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- 3. CONN’S CURRENT THERAPY 2015 EDWARD T. BOPE, MD Chief of Primary Care Columbus VA Assistant Dean for VA Medical Students and Clinical Professor, Family Medicine, The Ohio State University Columbus, Ohio RICK D. KELLERMAN, MD Professor and Chair Department of Family and Community Medicine University of Kansas School of Medicine–Wichita Wichita, Kansas Latest Approved Methods of Treatment for the Practicing Physician CONN TERAPIA ATUAL CONN’S CURRENT THERAPY 2015 EDWARD T. BOPE, MD Chief of Primary Care Columbus VA Assistant Dean for VA Medical Students and Clinical Professor, Family Medicine, The Ohio State University Columbus, Ohio RICK D. KELLERMAN, MD Professor and Chair Department of Family and Community Medicine University of Kansas School of Medicine–Wichita Wichita, Kansas Latest Approved Methods of Treatment for the Practicing Physician CONN’S CURRENT THERAPY 2015 EDWARD T. BOPE, MD Chief of Primary Care Columbus VA Assistant Dean for VA Medical Students and Clinical Professor, Family Medicine, The Ohio State University Columbus, Ohio RICK D. KELLERMAN, MD Professor and Chair Department of Family and Community Medicine University of Kansas School of Medicine–Wichita Wichita, Kansas Latest Approved Methods of Treatment for the Practicing PhysicianÚltimos Métodos Aprovados de Tratamento para o Clínico CONN’S CURRENT THERAPY 2015 EDWARD T. BOPE, MD Chief of Primary Care Columbus VA Assistant Dean for VA Medical Students and Clinical Professor, Family Medicine, The Ohio State University Columbus, Ohio RICK D. KELLERMAN, MD Professor and Chair Department of Family and Community Medicine University of Kansas School of Medicine–Wichita Wichita, Kansas Latest Approved Methods of Treatment for the Practicing Physician
- 4. 1600 John F. Kennedy Blvd. Ste 1800 Philadelphia, PA 19103-2899 Conn’s Current Therapy 2015 ISBN: 978-1-4557-0297-8 Copyright © 2015, 2014, 2013, 2012, 2011, 2010, 2009 by Saunders, an imprint of Elsevier, Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Permissions may be sought directly from Elsevier’s Health Sciences Rights Department in Philadelphia, PA, USA: phone: (+1) 215 239 3804, fax: (+1) 215 239 3805, e-mail: healthpermissions@elsevier.com. You may also complete your request on-line via the Elsevier homepage (http://www.elsevier.com), by selecting ‘Customer Support’ and then ‘Obtaining Permissions’. Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. International Standard Book Number: 978-1-4557-0297-8 Acquisitions Editor: Suzanne Toppy Developmental Editor: Joan Ryan Publishing Services Manager: Anne Altepeter Project Manager: Ted Rodgers Designer: Steven Stave and Brian Salisbury Printed in the United States of America Last digit is the print number: 9 8 7 6 5 4 3 2 1 Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. International Standard Book Number: 978-1-4557-0297-8 Acquisitions Editor: Suzanne Toppy Developmental Editor: Joan Ryan Publishing Services Manager: Anne Altepeter Project Manager: Ted Rodgers Designer: Steven Stave and Brian Salisbury Printed in the United States of America Last digit is the print number: 9 8 7 6 5 4 3 2 1 1600 John F. Kennedy Blvd. Ste 1800 Philadelphia, PA 19103-2899 Conn’s Current Therapy 2015 ISBN: 978-1-4557-0297-8 Copyright © 2015, 2014, 2013, 2012, 2011, 2010, 2009 by Saunders, an imprint of Elsevier, Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Permissions may be sought directly from Elsevier’s Health Sciences Rights Department in Philadelphia, PA, USA: phone: (+1) 215 239 3804, fax: (+1) 215 239 3805, e-mail: healthpermissions@elsevier.com. You may also complete your request on-line via the Elsevier homepage (http://www.elsevier.com), by selecting ‘Customer Support’ and then ‘Obtaining Permissions’. Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. International Standard Book Number: 978-1-4557-0297-8 Acquisitions Editor: Suzanne Toppy Developmental Editor: Joan Ryan Publishing Services Manager: Anne Altepeter Project Manager: Ted Rodgers Designer: Steven Stave and Brian Salisbury Printed in the United States of America Last digit is the print number: 9 8 7 6 5 4 3 2 1 1600 John F. Kennedy Blvd. Ste 1800 Philadelphia, PA 19103-2899 Conn’s Current Therapy 2015 ISBN: 978-1-4557-0297-8 Copyright © 2015, 2014, 2013, 2012, 2011, 2010, 2009 by Saunders, an imprint of Elsevier, Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Permissions may be sought directly from Elsevier’s Health Sciences Rights Department in Philadelphia, PA, USA: phone: (+1) 215 239 3804, fax: (+1) 215 239 3805, e-mail: healthpermissions@elsevier.com. You may also complete your request on-line via the Elsevier homepage (http://www.elsevier.com), by selecting ‘Customer Support’ and then ‘Obtaining Permissions’. Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. International Standard Book Number: 978-1-4557-0297-8 Acquisitions Editor: Suzanne Toppy Developmental Editor: Joan Ryan Publishing Services Manager: Anne Altepeter Project Manager: Ted Rodgers Designer: Steven Stave and Brian Salisbury Printed in the United States of America Last digit is the print number: 9 8 7 6 5 4 3 2 1 © 2015 Elsevier Editora Ltda. RJ • Tel. 21 3970-9300 Fax. 21 2507-1991 SP • Tel. 11 5105-8555 Fax. 11 5505-8908 Website: www.elsevier.com.br Diretor: Claudio Della Nina • Gerente Nacional: Carlos Eduardo Figueiredo • Gerente Comercial: Ana Paula Vicente • Coordenadora de Conteúdo: Solange Davino • Coordenadora Editorial: Rosemeire A. Modolo • Editora de Produção: Gláucia A. Silva • Tradutor: Fernando Nascimento • Revisor Técnico: Dr. Rodrigo Rizek Schultz - CRM-SP: 80.201 • Capa e Diagramação: O Mercador Todos os direitos reservados e protegidos pela lei 9.610 de 19/02/98. Nenhuma parte desta publicação poderá ser reproduzida, sem autorização prévia, por escrito, da Elsevier Editora Ltda., sejam quais forem os meios empregados, eletrônicos, mecânicos, fotográficos, gravação ou quaisquer outros. A Elsevier não assume nenhuma responsabilidade por qualquer injúria e/ou danos a pessoas ou bens como questões de responsabilidade civil do fabricante do produto, de negligência ou de outros motivos, ou por qualquer uso ou exploração de métodos, produtos, instruções ou ideias contidas no material incluso. Devido ao rápido avanço no campo das ciências médicas, em especial, uma verificação independente dos diagnósticos e dosagens de drogas deve ser realizada. Embora todo o material de publicidade deva estar em conformidade com os padrões éticos (médicos), a inclusão nesta publicação não constitui uma garantia ou endosso da qualidade ou valor de tal produto ou das alegações feitas pelo seu fabricante. O conteúdo desta publicação reflete exclusivamente a opinião dos autores e não necessariamente a opinião da Elsevier Editora Ltda. ou do laboratório União Química Farmacêutica Nacional S/A. Material de distribuição exclusiva à classe médica. Este material foi traduzido pela Elsevier Editora Ltda. e distribuído com o apoio do laboratório União Química Farmacêutica Nacional S/A. EM 8971 Diretor: Claudio Della Nina Gerente Nacional: Carlos Eduardo Figueiredo Gerente Comercial: Ana Bendersky Coordenadoras de Conteúdo: Luana Ludwig e Solange Davino Coordenadora Editorial: Rosemeire A. Módolo Editora de Produção: Gláucia A. B. Silva Assistente Editorial: Monika Uccella Capa e Diagramação: Marcelo S. Brandão Material de distribuição exclusiva à classe médica. Esta publicação foi distribuída com o apoio do Abbott Laboratórios do Brasil Ltda. Todos os direitos reservados e protegidos pela lei 9.610 de 19/02/98. Nenhuma parte desta publicação poderá ser reproduzida, sem autorização prévia, por escrito, da Elsevier Editora Ltda., sejam quais forem os meios empregados, eletrônicos, mecânicos, fotográficos, gravação ou quaisquer outros. A Elsevier não assume nenhuma responsabilidade por qualquer injúria e/ou danos a pessoas ou bens como questões de responsabilidade civil do fabricante do produto, de negligência ou de outros motivos, ou por qualquer uso ou exploração de métodos, produtos, instruções ou ideias contidas no material incluso. Devido ao rápido avanço no © 2014 Elsevier Editora Ltda. RJ • Tel. 21 3970-9300 Fax. 21 2507-1991 SP • Tel. 11 5105-8555 Fax. 11 5505-8908 Website: www.elsevier.com.br 1600 John F. Kennedy Blvd. Ste 1800 Philadelphia, PA 19103-2899 Conn’s Current Therapy 2015 ISBN: 978-1-4557-0297-8 Copyright © 2015, 2014, 2013, 2012, 2011, 2010, 2009 by Saunders, an imprint of Elsevier, Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Permissions may be sought directly from Elsevier’s Health Sciences Rights Department in Philadelphia, PA, USA: phone: (+1) 215 239 3804, fax: (+1) 215 239 3805, e-mail: healthpermissions@elsevier.com. You may also complete your request on-line via the Elsevier homepage (http://www.elsevier.com), by selecting ‘Customer Support’ and then ‘Obtaining Permissions’. Notices Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. International Standard Book Number: 978-1-4557-0297-8 Acquisitions Editor: Suzanne Toppy Developmental Editor: Joan Ryan Publishing Services Manager: Anne Altepeter Project Manager: Ted Rodgers Designer: Steven Stave and Brian Salisbury Printed in the United States of America Last digit is the print number: 9 8 7 6 5 4 3 2 1
