What is the appropriate approach to managing a patient with a history of alcohol (ethanol) use who presents to the clinic seeking assistance for their alcohol dependence?

Documentation for Patients Seeking Help for Alcohol Use

When documenting a patient with alcohol use history who is motivated for treatment, frame the note around their readiness for change and structure your assessment using validated screening tools, while clearly documenting the severity and creating an actionable treatment plan.

Initial Documentation Framework

History of Present Illness

Document the patient's alcohol consumption pattern using specific quantitative measures rather than vague descriptors 1:

• Quantity and frequency: Number of standard drinks per day/week (1 standard drink = 14g alcohol) 1
• Pattern of use: Daily vs. binge drinking (≥5 drinks within 2 hours for men <65 years; ≥4 drinks for women/men ≥65 years) 1
• Duration: How long has heavy drinking occurred
• Last drink: Critical for assessing withdrawal risk 2
• Previous quit attempts: Document what has been tried and why it failed

Structured Screening Assessment

Administer and document the AUDIT (Alcohol Use Disorders Identification Test) score, which is the gold standard screening tool with proven sensitivity and specificity across clinical settings 1:

• Score 0-7: Low risk
• Score 8-15: Hazardous drinking
• Score 16-19: Harmful drinking
• Score ≥20: Likely alcohol dependence 1

For time-constrained settings, you can use AUDIT-C (first 3 questions only) or even AUDIT-3 (question 3 alone about binge drinking) 1. Document the actual numerical score in your note 1.

Severity Classification

Based on DSM-5 criteria, document if the patient meets criteria for Alcohol Use Disorder and its severity 1:

• Mild AUD: 2-3 criteria met
• Moderate AUD: 4-5 criteria met
• Severe AUD: ≥6 criteria met

Key criteria to assess include: inability to cut down, craving, failure to fulfill obligations, continued use despite problems, tolerance, and withdrawal symptoms 1.

Assessment Section

Medical Complications

Document any alcohol-related organ damage:

• Liver: Transaminases, bilirubin, coagulation studies for alcoholic liver disease 1
• Neurological: Assess for peripheral neuropathy, cognitive deficits, history of seizures 3
• Cardiovascular: Blood pressure, history of cardiomyopathy 3
• Gastrointestinal: GI bleeding, pancreatitis history 3

Psychiatric Comorbidities

Screen for concurrent psychiatric disorders including anxiety, depression, and suicidality, as alcoholics have high psychiatric comorbidity 1. Document whether these are independent disorders requiring separate treatment or concurrent disorders that may resolve with abstinence 1.

Withdrawal Risk Assessment

Critical for patient safety: Document risk factors for severe alcohol withdrawal syndrome 2:

• History of previous withdrawal seizures or delirium tremens
• Chronic heavy use pattern
• Concurrent medical illness
• Time since last drink
• Vital sign abnormalities (elevated BP, pulse, tremor) 2

Plan Documentation

Immediate Management

For patients at risk of withdrawal, document benzodiazepine prophylaxis 2:

• Long-acting agents (diazepam 10mg 3-4 times daily, chlordiazepoxide) for most patients 2
• Short-acting agents (lorazepam, oxazepam) for elderly or those with liver disease 1, 4
• Consider CIWA-Ar protocol for symptom-triggered dosing 2

Document thiamine supplementation (100-300mg immediately, then daily) to prevent Wernicke's encephalopathy 2, 4. This is non-negotiable for all patients with alcohol use disorder.

Disposition Decision

Document your reasoning for inpatient vs. outpatient management 4:

Admit if:

• Risk of severe withdrawal (history of DTs, seizures)
• Concurrent serious medical/psychiatric conditions
• Inadequate social support
• Inability to ensure reliable supervision 2

Outpatient management acceptable if:

• Stable vital signs
• Low withdrawal risk
• Adequate support system
• Reliable follow-up available 4

Long-term Treatment Plan

Document specific pharmacotherapy recommendations for abstinence maintenance 4, 5:

• Acamprosate 1,998mg/day (two 333mg tablets three times daily) for patients ≥60kg, reduced by one-third for <60kg, for 3-6 months 4, 5. This has the highest quality evidence for maintaining abstinence in detoxified patients 4.
• Naltrexone for relapse prevention (avoid in severe liver disease due to hepatotoxicity) 4
• Disulfiram (avoid in severe alcoholic liver disease) 4
• Baclofen shows promise particularly in cirrhotic patients 4

Document psychosocial interventions 1, 4:

• Brief intervention (15-minute personalized counseling with feedback, advice, goal-setting) 1, 4
• Referral to addiction specialist if moderate-severe AUD 1
• Recommendation for mutual help groups (Alcoholics Anonymous) 4
• Arrange follow-up within 1-2 weeks 1

Key Documentation Phrases

Use motivational language that acknowledges the patient's readiness for change:

• "Patient expresses motivation to reduce/stop alcohol use and is seeking treatment assistance"
• "AUDIT score of [X] indicates [hazardous/harmful/dependent] drinking pattern"
• "Patient demonstrates readiness for change and agrees to treatment plan"
• "Discussed risks of continued alcohol use including [specific complications]"
• "Patient counseled on importance of abstinence and provided resources for support"

Common Documentation Pitfalls to Avoid

• Never delay psychiatric evaluation waiting for specific blood alcohol levels if the patient is alert, cooperative, and has normal vital signs 4. Base assessment on cognitive abilities, not arbitrary BAC thresholds.
• Never administer glucose before thiamine, as this can precipitate acute Wernicke's encephalopathy 2
• Never discharge patients with suspected dependence without withdrawal prophylaxis plan, as delirium tremens and seizures can be fatal 2
• Don't overlook concurrent substance use disorders that may complicate recovery 4
• Avoid vague terms like "social drinker" or "occasional use"—use specific quantities 1