explore things a bit further.

You ask the patient, "In the past year, how many times have you had four or more drinks in a day (for women) or five or more drinks in a day (for men)? If their answer is yes (once or more), that's an invitation to explore their alcohol use.

Whether that's going to the DSM criteria or doing the full AUDIT questionnaire, it's a prompt to explore a little further. I thought that was a really useful takeaway and it will change my practice for sure.

Abstinence Is Not the Only Goal

Watto: The thing that I took away most is the fact that abstinence is not the only thing we are shooting for when treating AUD. Now, the words "harm reduction" are popular. This is a form of harm reduction. Anything we can do to get the patient to stop drinking as heavily or as often, so they can have a better social life and fewer problems in other areas of their life. And less drinking overall is better for their health.

Abstinence is not the only path. If they can do that, that's great, but life is messy and it's just not always realistic. This was a huge revelation to me.

Try Naltrexone

Brigham: My favorite part was—straight-up—the medications, specifically the use of naltrexone for AUD. During the entire interview I was a little quiet, because there was a lot of introspection about whether I've been doing a lot of things wrong when it comes to treating AUD. I realized that I've been treating the alcohol withdrawal symptoms but not the underlying AUD. I felt like I had failed my patients and my residents.

Soon after recording that episode, we used it in the outpatient teaching room and on the inpatient wards to teach how to treat AUD, and I realized that my armamentarium was—really nothing.

Watto: Yes, you can start naltrexone as the patient is leaving the hospital. It's a pretty safe medication with not a lot of side effects. We should be using it more. The number-needed-to-treat is about 12 to prevent a return to heavy drinking, and about 20 to stop drinking altogether. Insanely good numbers there.

If this sounds great to you and you want to hear the rest of our conversation with Dr Marlene Martin, where we get into the details about prescribing the different medications, such as acamprosate and some of the off-label medications, then click on the episode link below. Don't forget to subscribe to our show and to our mailing list, where you can get all of our great content on a weekly basis.

Click to hear the full episode of Alcohol Use Disorder Treatment with Dr. Marlene Martin or find the Curbsiders podcasts on iTunes.

The Curbsiders is a national network of students, residents, and clinician educators from across the country, representing 15 different institutions. They "curbside" experts to deconstruct various topics in the world of medicine to provide listeners with clinical pearls, practice-changing knowledge, and bad puns. Learn more about their contributors and follow them on Twitter.

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