- 5. Esta é a 67ª edição do Conn – Terapia Atual, assinalando os muitos anos de oferecimento de diagnósticos e planos terapêuticos atualiza- dos, com o objetivo de ajudar o clínico atarefado. Conn – Terapia Atual é uma fonte de informações absolutamente bem-sucedida, tanto offline em seu computador como online, e tem como base o modo como os especialistas na área diagnosticam e tratam os estágios de doença. Os especialistas revelam seus próprios métodos e procedimentos clínicos fundamentados em evidências referenciadas. Muitos médicos, em especial os de família e clínicos gerais, usam este livro ou os capítulos e tabelas online para acessar facilmente infor- mações práticas sobre os problemas do dia a dia na assistência a seus pacientes; para uma rápida revisão dos avanços na medicina clínica; e para o estudo voltado a exames de certificação. Especialistas em cirur- gia, por exemplo, cirurgiões gerais, cirurgiões ortopédicos e oftalmo- logistas, também utilizam este livro como uma referência abrangente para a obtenção de informações básicas atualizadas sobre ampla va- riedade de temas médicos. Os profissionais da área da saúde mental sabem que é muito comum uma doença física se tornar um problema complicador, assim uma consulta ao Conn – Terapia Atual os ajuda a relembrar os seus conhecimentos sobre doenças comuns e também so- bre patologias raras. Este livro conta com mais opções online, tais como o acesso ele- trônico a edições anteriores, e uma efetiva ferramenta de busca por palavra-chave.A edição deste ano,mais uma vez,apresenta tópicos no- vos, um índice revisado, tabelas de acesso rápido, figuras que destacam informações importantes e quadros de Diagnóstico Atual e de Trata- mento Atual para referência rápida. Como a cada ano, a obra conta com novos autores, e a conexão com as edições anteriores possibilita ao leitor o acesso a diferentes abordagens e opiniões. Embora sejam muitas as alterações a cada edição, o que não muda é a fusão entre a medicina fundamentada em evidências e as melhores práticas de especialistas nas diferentes áreas. Cada autor explica o seu método, o que garante a cada capítulo o caráter prático. Os autores estão empenhados em fornecer informações atualizadas. Na verdade, cada capítulo é uma “consulta com o especialista” ao alcance imediato. Prefácio Miriam Chan, PharmD, revisou todos os manuscritos que com- puseram este livro. Dra. Chan conferiu cada dose e formulação das medicações para ter certeza de que são precisas e seguras. Como nas edições anteriores, este livro usa nomes genéricos e nomes comerciais para que se tornem familiares para o clínico. Foram adicionadas notas de rodapé em todos os casos em que a medicação ainda não foi apro- vada para determinada indicação pela Food and Drug Administration (FDA), agência estadunidense de regulação; e, da mesma forma, estão informadas em notas de rodapé as doses que estão fora da faixa habi- tual aprovada pela FDA. Agradecemos sinceramente os autores por seu cuidado e precisão. Muitos se tornaram amigos,muitas vezes nas trocas de e-mails durante o processo de edição.Levando em conta que cada capítulo foi integral- mente lido, reconhecemos o esforço considerável desses profissionais para manter elevada a qualidade deste livro. Em muitas ocasiões, fi- camos admirados em perceber como um convite para escrever para o Conn – Terapia Atual é recebido com uma resposta nitidamente orgu- lhosa e positiva. Autores internacionais são convidados a discorrer, por escrito, sobre transtornos que podem não ser comuns em determinado país. Esses profissionais acrescentam considerável experiência ao livro. Selecionamos novos autores a cada ano, com base nas recomendações dos autores atuais ou no destaque pessoal na literatura médica. A equipe editorial da Elsevier,particularmente a Estrategista Sênior de Conteúdo Suzanne Toppy,a Especialista Sênior de Desenvolvimento de Conteúdo Joan Ryan e o Gerente de Projetos Ted Rodgers, é sim- plesmente o que há de melhor na produção de livros. E reconhecemos aqui sua importância no sucesso do Conn –Terapia Atual.A esses profis- sionais, os nossos sinceros agradecimentos pela ajuda com este projeto. Por fim,agradecemos aos nossos amigos e familiares pela paciência durante o período em que devotávamos nosso tempo para fazer do Conn – Terapia Atual um livro de fácil consulta e clinicamente ines- timável. Edward T. Bope, MD Rick D. Kellerman, MD
- 6. 2 ALCOOLISMO Método de Richard N. Rosenthal, MD DIAGNÓSTICO ATUAL Colocar-se em risco ou em perigo pelo consumo de bebida (necessário avaliação mais aprofundada) • Homens que bebem mais de quatro doses por dia ou 14 doses por semana. • Mulheres e pessoas com mais de 65 anos que bebem mais de três doses por dia ou mais de sete doses por semana. • Beber quando apresenta qualquer problema médico para o qual haja contraindicação de álcool. Abuso de álcool • Deixar, com frequência, de cumprir as obrigações em casa, na escola ou no trabalho. • Maior risco de danos físicos. • Problemas jurídicos ou interpessoais em qualquer ano. Dependência de álcool (três ou mais episódios em qualquer ano considerado) • Não conseguir diminuir ou parar. • Reduzir o tempo gasto em outras atividades habituais. • Beber, apesar das consequências físicas ou psicológicas. • Beber mais do que o pretendido. • Apresentar tolerância física. • Preocupar-se com a bebida. • Apresentar episódios de abstinência. TERAPIA ATUAL Todos os pacientes em risco • Avalie. Faça a triagem do paciente com instrumentos de roti- na e compute o número médio de doses por semana. • Aconselhe. Opine, demonstre preocupação, apresente acha- dos e conclusões e recomende mudanças comportamentais específicas. • Estabeleça um acordo. Predisponha o paciente a realizar mu- dança, incentive a reflexão, ouça com empatia, incentive os cuidados do paciente, evite discutir/argumentar, expresse otimismo, defina uma meta específica para a diminuição ou abstinência. • Ajude. Formule um plano de implementação concreto, inclu- sive que evite situações de alto risco, registrando o consumo de álcool e envolvendo a família e a comunidade no apoio para a concretização dos objetivos do paciente. • Organize. Estabeleça visitas de acompanhamento e encami- nhe os pacientes que atendam a critérios de dependência para tratamento com um especialista. Adicionalmente, para pacientes dependentes de álcool • Ofereça ou crie condições para desintoxicação, se for possível. • Ofereça ou crie condições para tratamento especializado do alcoolismo e/ou grupos de ajuda mútua. • Ofereça farmacoterapia para ajudar na manutenção da absti- nência: naltrexona, acamprosato ou dissulfiram. • Ofereça apoio para o tratamento farmacológico durante as consultas de acompanhamento. Epidemiologia Os transtornos por uso de álcool se situam entre os transtornos men- tais mais prevalentes na população, ocorrendo em frequências que ri- valizam com os transtornos de humor e ansiedade. Em qualquer ano considerado, quase 8,5% da população estadunidense com mais de 18 anos estará atendendo aos critérios para um transtorno formal por uso de álcool (abuso ou dependência de álcool), e quase 4% atendem aos critérios para dependência do álcool. Sequelas econômicas e clínicas É importante que os transtornos relacionados ao uso de álcool se- jam identificados e tratados, por diversos motivos. O primeiro deles é o impacto negativo direto decorrente da intensa exposição crôni- ca ao álcool no funcionamento cognitivo, físico, social e profissional. O segundo motivo consiste nas sequelas clínicas a longo prazo, exaus- tivamente descritas, decorrentes da dependência de álcool, tais como: cirrose hepática, pancreatite e demência. O consumo crônico e abusivo de bebidas alcoólicas, mesmo na ausência de um diagnóstico formal de dependência de álcool, está associado a um maior risco de diabe- tes melito, hipertensão, hemorragia gastrointestinal, acidente vascular cerebral hemorrágico e várias formas de carcinoma. A terceira razão para a identificação e tratamento é o impacto público dos transtornos por uso de álcool, que abrange as lesões traumáticas associadas causa- das por acidentes automobilísticos e acidentes de trabalho, criminali- dade relacionada ao uso de álcool, e seus custos econômicos correlatos. A cada ano, na economia dos Estados Unidos, mais de 180 bilhões de dólares são desperdiçados como resultado de crimes relacionados ao uso do álcool; lesões; gastos com cuidados da saúde; e perda de produ- tividade no local de trabalho. Triagem Justificativa da triagem A triagem para os problemas do álcool dispõe os pacientes em um continuum que vai desde a abstinência até a dependência, e é uma ma- neira altamente eficiente para identificar pacientes que estejam em risco agudo para os efeitos do abuso e da dependência de álcool, bem 15 Transtornos psiquiátricos
- 7. questions (Box 3) during the clinical examination. A positive answer to any of these questions also indicates the need for further evaluation of alcohol use. Two or more CAGE questions answered affirmatively identifies a patient at high risk for alcohol depen- dence. Because the CAGE screens for consequences, it is not as sen- sitive for risky drinking. There are other question sets that are more sensitive than the CAGE in specific demographic subsets, and these can also be easily asked during a routine history. The five-item TWEAK questionnaire (Table 2) may be a more optimal screening questionnaire for iden- tifying women (including pregnant women) with risky drinking or alcohol use disorders in racially mixed populations. The CRAFFT (Box 4) is a 6-item question set that has high sensitivity in screening adolescents for alcohol and other substance-abuse problems. For patients older than 65 years, the Short Michigan Alcoholism Screen- ing Test—Geriatric (S-MAST-G) (Box 5) is useful in identifying those at risk for alcohol problems, because these patients might not need the same volumes of alcohol intake as others to develop alcohol-related problems. To complete the initial screening, one should compute the average number of drinks per week by multiply- ing the days per week on average that the patient drinks by the num- ber of drinks consumed on a typical drinking day. Laboratory testing for elevations of alanine aminotransferase (ALT), aspartate aminotransferase (AST), γ-glutamyltransferase (GGT), or carbohydrate-deficient transferrin (CDT) have no incremental sensitivity over those of