Why Treat Alcohol Use Disorders in Primary Care?

Psychiatrists who provide integrated care and consultative services to primary care practices are often asked about help for patients with alcohol use disorders. This month, I have asked Drs. Katharine Bradley, Evette Ludman, and Ryan Caldeiro to share an update on the treatment of alcohol use disorders in primary care, which will be followed in the next issue by a review of the lessons they have learned from their work.—Jürgen Unützer, M.D., M.P.H.

When asked about appropriate primary care for patients with alcohol use disorders (AUDs), many primary care providers as well as psychiatrists and other behavioral health clinicians say: “I refer them to treatment, but most don’t go.” Many then add something like: “Of course I tell them they need to stop drinking, but there’s nothing I can do if they aren’t ready to quit.”

These commonly held views—first, that referral to abstinence-oriented treatment is the only option even though most patients never go, and second, that patients have to be “ready” or there is nothing that can be done—are not supported by evidence. While remarkably little is known about management of AUDs in primary care, research is increasing.

In this article, we summarize prior research that informs care models that are being tested. In a subsequent article, we will review lessons we have learned from our work in this area.

Repeated medical interventions can be effective: Screening and brief interventions (SBI) are effective for people who drink above recommended limits—for women, not more than three drinks in a single day and not more than seven drinks in a week; for men, not more than four drinks in a single day and not more than 14 drinks in a week. However, SBI has not been proven effective for AUDs. Nevertheless, research has shown that repeated interventions may be effective for patients who have an AUD or who are at high risk for AUDs.

• Willenbring and colleagues demonstrated that monthly primary care visits could benefit people who were hospitalized for alcohol-related problems and did not accept referral to treatment.

• Kristenson and colleagues showed that Swedish men with elevated GGT benefited from nurse visits for monitoring GGT every three months.

• Nordback and colleagues showed that visits every six months decreased subsequent hospital admissions in patients with acute pancreatitis.

• The COMBINE trial tested the efficacy of medications for AUDs—including a placebo—when combined with 20 minutes of “medical monitoring,” such as that used for warfarin in primary care. Placebo plus medical monitoring was as effective as a state-of-the-art behavioral intervention for achieving abstinence, preventing return to heavy drinking, or drinking without alcohol-related symptoms.

• Finally, Oslin showed that care management for AUDs with an offer of naltrexone could markedly increase engagement in care and decrease heavy drinking.

Cutting down can decrease symptoms of AUDs: Dawson studied people with AUDs in remission in the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC). Three years later, those who had stopped drinking were less likely to have AUD symptoms (7 percent) than those who continued to drink but below recommended limits (27 percent). However, the latter group had fewer alcohol-related symptoms and a lower probability of having an active AUD than those who continued to drink above recommended limits (51 percent).

Many treatments work: Extensive efforts to match patients to the right treatment for them or to compare treatments—such as Project Match, UKATT, or the COMBINE trial—have found that no single behavioral treatment or medication is generally superior to all others. Moreover, a recent review of trials by Jonas highlighted that several medications available in the United States—naltrexone, acamprosate, and topiramate—can help people cut down and/or quit drinking. Disulfiram is also effective when pill taking is supervised.

Starting where patients are helps: Interventions based on concepts of motivational interviewing that “meet patients where they are” and build on patients’ own self-efficacy and reasons for change have been proven effective. Chafetz demonstrated over 45 years ago that addressing patients’ goals increased engagement in addictions treatment.

Self-change is common: NESARC has also clearly documented what many had observed for years: that many people with AUDs resolve their addictions on their own. The proportion of people with prior AUDs who recovered without ever seeking help was 33 percent, although the recovery rate was higher for those who had sought help (46 percent).

Several approaches can decrease relapse: Mutual support like Alcoholics Anonymous, behavioral interventions—including newer online tools such as ACHESS (Addiction-Comprehensive Health Enhancement Support System)—and medications for AUDs can all support patients in maintaining positive change.

In summary, evidence is building that repeated, patient-centered interventions in medical settings can help people with AUDs recover. However, primary care providers are perfectly positioned to help patients with AUDs by offering shared decision making about treatment options. Finally, many patients will change on their own; primary care providers can offer these and other patients with AUDs support to sustain their recovery. As a result, a number of new models of primary care for AUDs are being tested. In a subsequent article, we will summarize some of the lessons we learned while testing new models of care for AUDs and psychiatrists’ roles in these models. ■