Unable to account for the drastic change in his health status, you begin to leaf through his chart searching for results of previous labs or any other clues as to what’s happening. You see the results of Mr. Hake’s substance use screening form and note that he is drinking alcohol daily. Upon further questioning, Mr. Hake tells you that he just has “a few beers to help me fall asleep.” He states that he used to drink “the hard stuff” in the past but quit years ago after he served some jail time for “driving drunk a few times.” As you question further, you learn that Mr. Hake’s wife of 40 years recently died after a stroke and he has been having trouble adjusting to this.
What should you do next?
a. Screen Mr. Hake for depression by asking him about his mood and interest in his usual pleasurable activities
This is a reasonable next step given that depression can complicate chronic disease management in a variety of ways. Depression screening can be achieved a number of ways including simply asking all the SIG-E-CAPS questions.
b. Tell Mr. Hake to stop using alcohol immediately
This seems like a good idea, but it’s not likely to ever be effective on its own. While this is probably what is best for him in the long run, this advice alone may be insufficient for a person who appears to have a history of alcohol dependence.
c. Start disulfiram
This would definitely not be the right choice. Medications to maintain sobriety should only be used in conjunction with counseling and only after discussing his treatment goals as well as the risks of these medications. These medications can be used in the primary care setting but only in conjunction with counseling. For this reason, these medications are most often prescribed in a specialty setting by addition specialists who can draw upon the help of a multidisciplinary team experienced in the management of substance use disorders.
d. Refer Mr. Hake to a substance use counselor
This may eventually be a reasonable choice, however, the referral is premature since you haven’t given him your assessment nor asked what he thinks about his alcohol use. A more in-depth conversation about his beliefs and goals regarding his use should precede a referral of this kind.
e. Increase Mr. Hake’s antihypertensive medications and schedule a follow-up visit to review blood pressure and blood glucose in 2 weeks
As with any chief complaint, the problem of chronic disease exacerbation should be explored and a differential diagnosis made before a treatment is chosen. What are the most likely reasons for the change in Mr. Hake’s status?