validated screening instru- ments, and they may be better suited to monitoring patients already in treatment for alcohol use disorders. The patient must still be asked about quantity and frequency of alcohol use. How- ever, laboratory testing can provide indicators of covert heavy drinking (e.g., elevated GGT and CDT) when the patient does not reveal the extent of alcohol intake. CDT, which is perturbed less than other indices by nonalcoholic liver disease, may be a more specific and sensitive indicator of heavy drinking. Diagnosis Screening can identify those who are at risk for the sequelae of risky or hazardous drinking and who might benefit from a brief interven- tion conducted in the primary care office, but only a diagnostic evaluation can confirm the clinician’s suspicion that the patient’s use of alcohol meets syndromal criteria and warrants specific med- ical and psychosocial treatment beyond the brief intervention. According to Diagnostic and Statistical Manual of Mental Disor- ders, fifth edition (DSM-5) criteria (Table 3), the patient has a diagnosis of an alcohol use disorder if he or she has two or more of the following criteria over a 12-month period related to alcohol use: physical tolerance, symptoms of withdrawal, repeatedly drink- ing more than intended, unsuccessful reduction or quit attempts, repeated episodes of failure to fulfill obligations at home, school or work, episodes of increased risk of physical harm, recurrent problems with significant others, increased time drinking or recov- ering from drinking, reduced time in other pleasurable or important activities, and continued drinking despite physical or psychological problems. With DSM 5, the term alcohol dependence describes the symptoms of physical tolerance and withdrawal, not the use disor- der syndrome. Severity is defined as: Mild 2-3 symptoms; Moderate 4-5 symptoms; and, Severe 6 or more symptoms. Box 3 CAGE Questionnaire • Have you ever felt that you should Cut down on your drinking? • Have people Annoyed you by criticizing your drinking? • Have you ever felt bad or Guilty about your drinking? • Have you ever taken a drink (Eye opener) first thing in the morning to steady your nerves or to get rid of a hangover? One yes response indicates need for further assessment. Two yes responses indicate risk of an alcohol use disorder. Box 4 CRAFFT Questionnaire • Have you ever ridden in a Car driven by someone (including yourself) who was high or had been using alcohol or drugs? • Do you ever use alcohol or drugs to Relax, feel better about yourself, or fit in? • Do you ever use alcohol or drugs while you are Alone? • Do you ever Forget things you did while using alcohol or drugs? • Do your Family or Friends ever tell you that you should cut down on your drinking or drug use? • Have you ever gotten into Trouble while you were using alco- hol or drugs? One yes response indicates need for further assessment. Two yes responses indicate risk of alcohol use disorder. Box 5 S-MAST-G Questionnaire • When talking with others, do you ever underestimate how much you actually drink? • After a few drinks, have you sometimes not eaten or been able to skip meals because you didn’t feel hungry? • Does having a few drinks help decrease your shakiness or tremors? • Does alcohol sometimes make it hard for you to remember parts of the day or night? • Do you usually take a drink to relax or calm your nerves? • Do you drink to take your mind off your problems? • Have you ever increased your drinking after experiencing a loss in your life? • Has a doctor or nurse ever said that he or she was worried or concerned about your drinking? • Have you ever made rules to manage your drinking? • When you feel lonely, does having a drink help? Two or more yes responses indicate a probable alcohol problem. Abbreviation: S-MAST-G ¼ Short Michigan Alcoholism Screening Test— Geriatric. TABLE 2 TWEAK Questionnaire FEATURE QUESTION ANSWER SCORE Tolerance How many drinks does it take before you begin to feel the first effects of alcohol? �3 2 Worry Have your friends or relatives worried or complained about your drinking in the past year? Yes 2 Eye-opener Do you sometimes take a drink in the morning when you first get up? Yes 1 Amnesia Are there times when you drink and afterward you can’t remember what you said or did? Yes 1 Kut Do you sometimes feel the need to cut down on your drinking? Yes 1 Scoring and interpretation: Two or more points indicate a possible alcohol problem. 965 alcohol, the simplest strategy is to ask about the number of heavy drinking days in the past year, where heavy drinking is defined as more than four drinks for men and more than three drinks for women in one day. If that threshold is reached, which corresponds to at-risk or hazardous drinking, then further evaluation of alcohol-related problems is indicated through the use of screening instruments. A standard drink is the same amount of alcohol con- tained in different volumes of alcoholic beverages (Box 2). The Alcohol Use Disorders Identification Test (AUDIT) (Table 1) is a 10-item screen developed by the World Health Orga- nization. Given its length, the AUDIT can be used as a self-report screener that patients can fill out in the waiting area before seeing the clinician. The minimum score is 0 and the maximum score is 40. A score of 8 or more for men or 4 or more for women, adoles- cents, and persons older than 65 years, like a positive endorsement of any heavy drinking days, indicates the need for further evalua- tion of alcohol use and an increased risk of an alcohol use disorder. For brevity, the AUDIT-C, a truncated version of the AUDIT con- sisting of the first three AUDIT questions focused on alcohol con- sumption, can be used as a part of a waiting-room health history form. A score of 6 or more for men or 4 or more for women on the AUDIT-C indicates a need for further evaluation. Asking about alcohol consumption during a routine clinical interview is best bundled with other questions about lifestyle and health, such as diet, smoking, and exercise. In addition to giv- ing the patient a pre-examination questionnaire to fill out such as the AUDIT, another screening strategy is to ask the CAGE Abstinence • No alcohol use Moderate Drinking • Men: No more than 2 standard drinks per drinking d • Women: No more than 1 standard drink per drinking d • Elderly persons (>65 y): No more than 1 standard drink per drinking d Risky or Hazardous Drinking • Men • More than 4 standard drinks per drinking d • More than 14 standard drinks per wk • Women • More than 3 standard drinks per drinking d • More than 7 standard drinks per wk • Elderly persons (>65 y): • More than 3 standard drinks per drinking d • More than 7 standard drinks per wk QUESTIONS SCORING 0 1 2 3 4 Consumption (AUDIT-C) How often do you have a drink containing alcohol? Never Monthly or less 2 to 4 times a month 2 to 3 times a week 4 or more times a week How many drinks containing alcohol do you have on a typical day when you are drinking? 1 or 2 3 or 4 5 or 6 7 to 9 10 or more How often do you have five or more drinks on one occasion? Never Less than monthly Monthly Weekly Daily or almost daily Personal Consequences How often during the last year have you found that you were not able to stop drinking once you had started? Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year have you failed to do what was normally expected of you because of drinking? Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year have you had a feeling of guilt or remorse after drinking? Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year have you been unable to remember what happened the night before because of your drinking? Never Less than monthly Monthly Weekly Daily or almost daily Social Consequences Have you or someone else been injured because of your drinking? No Yes, but not in the last year Yes, during the last year Has a relative, friend, doctor, or other health care worker been concerned about your drinking or suggested you cut down? No Yes, but not in the last year Yes, during the last year Scoring and Interpretation Add all scores to obtain a total: >8 points for men or >4 points for women indicates a high risk of alcohol use disorder. AUDIT-C (first three AUDIT questions): >6 points for men or >4 points for women indicates a need for further evaluation. Each equivalent drink contains about 14 g of pure alcohol: • 12 oz of beer or wine cooler • 8–9 oz of malt liquor • 5 oz of wine • 3–4 oz of fortified wine (e.g., port) • 1½ oz of 80-proof distilled spirits (or 1 jigger of liquor before mixing) 3 como aqueles que atualmente não se encaixam em diagnósticos for- mais relacionados com o álcool, mas que, a longo prazo, correm o risco de sofrer as consequências médicas e sociais da intensa exposição ao álcool (Quadro 1). A U.S. Preventative Services Task Force (USPSTF) verificou que a triagem poderia identificar com precisão os pacien- tes cujos níveis ou padrões de consumo de álcool não satisfazem os critérios para dependência de álcool, mas que os colocam em risco para o aumento da morbidade e da mortalidade. A USPSTF também encontrou boas evidências de que intervenções breves, consistindo de aconselhamento comportamental e acompanhamento do paciente, podem reduzir o consumo de álcool durante 6 a 12 meses ou por mais tempo ainda, e que os benefícios superam quaisquer danos eventuais. Assim, recomenda-se que a triagem para consumo de álcool e inter- venções breves sejam realizadas em ambientes de cuidados primários, visando a redução dos problemas com o álcool em adultos, inclusive mulheres grávidas. Triagem rápida Cada paciente deve ser questionado sobre o consumo de álcool. Le- vando em conta que o hábito de ingerir bebidas alcoólicas é comum nos Estados Unidos, se algum paciente informar que não bebe, será válido determinar se o paciente