RESEARCH to PRACTICE

Reducing Alcohol Abuse in Active Patients

Lymperis (Perry) Koziris, PhD

THE PHYSICIAN AND SPORTSMEDICINE - VOL 28 - NO. 12 - DECEMBER 2000

Alcohol abuse is recognized as one of our most acute societal concerns and has widespread consequences. The main costs from alcohol consumption each year in the United States are an estimated $150 billion, which includes those of related healthcare and productivity losses from the estimated 100,000 lives lost. Substance abuse figures prominently among public health priorities; many mention alcohol or drinking. Achieving reductions in abuse has been mediocre in recent years (1). Although progress was made toward the Healthy People 2000 targets, none of the goals was met.

The healthcare professional's role in addressing alcohol abuse has not been well documented recently, but any perceived de-emphasis probably stems from inadequate data collection rather than reflecting the clinician's potential role in achieving this public health goal. Admittedly, though, most of the opportunity for clinical intervention is apparently wasted. In 1992, only 29% of pediatricians and 39% of family physicians routinely inquired about alcohol consumption (1). Even fewer physicians provided referrals to alcohol treatment.

Screening and Intervention

The physician can establish a screening and intervention program for alcohol abuse and alcoholism by following a protocol from the National Institute on Alcohol Abuse and Alcoholism (NIAAA) (2). If a screening instrument suggests a drinking problem, a specific interview and examination of the patient can follow. Various laboratory tests have also been attempted but thus far have not been broadly successful in detecting the presence, and especially the risk, of alcohol abuse unless these tests are used concomitantly with a questionnaire, interview, and/or physical examination. One example of a time-efficient initial screening device is the CAGE instrument (table 1). It may be used as a separate written questionnaire, part of the medical history, or incorporated into conversation during an examination. Currently, the typical preparticipation physical evaluation form contains no such questions or others that quantify alcohol consumed (3). At an absolute minimum, alcoholism can be added to the other diseases in a family history list.

TABLE 1. The CAGE Questionnaire for Alcohol Abuse*
1. Have you ever felt you should Cut down on your drinking?	Yes__ No__
2. Have people Annoyed you by criticizing your drinking?	Yes__ No__
3. Have you ever felt bad or Guilty about your drinking?	Yes__ No__
4. Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (Eye-opener)?	Yes__ No__
* Positive answers on one or more questions indicate a potential problem with alcohol abuse.

As part of the subsequent intervention, a physician can use a psychometric instrument to further assess the client's need for treatment. The NIAAA offers guidance for physicians wishing to select a patient-specific instrument (2). For the healthcare professional interested in gaining proficiency in program implementation, the NIAAA offers two guides detailing screening, counseling, and referral; several patient brochures; and contact information for other resources (2).

Negative Effects of Alcohol

Acute effects. Alcohol use and abuse are at least as common in athletes as they are in nonathletes. Alcohol's acute negative effects on athletic performance are widely known (4,5). Moderate blood alcohol levels (BALs, 0.06 to 0.10 g/dL) compromise reaction time, hand-eye coordination, and skills that involve balance and accuracy. Although a low BAL (0.02 to 0.05 g/dL) can decrease hand tremors and improve balance and accuracy, this level still hinders reaction time and hand-eye coordination. Alcohol can attenuate aerobic performance, with potential acute medical implications from its effect on thermoregulatory mechanisms. The effect of low-to-moderate BALs on strength and short-term power varies across different performance variables. Also, some data indicate decreased muscle endurance after alcohol is metabolized, possibly because of an ethanol metabolite.

Chronic effects. Potential chronic effects on athletic performance are sequelae of alcohol's long-term toxicity to several organs and physiologic systems. The NIAAA provides a current review of the scientific literature on the medical effects of alcohol use and other areas of alcohol research (2). Other sources provide detailed reviews of alcohol's effect on the endocrine system (6) and on muscles (7), two systems of particular interest to sports medicine professionals. Alcohol abuse can provoke a catabolic hormonal environment that precipitates muscle atrophy and weakness. Myopathy, often present with neuropathy, can occur in various skeletal muscles and the myocardium.

Minimum guidelines. Athletes should be informed about all of alcohol's detrimental effects, including those that can more directly affect their performance, in case some athletes relate more to these as deterrents. Suggested minimum guidelines for avoiding alcohol's negative effects are (1) pre-event: Avoid alcohol beyond low-amount social drinking for 48 hours, and (2) postexercise: Rehydrate before drinking alcohol and consume food to retard alcohol absorption (5).

The Healthcare Team

Although the physician is one gateway to an intervention program, screening and guiding a person to appropriate care may also be done by personal trainers, physical therapists, sport psychologists, and other professionals. As long as they are prepared to follow through with proper referral, these allied professionals should use some alcohol-screening questions when taking histories. School- or team-based prevention programs can also be developed through proven guidelines (8).

Future Research

Further research is needed on the interaction of physical conditioning and alcohol consumption in long-term alcohol abusers as well as in those who are recovering from alcoholism. Other areas for aggressive research include biological markers that can serve as early indicators of alcohol abuse, haplotypes that can predict alcoholism, and techniques that increase physician use of brief intervention.

References

1. National Center for Health Statistics. Healthy People 2000 Review, 1998-99. Hyattsville, MD, Public Health Service, 1999. Available at: http://www.cdc.gov/nchs/data/hp2k99.pdf. Accessed September 11, 2000
2. National Institute on Alcohol Abuse and Alcoholism: Publications. Available at http://silk.nih.gov/silk/niaaa1/publication/publication.htm. Accessed September 11, 2000
3. Kovan JR: The preparticipation physical examination, in Safran MR, McKeag DB, Van Camp SP (eds): Manual of Sports Medicine. Philadelphia, Lippincott-Raven, 1998, pp 10-20
4. Williams MH: Alcohol, marijuana and beta blockers, in Lamb DR, Williams MH (eds): Perspectives in Exercise Science and Sports Medicine, vol. 4: Ergogenics — Enhancement of Performance in Exercise and Sport. Dubuque, IA, Brown & Benchmark, 1991, pp 331-372
5. Koziris LP: Alcohol and athletic performance. Current Comment from the American College of Sports Medicine, April 2000
6. Gordon GG, Lieber CS: Alcohol, hormones, and metabolism, in Lieber CS (ed): Medical and Nutritional Complications of Alcoholism: Mechanisms and Management. New York City, Plenum Medical, 1992, pp 55-90
7. Preedy VR, Peters TJ: Alcohol and skeletal muscle disease. Alcohol 1990; 25(2-3):177-187
8. Stainback RD: Alcohol and Sport. Champaign, IL, Human Kinetics, 1997

Dr Koziris is an assistant professor in the department of kinesiology, health promotion, and recreation at the University of North Texas in Denton. Address correspondence to Perry Koziris, PhD, Dept of Kinesiology, Health Promotion, and Recreation, University of North Texas, Box 311337, Denton, TX 76203-1337; e-mail to Koziris@coefs.coe.unt.edu.