Definitions of Heavy Drinking

Men: More than 4 drinks per day or 14 drinks per week

Women: More than 3 drinks per day or 7 drinks per week

Standard drink equivalents:

12 oz beer (5% alcohol)

5 oz wine (12% alcohol)

1.5 oz distilled spirits (40% alcohol)

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Alcohol Use Disorder (DSM-5)

Definition:
A problematic pattern of alcohol use leading to clinically significant impairment or distress, occurring within a 12-month period.

Diagnostic Criteria (need at least 2 of 11 in 12 months):

-Alcohol is often taken in larger amounts or over a longer period than intended.

-Persistent desire or unsuccessful efforts to cut down or control alcohol use.

-Great deal of time spent in activities necessary to obtain, use, or recover from alcohol.

-Craving or strong desire to use alcohol.

-Recurrent alcohol use resulting in failure to fulfill major role obligations.

-Continued alcohol use despite social or interpersonal problems caused by alcohol.

-Important activities given up or reduced because of alcohol use.

-Recurrent alcohol use in physically hazardous situations.

-Continued use despite physical or psychological problems caused or worsened by alcohol.

-Tolerance, as defined by:

Need for markedly increased amounts to achieve intoxication, or

Markedly diminished effect with continued use of same amount.

-Withdrawal, as manifested by:

Characteristic withdrawal syndrome, or

Alcohol (or closely related substance) taken to relieve or avoid withdrawal symptoms.

Severity:

Mild: 2–3 criteria

Moderate: 4–5 criteria

Severe: 6 or more criteria

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1. Stages of Change

Explore the individual’s stage of change (Precontemplation, Contemplation, Preparation, Action, Maintenance).

Utilize OARS (Open questions, Affirmations, Reflective listening, Summarizing) techniques.

Escalate to the clinical team if the individual is in the contemplative stage (or later).

2. Understanding Motivation

Identify the main leverage for change: often it is a relationship they want to improve.

Recognize co-morbid mental health conditions (e.g., depression, anxiety).

If significant co-morbidities exist, we may want to begin treatment of these as far as 2–3 months prior to the planned quit date.

3. Medical Support

Barriers toward quit assist often exist in primary care, and specialist wait times (e.g., substance abuse services) are often long.

HōttoCare can prescribe:

-Naltrexone (oral) - Typically 50mg daily. Data to support maintenance of abstinence, also safe to continue if relapse. Cannot be concurrently taking opioids.

-SSRIs

-Gabapentin - Typically titrated to 900mg three times daily, though dose may be individualized

-Acamprosate - Usually started after withdrawal phase has ended, but once established safe to continue if relapse

Note that every case is individualized and certain patients may not be candidates for all of these medications. For example, persons taking opioids are usually not candidates for naltrexone.

HōttoCare cannot prescribe:

-Benzodiazepines (Xanax, Ativan, Klonopin, Librium, etc.)

-Other controlled substances, such as opioids

-Drugs used for acute detox. We are able to do quit assist, not detox.

4. Outpatient Pathways

Most patients follow an outpatient pathway, such as:

Alcoholics Anonymous (AA) or similar support groups. Online directory called “meeting guide” both virtual and in person. Free app, search for “Meeting Guide” on iphone/android/web that shows AA by zip code, virtual or in person.

Use of a sponsor for accountability.

SMART recovery - validated CBT-based program that is more secular and science-based than AA. 

5. Special Considerations

Be aware of potential complications in dementia during the process of reducing alcohol use.

Monitor behavioral changes that may occur during this time.