costumava beber, mas parou devido alcohol, the simplest strategy is to ask about the number of heavy drinking days in the past year, where heavy drinking is defined as more than four drinks for men and more than three drinks for women in one day. If that threshold is reached, which corresponds to at-risk or hazardous drinking, then further evaluation of alcohol-related problems is indicated through the use of screening instruments. A standard drink is the same amount of alcohol con- tained in different volumes of alcoholic beverages (Box 2). The Alcohol Use Disorders Identification Test (AUDIT) (Table 1) is a 10-item screen developed by the World Health Orga- nization. Given its length, the AUDIT can be used as a self-report screener that patients can fill out in the waiting area before seeing the clinician. The minimum score is 0 and the maximum score is 40. A score of 8 or more for men or 4 or more for women, adoles- cents, and persons older than 65 years, like a positive endorsement of any heavy drinking days, indicates the need for further evalua- tion of alcohol use and an increased risk of an alcohol use disorder. For brevity, the AUDIT-C, a truncated version of the AUDIT con- sisting of the first three AUDIT questions focused on alcohol con- sumption, can be used as a part of a waiting-room health history form. A score of 6 or more for men or 4 or more for women on the AUDIT-C indicates a need for further evaluation. Asking about alcohol consumption during a routine clinical interview is best bundled with other questions about lifestyle and health, such as diet, smoking, and exercise. In addition to giv- ing the patient a pre-examination questionnaire to fill out such as the AUDIT, another screening strategy is to ask the CAGE Abstinence • No alcohol use Moderate Drinking • Men: No more than 2 standard drinks per drinking d • Women: No more than 1 standard drink per drinking d • Elderly persons (>65 y): No more than 1 standard drink per drinking d Risky or Hazardous Drinking • Men • More than 4 standard drinks per drinking d • More than 14 standard drinks per wk • Women • More than 3 standard drinks per drinking d • More than 7 standard drinks per wk • Elderly persons (>65 y): • More than 3 standard drinks per drinking d • More than 7 standard drinks per wk QUESTIONS SCORING 0 1 2 3 4 Consumption (AUDIT-C) How often do you have a drink containing alcohol? Never Monthly or less 2 to 4 times a month 2 to 3 times a week 4 or more times a week How many drinks containing alcohol do you have on a typical day when you are drinking? 1 or 2 3 or 4 5 or 6 7 to 9 10 or more How often do you have five or more drinks on one occasion? Never Less than monthly Monthly Weekly Daily or almost daily Personal Consequences How often during the last year have you found that you were not able to stop drinking once you had started? Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year have you failed to do what was normally expected of you because of drinking? Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year have you had a feeling of guilt or remorse after drinking? Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year have you been unable to remember what happened the night before because of your drinking? Never Less than monthly Monthly Weekly Daily or almost daily Social Consequences Have you or someone else been injured because of your drinking? No Yes, but not in the last year Yes, during the last year Has a relative, friend, doctor, or other health care worker been concerned about your drinking or suggested you cut down? No Yes, but not in the last year Yes, during the last year Scoring and Interpretation Add all scores to obtain a total: >8 points for men or >4 points for women indicates a high risk of alcohol use disorder. AUDIT-C (first three AUDIT questions): >6 points for men or >4 points for women indicates a need for further evaluation. Each equivalent drink contains about 14 g of pure alcohol: • 12 oz of beer or wine cooler • 8–9 oz of malt liquor • 5 oz of wine • 3–4 oz of fortified wine (e.g., port) • 1½ oz of 80-proof distilled spirits (or 1 jigger of liquor before mixing) alcohol, the simplest strategy is to ask about the number of heavy drinking days in the past year, where heavy drinking is defined as more than four drinks for men and more than three drinks for women in one day. If that threshold is reached, which corresponds to at-risk or hazardous drinking, then further evaluation of alcohol-related problems is indicated through the use of screening instruments. A standard drink is the same amount of alcohol con- tained in different volumes of alcoholic beverages (Box 2). The A (Table 1) nization. screener t the clinici 40. A sco cents, and of any he tion of alc For brevit sisting of sumption form. A sc AUDIT-C Asking interview and health ing the pa the AUD Abstinence • No alcohol use Moderate Drinking • Men: No more than 2 standard drinks per drinking d • Women: No more than 1 standard drink per drinking d • Elderly persons (>65 y): No more than 1 standard drink per drinking d Risky or Hazardous Drinking • Men • More than 4 standard drinks per drinking d • More than 14 standard drinks per wk • Women • More than 3 standard drinks per drinking d • More than 7 standard drinks per wk • Elderly persons (>65 y): • More than 3 standard drinks per drinking d • More than 7 standard drinks per wk QUESTIONS 0 Consumption (AUDIT-C) How often do you have a drink containing alcohol? Never Mo o How many drinks containing alcohol do you have on a typical day when you are drinking? 1 or 2 3 o How often do you have five or more drinks on one occasion? Never Les m Personal Consequences How often during the last year have you found that you were not able to stop drinking once you had started? Never Les m How often during the last year have you failed to do what was normally expected of you because of drinking? Never Les m How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? Never Les m How often during the last year have you had a feeling of guilt or remorse after drinking? Never Les m How often during the last year have you been unable to remember what happened the night before because of your drinking? Never Les m Social Consequences Have you or someone else been injured because of your drinking? No Has a relative, friend, doctor, or other health care worker been concerned about your drinking or suggested you cut down? No Scoring and Interpretation Add all scores to obtain a total: >8 points for men or >4 points for women indicates AUDIT-C (first three AUDIT questions): >6 points for men or >4 points for women Each eq • 12 oz • 8–9 o • 5 oz o • 3–4 o • 1½ oz mixin Quadro 1 Termos de risco atuais Abstinência • Sem uso de álcool Beber moderadamente • Homens: não mais do que duas doses por dia em que beber. • Mulheres: não mais do que uma dose por dia em que beber. • Idosos (> 65 anos): Não mais do que uma dose por dia em que beber. Consumo de risco ou perigoso • Homens • Mais de 4 doses por dia em que beber. • Mais de 14 doses por semana. • Mulheres • Mais de 3 doses por dia em que beber. • Mais de 7 doses por semana. • Idosos (> 65 anos) • Mais de 3 doses por dia em que beber. • Mais de 7 doses por semana. Cada dose equivalente contém cerca de 14 g de álcool puro. • 12 onças de cerveja ou cooler de vinho. • 8 - 9 onças de cerveja com alto teor de álcool (malt liquor). • 5 onças de vinho. • 3 - 4 onças de vinho fortificado (por exemplo, vinho do porto). • 1½ onça de aguardente 80-proof (ou 1 coqueteleira de bebida alcoólica antes de misturar). Quadro 2 Doses TABELA 1 Teste de identificação de transtornos do uso de álcool (AUDIT) PONTUAÇÃO PERGUNTAS 0 1 2 3 4 Consumo (AUDIT-C) Com que frequência você consome bebidas alcoólicas? Nunca Mensalmente, ou menos 2 a 4 vezes por mês 2 a 3 vezes por semana 4 ou mais vezes por semana Quantas doses de álcool você consome em um dia normal, quando você está bebendo? 1 ou 2 3 ou 4 5 ou 6 7 a 9 10 ou mais Com que frequência você consome cinco ou mais doses em uma única ocasião? Nunca Menos que mensalmente Mensalmente Semanalmente Diariamente, ou quase diariamente Consequências pessoais Quantas vezes durante o ano passado, você percebeu que não foi capaz de parar de beber, depois de ter começado? Nunca Menos que mensalmente Mensalmente Semanalmente Diariamente, ou quase diariamente Quantas vezes, durante o ano passado, você não conseguiu fazer o que era normalmente esperado de você por causa da bebida? Nunca Menos que mensalmente Mensalmente Semanalmente Diariamente, ou quase diariamente Com que frequência, durante o ano passado, você precisou de uma primeira dose pela manhã para sentir-se melhor depois de uma bebedeira? Nunca Menos que mensalmente Mensalmente Semanalmente Diariamente, ou quase diariamente Quantas vezes, durante o ano passado, você se sentiu culpado ou com remorso após ter bebido? Nunca Menos que mensalmente Mensalmente Semanalmente Diariamente, ou quase diariamente Quantas vezes, durante o ano passado, você não foi capaz de lembrar o que aconteceu na noite anterior devido à bebida? Nunca Menos que mensalmente Mensalmente Semanalmente Diariamente, ou quase diariamente Consequências sociais Você ou outra pessoa sofreu algum ferimento por causa de seu modo de beber? Não Sim, mas não no ano passado Sim, durante o ano passado Alguém ou algum parente, amigo, médico ou outro profissional de saúde já se preocupou com o fato de você beber ou sugeriu que você diminuísse? Não Sim, mas não no ano passado Sim, durante o ano passado Pontuação e Interpretação Somar todas as pontuações para obter um total: > 8 pontos para os homens ou > 4 pontos para as mulheres indica alto risco de transtorno por uso de álcool. AUDIT-C (as três primeiras perguntas do AUDIT): > 6 pontos para os homens e > 4 pontos para as mulheres indica a necessidade de uma avaliação mais aprofundada.
- 8. alcohol, the simplest strategy is to ask about the number of heavy drinking days in the past year, where heavy drinking is defined as more than four drinks for men and more than three drinks for women in one day. If that threshold is reached, which corresponds to at-risk or hazardous drinking, then further evaluation of alcohol-related problems is indicated through the use of screening instruments. A standard drink is the same amount of alcohol con- tained in different volumes of alcoholic beverages (Box 2). The Alcohol Use Disorders Identification Test (AUDIT) (Table 1) is a 10-item screen developed by the World Health Orga- nization. Given its length, the AUDIT can be used as a self-report screener that patients can fill out in the waiting area before seeing the clinician. The minimum score is 0 and the maximum score is 40. A score of 8 or more for men or 4 or more for women, adoles- cents, and persons older than 65 years, like a positive endorsement of any heavy drinking days, indicates the need for further evalua- tion of alcohol use and an increased risk of an alcohol use disorder. For brevity, the AUDIT-C, a truncated version of the AUDIT con- sisting of the first three AUDIT questions focused on alcohol con- sumption, can be used as a part of a waiting-room health history form. A score of 6 or more for men or 4 or more for women on the AUDIT-C indicates a need for further evaluation. Asking about alcohol consumption during a routine clinical interview is best bundled with other questions about lifestyle and health, such as diet, smoking, and exercise. In addition to giv- ing the patient a pre-examination questionnaire to fill out such as the AUDIT, another screening strategy is to ask the CAGE Abstinence • No alcohol use Moderate Drinking • Men: No more than 2 standard drinks per drinking d • Women: No more than 1 standard drink per drinking d • Elderly persons (>65 y): No more than 1 standard drink per drinking d Risky or Hazardous Drinking • Men • More than 4 standard drinks per drinking d • More than 14 standard drinks per wk • Women • More than 3 standard drinks per drinking d • More than 7 standard drinks per wk • Elderly persons (>65 y): • More than 3 standard drinks per drinking d • More than 7 standard drinks per wk QUESTIONS SCORING 0 1 2 3 4 Consumption (AUDIT-C) How often do you have a drink containing alcohol? Never Monthly or less 2 to 4 times a month 2 to 3 times a week 4 or more times a week How many drinks containing alcohol do you have on a typical day when you are drinking? 1 or 2 3 or 4 5 or 6 7 to 9 10 or more How often do you have five or more drinks on one occasion? Never Less than monthly Monthly Weekly Daily or almost daily Personal Consequences How often during the last year have you found that you were not able to stop drinking once you had started? Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year have you failed to do what was normally expected of you because of drinking? Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year have you had a feeling of guilt or remorse after drinking? Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year have you been unable to remember what happened the night before because of your drinking? Never Less than monthly Monthly Weekly Daily or almost daily Social Consequences Have you or someone else been injured because of your drinking? No Yes, but not in the last year Yes, during the last year Has a relative, friend, doctor, or other health care worker been concerned about your drinking or suggested you cut down? No Yes, but not in the last year Yes, during the last year Scoring and Interpretation Add all scores to obtain a total: >8 points for men or >4 points for women indicates a high risk of alcohol use disorder. AUDIT-C (first three AUDIT questions): >6 points for men or >4 points for women indicates a need for further evaluation. Each equivalent drink contains about 14 g of pure alcohol: • 12 oz of beer or wine cooler • 8–9 oz of malt liquor • 5 oz of wine • 3–4 oz of fortified wine (e.g., port) • 1½ oz of 80-proof distilled spirits (or 1 jigger of liquor before mixing) alcohol, the simplest strategy is to ask about the number of heavy drinking days in the past year, where heavy drinking is defined as more than four drinks for men and more than three drinks for women in one day. If that threshold is reached, which corresponds to at-risk or hazardous drinking, then further evaluation of alcohol-related problems is indicated through the use of screening instruments. A standard drink is the same amount of alcohol con- tained in different volumes of alcoholic beverages (Box 2). The Alcohol Use Disorders Identification Test (AUDIT) (Table 1) is a 10-item screen developed by the World Health Orga- nization. Given its length, the AUDIT can be used as a self-report screener that patients can fill out in the waiting area before seeing the clinician. The minimum score is 0 and the maximum score is 40. A score of 8 or more for men or 4 or more for women, adoles- cents, and persons older than 65 years, like a positive endorsement of any heavy drinking days, indicates the need for further evalua- tion of alcohol use and an increased risk of an alcohol use disorder. For brevity, the AUDIT-C, a truncated version of the AUDIT con- sisting of the first three AUDIT questions focused on alcohol con- sumption, can be used as a part of a waiting-room health history form. A score of 6 or more for men or 4 or more for women on the AUDIT-C indicates a need for further evaluation. Asking about alcohol consumption during a routine clinical interview is best bundled with other questions about lifestyle and health, such as diet, smoking, and exercise. In addition to giv- ing the patient a pre-examination questionnaire to fill out such as the AUDIT, another screening strategy is to ask the CAGE Abstinence • No alcohol use Moderate Drinking • Men: No more than 2 standard drinks per drinking d • Women: No more than 1 standard drink per drinking d • Elderly persons (>65 y): No more than 1 standard drink per drinking d Risky or Hazardous Drinking • Men • More than 4 standard drinks per drinking d • More than 14 standard drinks per wk • Women • More than 3 standard drinks per drinking d • More than 7 standard drinks per wk • Elderly persons (>65 y): • More than 3 standard drinks per drinking d • More than 7 standard drinks per wk QUESTIONS SCORING 0 1 2 3 4 Consumption (AUDIT-C) How often do you have a drink containing alcohol? Never Monthly or less 2 to 4 times a month 2 to 3 times a week 4 or more times a week How many drinks containing alcohol do you have on a typical day when you are drinking? 1 or 2 3 or 4 5 or 6 7 to 9 10 or more How often do you have five or more drinks on one occasion? Never Less than monthly Monthly Weekly Daily or almost daily Personal Consequences How often during the last year have you found that you were not able to stop drinking once you had started? Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year have you failed to do what was normally expected of you because of drinking? Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year have you needed a first drink in the Never Less than Monthly Weekly Daily or almost Each equivalent drink contains about 14 g of pure alcohol: • 12 oz of beer or wine cooler • 8–9 oz of malt liquor • 5 oz of wine • 3–4 oz of fortified wine (e.g., port) • 1½ oz of 80-proof distilled spirits (or 1 jigger of liquor before mixing) 4 a algum problema passado. Depois de determinar se o paciente atualmente consome álcool, a estratégia mais simples é perguntar sobre o número de dias em que o paciente bebeu exageradamen- te no ano anterior (em que “beber excessivamente” é definido como mais de quatro doses para os homens e mais de três doses para as mulheres em um mesmo dia). Se esse limite for atingido, corres- pondendo a um consumo perigoso ou de risco, então ficará indica- da uma avaliação mais aprofundada dos problemas relacionados com o álcool por meio do uso de instrumentos de triagem. Uma dose corresponde à mesma quantidade de álcool contida em diferentes volumes de bebidas alcoólicas (Quadro 2). O Teste de Identificação de Transtornos do Uso de Álcool (Alcohol Use Disorders Identification Test,AUDIT) (Tabela 1) é uma triagem com 10 itens, desenvolvida pela Organização Mundial da Saúde. Dada a sua extensão, AUDIT pode ser usado como um formulário de triagem por autorrelato que os pacientes podem preencher na sala de espera, antes da consulta com o seu médico. A pontuação mínima é 0 e a pontuação máxima é 40. Um escore igual ou superior a 8 para homens ou igual ou superior a 4 para mulheres, adolescentes e pessoas com mais de 65 anos, como endosso positivo de qualquer dia de consumo abusivo,indica a ne- cessidade de uma avaliação mais aprofundada do uso de álcool e implica maior risco de algum transtorno causado pela bebida. Para ganhar tem- po, pode-se aplicar o AUDIT-C, uma versão resumida do AUDIT, que consiste das três primeiras perguntas da versão estendida (que enfatizam o consumo de álcool), como parte de um formulário de histórico clínico a ser preenchido na sala de espera. Uma pontuação igual ou superior a 6 para homens ou igual ou superior a 4 para mulheres no AUDIT-C sugere a necessidade de uma avaliação mais aprofundada. Uma estratégia mais adequada propõe que, durante uma consul- ta clínica de rotina, as perguntas sobre consumo de álcool sejam feitas juntamente com outros questionamentos sobre estilo de vida e saúde, tais como dieta, tabagismo e exercício. Além de fornecer ao paciente um questionário para preenchimento antes do exame, por exemplo, o AUDIT, outra estratégia de triagem cabível consiste em usar as pergun- tas do questionário CAGE (Quadro 3) durante o exame clínico. Uma resposta positiva a qualquer uma dessas perguntas também sugere a necessidade de uma avaliação mais detalhada do uso de bebidas alcoó- licas. Duas ou mais perguntas CAGE respondidas afirmativamente identificam o paciente como de alto risco para dependência do álcool. Levando em conta que o questionário CAGE faz a triagem para as con- sequências, esse instrumento não é tão sensível para consumo de risco. alcohol, the simplest strategy is to ask about the number of heavy drinking days in the past year, where heavy drinking is defined as more than four drinks for men and more than three drinks for women in one day. If that threshold is reached, which corresponds to at-risk or hazardous drinking, then further evaluation of alcohol-related problems is indicated through the use of screening instruments. A standard drink is the same amount of alcohol con- tained in different volumes of alcoholic beverages (Box 2). Th (Tabl nizat scree the c 40. A cents of an tion o For b sistin sump form AUD As interv and h ing th the A Abstinence • No alcohol use Moderate Drinking • Men: No more than 2 standard drinks per drinking d • Women: No more than 1 standard drink per drinking d • Elderly persons (>65 y): No more than 1 standard drink per drinking d Risky or Hazardous Drinking • Men • More than 4 standard drinks per drinking d • More than 14 standard drinks per wk • Women • More than 3 standard drinks per drinking d • More than 7 standard drinks per wk • Elderly persons (>65 y): • More than 3 standard drinks per drinking d • More than 7 standard drinks per wk QUESTIONS 0 Consumption (AUDIT-C) How often do you have a drink containing alcohol? Never How many drinks containing alcohol do you have on a typical day when you are drinking? 1 or 2 How often do you have five or more drinks on one occasion? Never Personal Consequences How often during the last year have you found that you were not able to stop drinking once you had started? Never How often during the last year have you failed to do what was normally expected of you because of drinking? Never How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? Never How often during the last year have you had a feeling of guilt or remorse after drinking? Never How often during the last year have you been unable to remember what happened the night before because of your drinking? Never Social Consequences Have you or someone else been injured because of your drinking? No Has a relative, friend, doctor, or other health care worker been concerned about your drinking or suggested you cut down? No Scoring and Interpretation Add all scores to obtain a total: >8 points for men or >4 points for women indi AUDIT-C (first three AUDIT questions): >6 points for men or >4 points for wo Ea • 1 • 8 • 5 • 3 • 1 m alcohol, the simplest strategy is to ask about the number of heavy drinking days in the past year, where heavy drinking is defined as more than four drinks for men and more than three drinks for women in one day. If that threshold is reached, which corresponds to at-risk or hazardous drinking, then further evaluation of alcohol-related problems is indicated through the use of screening instruments. A standard drink is the same amount of alcohol con- tained in different volumes of alcoholic beverages (Box 2). Th (Tabl nizat scree the c 40. A cents of an tion o For b sistin sump form AUD As interv and h ing th the A Abstinence • No alcohol use Moderate Drinking • Men: No more than 2 standard drinks per drinking d • Women: No more than 1 standard drink per drinking d • Elderly persons (>65 y): No more than 1 standard drink per drinking d Risky or Hazardous Drinking • Men • More than 4 standard drinks per drinking d • More than 14 standard drinks per wk • Women • More than 3 standard drinks per drinking d • More than 7 standard drinks per wk • Elderly persons (>65 y): • More than 3 standard drinks per drinking d • More than 7 standard drinks per wk QUESTIONS 0 Consumption (AUDIT-C) How often do you have a drink containing alcohol? Never How many drinks containing alcohol do you have on a typical day when you are drinking? 1 or 2 How often do you have five or more drinks on one occasion? Never Personal Consequences How often during the last year have you found that you were not able to stop drinking once you had started? Never How often during the last year have you failed to do what was normally expected of you because of drinking? Never How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? Never Ea • 1 • 8 • 5 • 3 • 1 m Quadro 4 Questionário CRAFFT Quadro 5 Questionário S-MAST-G • Você já andou em um carro dirigido por alguém (inclusive você) que estava embriagado ou estava usando drogas? • Já usou álcool ou drogas para relaxar, se sentir melhor em re- lação a si mesmo, ou“se sentir inserido”? • Já usou álcool ou drogas quando estava sozinho? • Já se esqueceu de coisas que fez enquanto consumia álcool ou drogas? • Alguém da sua família ou amigos alguma vez lhe disse que você deveria reduzir o seu consumo de álcool ou drogas? • Alguma vez você se meteu em problemas enquanto estava usando álcool ou drogas? Uma resposta“sim”indica a necessidade de uma avaliação mais aprofundada. Duas respostas “sim” indicam risco de um trans- torno por uso de álcool. • Ao falar com outras pessoas, você sempre subestima a quanti- dade de bebida realmente ingerida? • Depois de algumas doses, às vezes você não come ou é capaz de pular refeições, por não sentir fome? • Tomar algumas doses ajuda a diminuir seus tremores ou ins- tabilidade? • Em certas ocasiões a bebida alcoólica torna difícil para você se lembrar de partes do dia ou da noite? • Você costuma tomar uma bebida para relaxar ou acalmar seus nervos? • Você bebe para tirar seus problemas da cabeça? • Alguma vez já aumentou seu consumo de álcool, depois de sofrer uma perda em sua vida? • Algum médico ou enfermeiro já lhe disse que estava preocu- pado com seu hábito de beber? • Alguma vez já criou regras para controlar sua bebida? • Quando você se sente sozinho, tomar uma dose ajuda? Duas ou mais respostas “sim” indicam provável problema com o álcool. Abreviatura: S-MAST-G = Short Michigan Alcoholism Screening Test - Geriatric. alcohol, the simplest strategy is to ask about the number of heavy drinking days in the past year, where heavy drinking is defined as more than four drinks for men and more than three drinks for women in one day. If that threshold is reached, which corresponds to at-risk or hazardous drinking, then further evaluation of alcohol-related problems is indicated through the use of screening instruments. A standard drink is the same amount of alcohol con- tained in different volumes of alcoholic beverages (Box 2). The Alcohol Use Disorders Identification Test (AUDIT) (Table 1) is a 10-item screen developed by the World Health Orga- nization. Given its length, the AUDIT can be used as a self-report screener that patients can fill out in the waiting area before seeing the clinician. The minimum score is 0 and the maximum score is 40. A score of 8 or more for men or 4 or more for women, adoles- cents, and persons older than 65 years, like a positive endorsement of any heavy drinking days, indicates the need for further evalua- tion of alcohol use and an increased risk of an alcohol use disorder. For brevity, the AUDIT-C, a truncated version of the AUDIT con- sisting of the first three AUDIT questions focused on alcohol con- sumption, can be used as a part of a waiting-room health history form. A score of 6 or more for men or 4 or more for women on the AUDIT-C indicates a need for further evaluation. Asking about alcohol consumption during a routine clinical interview is best bundled with other questions about lifestyle and health, such as diet, smoking, and exercise. In addition to giv- ing the patient a pre-examination questionnaire to fill out such as the AUDIT, another screening strategy is to ask the CAGE Abstinence • No alcohol use Moderate Drinking • Men: No more than 2 standard drinks per drinking d • Women: No more than 1 standard drink per drinking d • Elderly persons (>65 y): No more than 1 standard drink per drinking d Risky or Hazardous Drinking • Men • More than 4 standard drinks per drinking d • More than 14 standard drinks per wk • Women • More than 3 standard drinks per drinking d • More than 7 standard drinks per wk • Elderly persons (>65 y): • More than 3 standard drinks per drinking d • More than 7 standard drinks per wk QUESTIONS SCORING 0 1 2 3 4 Consumption (AUDIT-C) How often do you have a drink containing alcohol? Never Monthly or less 2 to 4 times a month 2 to 3 times a week 4 or more times a week How many drinks containing alcohol do you have on a typical day when you are drinking? 1 or 2 3 or 4 5 or 6 7 to 9 10 or more How often do you have five or more drinks on one occasion? Never Less than monthly Monthly Weekly Daily or almost daily Personal Consequences How often during the last year have you found that you were not able to stop drinking once you had started? Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year have you failed to do what was normally expected of you because of drinking? Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year have you had a feeling of guilt or remorse after drinking? Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year have you been unable to remember what happened the night before because of your drinking? Never Less than monthly Monthly Weekly Daily or almost daily Social Consequences Have you or someone else been injured because of your drinking? No Yes, but not in the last year Yes, during the last year Has a relative, friend, doctor, or other health care worker been concerned about your drinking or suggested you cut down? No Yes, but not in the last year Yes, during the last year Scoring and Interpretation Add all scores to obtain a total: >8 points for men or >4 points for women indicates a high risk of alcohol use disorder. AUDIT-C (first three AUDIT questions): >6 points for men or >4 points for women indicates a need for further evaluation. Each equivalent drink contains about 14 g of pure alcohol: • 12 oz of beer or wine cooler • 8–9 oz of malt liquor • 5 oz of wine • 3–4 oz of fortified wine (e.g., port) • 1½ oz of 80-proof distilled spirits (or 1 jigger of liquor before mixing) • Alguma vez você sentiu que deveria reduzir a bebida? • Alguém já lhe aborreceu por criticar o seu hábito de beber? • Já se sentiu mal ou culpado por causa de seu hábito de beber? • Já tomou uma dose logo pela manhã para acalmar os nervos, ou para se livrar de uma ressaca? Uma resposta“sim”indica a necessidade de uma avaliação mais aprofundada. Duas respostas “sim” indicam risco de um trans- torno por uso de álcool. Quadro 3 Questionário CAGE Há outros conjuntos de perguntas que são mais sensíveis do que o CAGE para subconjuntos demográficos específicos, e estes instrumen- tos também podem ser facilmente aplicados durante uma anamnese de rotina. O questionário TWEAK de cinco itens (Tabela 2) pode ser um instrumento de triagem mais adequado para a identificação de mulheres (incluindo grávidas) com consumo de risco ou com transtornos pelo uso TABELA 2 Questionário TWEAK CARACTERÍSTICA PERGUNTA RESPOSTA PONTUAÇÃO Tolerância Quantas doses você deve tomar antes de começar a sentir os primeiros efeitos do álcool? ≥3 2 Preocupação Seus amigos ou parentes estão preocupados ou se queixaram de seu modo de beber no ano passado? Sim 2 Estimulação Algumas vezes você toma uma bebida de manhã, ao se levantar da cama? Sim 1 Amnésia Há momentos em que você bebe e depois você não consegue se lembrar do que disse ou fez? Sim 1 Kut (desejo de interromper) Algumas vezes você sente necessidade de reduzir o seu consumo? Sim 1 Pontuação e interpretação: dois ou mais pontos indicam possível problema com álcool.
- 9. questions (Box 3) during the clinical examination. A positive answer to any of these questions also indicates the need for further evaluation of alcohol use. Two or more CAGE questions answered affirmatively identifies a patient at high risk for alcohol depen- dence. Because the CAGE screens for consequences, it is not as sen- sitive for risky drinking. There are other question sets that are more sensitive than the CAGE in specific demographic subsets, and these can also be easily asked during a routine history. The five-item TWEAK questionnaire (Table 2) may be a more optimal screening questionnaire for iden- tifying women (including pregnant women) with risky drinking or alcohol use disorders in racially mixed populations. The CRAFFT (Box 4) is a 6-item question set that has high sensitivity in screening adolescents for alcohol and other substance-abuse problems. For patients older than 65 years, the Short Michigan Alcoholism Screen- ing Test—Geriatric (S-MAST-G) (Box 5) is useful in identifying those at risk for alcohol problems, because these patients might not need the same volumes of alcohol intake as others to develop alcohol-related problems. To complete the initial screening, one should compute the average number of drinks per week by multiply- ing the days per week on average that the patient drinks by the num- ber of drinks consumed on a typical drinking day. Laboratory testing for elevations of alanine aminotransferase (ALT), aspartate aminotransferase (AST), γ-glutamyltransferase (GGT), or carbohydrate-deficient transferrin (CDT) have no incremental sensitivity over those of validated screening instru- ments, and they may be better suited to monitoring patients already in treatment for alcohol use disorders. The patient must still be asked about quantity and frequency of alcohol use. How- ever, laboratory testing can provide indicators of covert heavy drinking (e.g., elevated GGT and CDT) when the patient does not reveal the extent of alcohol intake. CDT, which is perturbed less than other indices by nonalcoholic liver disease, may be a more specific and sensitive indicator of heavy drinking. Diagnosis Screening can identify those who are at risk for the sequelae of risky or hazardous drinking and who might benefit from a brief interven- tion conducted in the primary care office, but only a diagnostic evaluation can confirm the clinician’s suspicion that the patient’s use of alcohol meets syndromal criteria and warrants specific med- ical and psychosocial treatment beyond the brief intervention. According to Diagnostic and Statistical Manual of Mental Disor- ders, fifth edition (DSM-5) criteria (Table 3), the patient has a diagnosis of an alcohol use disorder if he or she has two or more of the following criteria over a 12-month period related to alcohol use: physical tolerance, symptoms of withdrawal, repeatedly drink- ing more than intended, unsuccessful reduction or quit attempts, repeated episodes of failure to fulfill obligations at home, school or work, episodes of increased risk of physical harm, recurrent problems with significant others, increased time drinking or recov- ering from drinking, reduced time in other pleasurable or important activities, and continued drinking despite physical or psychological problems. With DSM 5, the term alcohol dependence describes the symptoms of physical tolerance and withdrawal, not the use disor- der syndrome. Severity is defined as: Mild 2-3 symptoms; Moderate 4-5 symptoms; and, Severe 6 or more symptoms. Box 3 CAGE Questionnaire • Have you ever felt that you should Cut down on your drinking? • Have people Annoyed you by criticizing your drinking? • Have you ever felt bad or Guilty about your drinking? • Have you ever taken a drink (Eye opener) first thing in the morning to steady your nerves or to get rid of a hangover? One yes response indicates need for further assessment. Two yes responses indicate risk of an alcohol use disorder. Box 4 CRAFFT Questionnaire • Have you ever ridden in a Car driven by someone (including yourself) who was high or had been using alcohol or drugs? • Do you ever use alcohol or drugs to Relax, feel better about yourself, or fit in? • Do you ever use alcohol or drugs while you are Alone? • Do you ever Forget things you did while using alcohol or drugs? • Do your Family or Friends ever tell you that you should cut down on your drinking or drug use? • Have you ever gotten into Trouble while you were using alco- hol or drugs? One yes response indicates need for further assessment. Two yes responses indicate risk of alcohol use disorder. Box 5 S-MAST-G Questionnaire • When talking with others, do you ever underestimate how much you actually drink? • After a few drinks, have you sometimes not eaten or been able to skip meals because you didn’t feel hungry? • Does having a few drinks help decrease your shakiness or tremors? • Does alcohol sometimes make it hard for you to remember parts of the day or night? • Do you usually take a drink to relax or calm your nerves? • Do you drink to take your mind off your problems? • Have you ever increased your drinking after experiencing a loss in your life? • Has a doctor or nurse ever said that he or she was worried or concerned about your drinking? • Have you ever made rules to manage your drinking? • When you feel lonely, does having a drink help? Two or more yes responses indicate a probable alcohol problem. Abbreviation: S-MAST-G ¼ Short Michigan Alcoholism Screening Test— Geriatric. TABLE 2 TWEAK Questionnaire FEATURE QUESTION ANSWER SCORE Tolerance How many drinks does it take before you begin to feel the first effects of alcohol? �3 2 Worry Have your friends or relatives worried or complained about your drinking in the past year? Yes 2 Eye-opener Do you sometimes take a drink in the morning when you first get up? Yes 1 Amnesia Are there times when you drink and afterward you can’t remember what you said or did? Yes 1 Kut Do you sometimes feel the need to cut down on your drinking? Yes 1 Scoring and interpretation: Two or more points indicate a possible alcohol problem. 965 instruments. A standard drink is the same amount of alcohol con- tained in different volumes of alcoholic beverages (Box 2). ing the patient a pre-examination questionnaire to fill out such as the AUDIT, another screening strategy is to ask the CAGE QUESTIONS SCORING 0 1 2 3 4 Consumption (AUDIT-C) How often do you have a drink containing alcohol? Never Monthly or less 2 to 4 times a month 2 to 3 times a week 4 or more times a week How many drinks containing alcohol do you have on a typical day when you are drinking? 1 or 2 3 or 4 5 or 6 7 to 9 10 or more How often do you have five or more drinks on one occasion? Never Less than monthly Monthly Weekly Daily or almost daily Personal Consequences How often during the last year have you found that you were not able to stop drinking once you had started? Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year have you failed to do what was normally expected of you because of drinking? Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year have you had a feeling of guilt or remorse after drinking? Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year have you been unable to remember what happened the night before because of your drinking? Never Less than monthly Monthly Weekly Daily or almost daily Social Consequences Have you or someone else been injured because of your drinking? No Yes, but not in the last year Yes, during the last year Has a relative, friend, doctor, or other health care worker been concerned about your drinking or suggested you cut down? No Yes, but not in the last year Yes, during the last year Scoring and Interpretation Add all scores to obtain a total: >8 points for men or >4 points for women indicates a high risk of alcohol use disorder. AUDIT-C (first three AUDIT questions): >6 points for men or >4 points for women indicates a need for further evaluation. 5 de álcool em populações racialmente mistas. O questionário CRAFFT (Quadro 4) é um conjunto de perguntas com seis itens que demonstrou elevada sensibilidade na triagem de adolescentes para problemas de con- sumo de bebidas alcoólicas e outros problemas de abuso de substâncias. No caso de pacientes com mais de 65 anos, o Short Michigan Alcoholism Screening Test-Geriatric (S-MAST-G) (Quadro 5) revelou-se útil para a identificação de idosos com risco de ter problemas com o álcool, pois é provável que, em comparação com outros grupos, esses pacientes não necessitem das mesmas quantidades de álcool para que venham ter pro- blemas relacionados à bebida. Para completar a triagem inicial, deve-se calcular o número médio de doses por semana,multiplicando a média de dias por semana de consumo de bebidas pelo número de doses consumi- das em um dia típico de consumo. As análises laboratoriais para determinação de elevações de ala- nina aminotransferase (ALT), aspartato aminotransferase (AST), γ- glutamil transferase (GGT), ou transferrina deficiente em carboidrato (CDT) não demonstram maior sensibilidade em comparação com a sensibilidade dos instrumentos de triagem validados; essas análises podem ser mais apropriadas para monitoramento de pacientes que já estejam em tratamento para transtornos por uso de álcool. O pacien- te deve ainda ser questionado sobre a quantidade e a frequência do consumo de bebidas alcoólicas. No entanto, as análises laboratoriais podem fornecer indicadores de ocultação de consumo abusivo (por exemplo, GGT e CDT elevadas) nos casos em que o paciente deixa de revelar a extensão de seu consumo de álcool. A CDT, que, em com- paração com outros indicadores, é menos afetada pela doença hepática não alcoólica, pode ser um indicador mais específico e sensível de con- sumo abusivo. Diagnóstico A triagem pode identificar os indivíduos que estejam na iminência de sofrer sequelas do consumo de risco ou perigoso e que podem se bene- ficiar com uma breve intervenção realizada em consulta ambulatorial primária, mas apenas uma avaliação diagnóstica poderá confirmar a suspeita do médico de que o consumo de álcool do paciente preenche critérios sindrômicos e justifica tratamento clínico e psicossocial espe- cífico, ultrapassando os limites de uma breve intervenção. De acordo com os critérios do Manual Diagnóstico e Estatístico de Transtornos Mentais, 5ª edição (DSM-5) (Tabela 3), o diagnóstico de transtorno pelo uso de álcool será constatado se o paciente preencher dois ou mais dos seguintes critérios ao longo de um período de 12 meses,em relação ao uso de álcool: tolerância física, sintomas de abstinência, consumir repetidamente bebida alcoólica além do pretendido, tentativas malo- gradas de diminuição ou de abandono da bebida, episódios repetidos de não cumprimento das obrigações em casa, na escola ou no trabalho, episódios de maior risco de danos físicos, problemas recorrentes com outras pessoas relevantes, mais tempo bebendo ou se recuperando de beber, diminuição do tempo em outras atividades prazerosas ou im- portantes e persistência no consumo de bebida alcoólica, apesar de problemas físicos ou psicológicos. No DSM-5, o termo “dependência de álcool” descreve os sintomas da tolerância física e de abstinência, não a síndrome de transtorno do uso. O nível de gravidade é definido como: Leve, 2-3 sintomas; Moderado, 4-5 sintomas; e Grave, 6 ou mais sintomas. Os percentuais de ocorrência simultânea de transtornos do humor e ansiedade são especialmente elevados entre indivíduos que apresen- tam transtornos por uso de álcool. Transtornos de humor e ansiedade não tratados tendem a exercer um impacto negativo na recuperação do alcoolismo. Entre os pacientes que procuram por tratamento na coorte da National Epidemiologic Survey on Alcohol and Related Con- ditions (NESARC) com transtorno por uso corrente de álcool, 40% sofreram pelo menos um transtorno do humor independente em curso, e mais de um terço desses indivíduos teve pelo menos um transtorno de ansiedade independente em curso. O consumo abusivo de álcool TABELA 3 Diagnóstico de problemas com o uso de álcool CRITÉRIOS SINTOMAS E HISTÓRIATÍPICOS Transtorno por uso de álcool (≥ 2 nos últimos 12 meses) O álcool tem causado ou contribuído para a repetida ocorrência de: não cumprimento das obrigações em casa, na escola, ou no trabalho? Ressaca no trabalho, absentismo escolar, falta a compromissos. episódios de aumento do risco de dano físico? Dirigir, nadar ou operar máquinas sob a influência de álcool. compulsão, ou um forte desejo ou vontade de consumir álcool? Incapacidade de abster-se de beber devido a impulsos fortes. problemas com pessoas relevantes? Discórdia conjugal, lutas corporais. desenvolvimento de tolerância física? Beber mais para obter o mesmo efeito. episódios de síndrome de abstinência (ver abaixo)? Tremores matinais, náusea, ansiedade. beber repetidamente mais do que o pretendido? Episódios de consumo desregrado. esforços infrutíferos para diminuir a bebida ou parar de beber? Não cumprir as resoluções de ano novo. aumento do tempo planejando para beber, bebendo, ou se recuperando da bebida? Em vez de ficar com os filhos, passar as manhãs de fim de semana dormindo. redução do tempo em outras atividades prazerosas ou importantes? Interromper a socialização com os amigos, se afastar de grupos de passatempo. o consumo do álcool persiste, apesar de problemas físicos ou psicológicos? Passar a apresentar um humor deprimido, mas continuar bebendo. Abstinência de álcool (≥ 2 em um período de horas ou dias, depois de terem baixado os níveis de álcool no sangue) Hiperatividade autonômica. Frequência cardíaca de 100 bpm, diaforese. Tremor das mãos. As mãos tremem quando estão estendidas. Insônia. Dificuldade em adormecer. Náusea ou vômito. Sentir-se enjoado. Ansiedade. Relato espontâneo de medo. Agitação psicomotora. Incapacidade de se manter calmo, andar de um lado para outro. Alucinações ou ilusões. Informar distúrbios visuais. Convulsões. Movimentos tônico-clônicos.
- 10. alcohol, the simplest strategy is to ask about the number of heavy drinking days in the past year, where heavy drinking is defined as more than four drinks for men and more than three drinks for women in one day. If that threshold is reached, which corresponds to at-risk or hazardous drinking, then further evaluation of alcohol-related problems is indicated through the use of screening instruments. A standard drink is the same amount of alcohol con- tained in different volumes of alcoholic beverages (Box 2). The Alcohol Use Disorders Identification Test (AUDIT) (Table 1) is a 10-item screen developed by the World Health Orga- nization. Given its length, the AUDIT can be used as a self-report screener that patients can fill out in the waiting area before seeing the clinician. The minimum score is 0 and the maximum score is 40. A score of 8 or more for men or 4 or more for women, adoles- cents, and persons older than 65 years, like a positive endorsement of any heavy drinking days, indicates the need for further evalua- tion of alcohol use and an increased risk of an alcohol use disorder. For brevity, the AUDIT-C, a truncated version of the AUDIT con- sisting of the first three AUDIT questions focused on alcohol con- sumption, can be used as a part of a waiting-room health history form. A score of 6 or more for men or 4 or more for women on the AUDIT-C indicates a need for further evaluation. Asking about alcohol consumption during a routine clinical interview is best bundled with other questions about lifestyle and health, such as diet, smoking, and exercise. In addition to giv- ing the patient a pre-examination questionnaire to fill out such as the AUDIT, another screening strategy is to ask the CAGE Abstinence • No alcohol use Moderate Drinking • Men: No more than 2 standard drinks per drinking d • Women: No more than 1 standard drink per drinking d • Elderly persons (>65 y): No more than 1 standard drink per drinking d Risky or Hazardous Drinking • Men • More than 4 standard drinks per drinking d • More than 14 standard drinks per wk • Women • More than 3 standard drinks per drinking d • More than 7 standard drinks per wk • Elderly persons (>65 y): • More than 3 standard drinks per drinking d • More than 7 standard drinks per wk QUESTIONS SCORING 0 1 2 3 4 Consumption (AUDIT-C) How often do you have a drink containing alcohol? Never Monthly or less 2 to 4 times a month 2 to 3 times a week 4 or more times a week How many drinks containing alcohol do you have on a typical day when you are drinking? 1 or 2 3 or 4 5 or 6 7 to 9 10 or more How often do you have five or more drinks on one occasion? Never Less than monthly Monthly Weekly Daily or almost daily Personal Consequences How often during the last year have you found that you were not able to stop drinking once you had started? Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year have you failed to do what was normally expected of you because of drinking? Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year have you had a feeling of guilt or remorse after drinking? Never Less than monthly Monthly Weekly Daily or almost daily How often during the last year have you been unable to remember what happened the night before because of your drinking? Never Less than monthly Monthly Weekly Daily or almost daily Social Consequences Have you or someone else been injured because of your drinking? No Yes, but not in the last year Yes, during the last year Has a relative, friend, doctor, or other health care worker been concerned about your drinking or suggested you cut down? No Yes, but not in the last year Yes, during the last year Scoring and Interpretation Add all scores to obtain a total: >8 points for men or >4 points for women indicates a high risk of alcohol use disorder. AUDIT-C (first three AUDIT questions): >6 points for men or >4 points for women indicates a need for further evaluation. Each equivalent drink contains about 14 g of pure alcohol: • 12 oz of beer or wine cooler • 8–9 oz of malt liquor • 5 oz of wine • 3–4 oz of fortified wine (e.g., port) • 1½ oz of 80-proof distilled spirits (or 1 jigger of liquor before mixing) 6 também pode induzir sintomas de humor e outros transtornos men- tais. Para diferenciar entre sintomas induzidos pelo álcool e distúrbios independentes,seria ideal uma reavaliação dos sintomas de determina- do transtorno mental algumas semanas após a interrupção ou redução significativa da ingestão de álcool. Breve intervenção Propósito Embora o consumo perigoso ou de risco não seja um diagnóstico formal, tal situação descreve um grupo com maior probabilidade de vir a sofrer problemas de alcoolismo, com concomitante risco de aci- dentes, lesões e problemas sociais e de saúde, em comparação com a população em geral (ver Quadro 1). Assim, mesmo sem um diagnós- tico formal, em uma situação de consumo de risco, é válido ajudar o paciente a mudar esse seu comportamento. Diversos intercâmbios de curta duração entre o médico e seu paciente, amplamente descritos na literatura e organizados sob a rubrica de “breves intervenções”, já foram validados em estudos randomizados como capazes de di- minuir o consumo de álcool por pessoas que bebem excessivamente, mas que não receberam um diagnóstico de dependência de álcool. Ficou demonstrado que a breve intervenção diminui o consumo semanal de álcool, a frequência de episódios de compulsão alimen- tar periódica, as enzimas hepáticas associadas ao consumo excessivo de álcool, a pressão arterial, os atendimentos de urgência, os dias de internação e os problemas psicossociais, geralmente em 6 a 12 me- ses; além disso, um estudo constatou que a breve intervenção reduz os dias de consumo e os dias passados no hospital em até 4 anos. Levando em conta que, em sua maioria, os pacientes de risco exami- nados em ambientes de atendimento primário são subsindrômicos para transtornos por uso de álcool, a interação clínica típica relacio- nada ao álcool será a de triagem e, em seguida, a de uma breve inter- venção para os casos positivos. Em geral, essas duas estratégias estão enfeixadas sob a sigla TBI (triagem e breve intervenção). Basicamente, a intenção de uma breve intervenção é educar o pa- ciente sobre os riscos do uso abusivo de álcool para motivá-lo a reduzir o seu consumo semanal. Como rotina, a primeira breve intervenção leva cerca de 15 minutos, consistindo de comentários, conselhos e estabelecimento de metas. Essa intervenção pode ser realizada intei- ramente no contexto do atendimento primário, pelo médico ou por outros membros da equipe de promoção da saúde. Com a inclusão da triagem para consumo de álcool, a USPSTF sugere cinco “A”s para a realização da TBI: avaliar o consumo de álcool pelo paciente com um instrumento de triagem e pela avaliação clínica (o que for mais indi- cado); aconselhar a redução do consumo de álcool a níveis adequados, inclusive com abstinência, se for possível; fazer acordos sobre as metas individuais para a redução do uso de álcool, incluindo a abstinência, se for possível; ajudar o paciente a obter motivação, habilidades ou ajuda necessárias para que sejam promovidas mudanças no consumo de bebida alcoólica; e providenciar apoio durante o acompanhamento do paciente, inclusive com encaminhamento para tratamento especia- lizado para os pacientes dependentes. As intervenções mais eficazes são aquelas que envolvem vários contatos e que prestam assistência e acompanhamento contínuos. Procedimento Avalie Faça a triagem dos pacientes com o instrumento AUDIT ou com os questionários CAGE,TWEAK,CRAFFT,ou S-MAST-G (o que for mais apropriado) e compute a média de doses por semana. Aconselhe Dê a sua opinião apresentando expressão de preocupação e emitindo conclusões diretas e fazendo recomendações. Mostre achados clínicos, por exemplo,enzimas hepáticas elevadas,para reforçar afirmações con- clusivas como “Estou preocupado porque seu consumo de álcool está excedendo os limites de segurança”. Transmita ao paciente informa- ções que comparem o seu consumo com o considerado normal para a população e informe os riscos associados para a sua saúde. Eduque o paciente,descrevendo como o álcool pode acarretar consequências mé- dicas, psicossociais e jurídicas. Sempre que possível, busque vincular os atuais sintomas do paciente ao uso de álcool. Recomende mudanças de comportamento adequadas e específicas, tais como “recomendo urgen- temente que você reduza o seu consumo”, ou, no caso em que qualquer quantidade consumida coloque o paciente em risco elevado,“você deve obrigatoriamente parar de beber”. Faça acordos Determine o grau de disposição do paciente para mudar seu compor- tamento em relação à bebida, perguntando, por exemplo, “você acha que consegue considerar a decisão de reduzir seu consumo de álcool?”. Se o paciente se mostrar ambivalente, evite rotular o seu comporta- mento com um diagnóstico nesta fase, pois isso poderia aumentar sua resistência à mudança; mas incentive-o a refletir sobre as razões posi- tivas para beber e as consequências negativas do consumo de álcool. Faça considerações sobre o fato de que manter o consumo de álcool no mesmo nível é um obstáculo para a concretização das metas do paciente, tais como a diminuição do desconforto gástrico ou a melhora de seu padrão de sono. Em geral, ouvir com empatia é mais eficaz do que uma abordagem de confronto; essa atitude também é útil para demonstrar otimismo diante da capacidade de o paciente conseguir mudar. Procure descobrir quais são as preocupações do paciente relacionadas à diminuição ou à desistência do consumo de álcool. Evite discussões ou confrontos quando o paciente ainda não estiver preparado para mudar,mas agende uma consulta de acompanhamento para que o diálogo tenha prosse- guimento e para que o comportamento de beber seja reavaliado. Reafirme seu compromisso de ajudar quando o paciente estiver pronto e demonstre que você permanece aberto a perguntas. Assim que o paciente concordar que uma mudança no consumo seria benéfi- ca, chegue a um acordo sobre uma meta específica para a redução até determinados limites diários e semanais objetivando um consumo de baixo risco, ou mesmo a interrupção do hábito (se for o caso), durante um período de tempo específico. Esse acordo deve ser registrado, e o paciente receberá uma cópia, para servir de lembrete e também como motivador para a mudança de comportamento. Ajude Trabalhe em conjunto com o paciente para formular medidas concre- tas voltadas à implementação do plano de redução do consumo de ál- cool. Essas etapas são: como evitar situações de consumo de alto risco; como manter um histórico do consumo de álcool; e pessoas que podem ajudar o paciente na concretização de seus objetivos. Forneça recursos na forma de material educativo para o paciente (exemplos desses meios podem ser baixados no site do National Institute of Alcohol Abuse and Alcoholism [NIAAA]) (www.niaaa.nih.gov). Providencie apoio Agende as consultas de apoio para acompanhamento e aconselha- mento, ou encaminhe o paciente que preencha os critérios de de- pendência para tratamento especializado. Aconselhe o paciente a procurar tratamento médico imediatamente, caso ocorram sintomas de abstinência. Tratamento Desintoxicação Explicando de maneira simples, desintoxicação é a estabilização clínica que possibilita o envolvimento do paciente no tratamento do alcoolismo, mas que não constitui, per se, tratamento para a de- pendência de álcool. Pacientes que bebem mais de 250 mililitros de álcool por dia estão propensos a sofrer sintomas fisiológicos de abstinência com a interrupção do consumo, mas volume não é o único indicador da gravidade da abstinência. Embora seja frequen- temente branda, a abstinência alcoólica não tratada pode resultar em convulsões ou em delirium tremens (DT), com aumento do risco de mortalidade. Avaliação A escala revisada Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) é uma escala de domínio público que atribui pontuação