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The role and specificities of primary care in the detection and treatment of alcohol use disorders

The topic of the Resource Centre this month is the role and specificities of primary care in the detection and treatment of alcohol use disorders. The vast majority of adults visit a physician at least once a year, and patients have an ongoing, trusting relationship with their physicians and expect to receive lifestyle advice from them. Primary care thus provides a unique opportunity for the provision of both alcohol screening and intervention. On many occasions in a primary care setting patients will not only accept but will expect to be asked about smoking and alcohol, especially if it is part of chronic disease management.

However, as Steve Brinksman comments in his video presentation, physicians don't always dig around enough when patients present with conditions which could be related to alcohol, and a correct diagnosis might be missed – a theme echoed in the discussion of Anne Lingford-Hughes and Devi Mathur on the patient's perspective on alcohol dependence. After screening other key roles of primary care in alcohol use disorders are delivering brief interventions and advice, and initiating treatment or referral. Primary care physicians can conduct most treatments for less severe cases of alcohol dependence. Carsten Grimm, in his video presentations, recommends evidence-based guidelines about alcohol dependence and how to treat alcohol use disorders, and discusses how to assess severity of alcohol dependence. Our selection of articles is a reflection of the key position primary care has in reducing alcohol-attributable harm.

Articles on primary care in AUD

  • Integration and sustainability of alcohol screening, brief intervention, and pharmacotherapy in primary care settings

    Steven M. Ornstein, Peter M. Miller, Andrea M. Wessell, Ruth G. Jenkins, Lynne S. Nemeth, Paul J. Nietert

    Journal of Studies on Alcohol and Drugs 2013, Volume 74, pages 598–604

    Editor's comment:
    The purpose of this study was to assess the impact of a practice-based quality improvement approach on alcohol screening, brief interventions (SBI) and use of medication for alcohol use disorders (AUDs) in adult patients with diagnoses of hypertension and/or diabetes, two conditions which are especially sensitive to alcohol. This approach (PPRNet-TRIP) combines audit and feedback, practice site visits for academic detailing and participatory planning, and network meetings to share “best practice” approaches. The study results showed that a more intensive intervention is more effective than passive dissemination of guidelines, electronic health record tools, and audit and feedback on alcohol SBI and use of medications for AUDs, and that its impact is sustained for at least 1 year after it ends. A third finding of the study was that adoption of prescribing medications for AUDs occurs more slowly than SBI. The authors conclude that the PPRNet-TRIP model is effective in improving and maintaining improvement in alcohol screening and brief intervention for patients with diabetes and/or hypertension in primary care settings.

  • General practitioners recognizing alcohol dependence: A large cross-sectional study in 6 European countries

    Jürgen Rehm, Allaman Allamani, Roberto Della Vedova, Zsuzsanna Elekes, Andrzej Jakubczyk, et al.

    Annals of Family Medicine 2015 Volume 13, pages 28-32.

    Editor's comment:
    The aim of this study was to compare how alcohol dependence is recognized in primary care facilities in 6 European countries based on the reference standard for assessing alcohol use disorders, the World Health Organization Composite International Diagnostic Interview (CIDI). Study results showed that, although the physician assessment and the assessment by CIDI yielded a similar prevalence, they identified different patient populations. Fewer than one-fifth of the cases were identified by both methods – diagnosis by GP only and CIDI only. A major finding of this study is that the CIDI was not as successful as a physician in identifying cases of alcohol dependence in older patients, which raises the questions about validity of CIDI and its status as a reference standard. The physicians in the study were able to detect cases of alcohol dependence in need of treatment. The detection and intervention rates of GPs could be improved by routinely checking patients’ alcohol consumption, much as they do for hypertension, by suggesting options for reduction, and by intervening if certain thresholds are crossed. The authors see no reason why primary care physicians could not conduct most treatments for less severe cases of alcohol dependence.

  • Prevention and screening, brief intervention, and referral to treatment for substance use in primary care

    Stephen Strobbe

    Primary Care: Clinics in Office Practice 2014, Volume 41, pages 185–213

    Editor's comment:
    In this article on the role primary care can play related to substance use, attention is paid to tobacco, alcohol, cannabis, and the nonmedical use of prescription opioid medications. The focus is on the US, where more than 85,000 deaths per year are attributable to alcohol consumption, making it the third leading cause of preventable death in the country. Next to underlining the importance of screening, brief intervention, and referral to treatment (SBIRT), the article offers practical information like the AUDIT-C questionnaire, guidelines for alcohol use, selected screening instruments, and the 5 As of behavioral counseling. Among other conclusions in the article, brief interventions, when provided by primary care clinicians, have been found to lessen alcohol consumption, reduce hospital days and health care costs, and decrease mortality.

  • Opportunities for prevention of alcohol-related death in primary care: Results from a population-based cross-sectional study

    Margaret Morris, David Johnson, David S. Morrison

    Alcohol 2012, Volume 46, pages 703–707

    Editor's comment:
    Deaths and hospital admissions for alcohol-related conditions have risen steeply in the United Kingdom such that they now represent a significant public health problem. The authors found that all adults who died as a result of alcohol in the study area, Greater Glasgow, had at least one physical or biochemical sign of alcohol abuse but there was often no evidence that assessment, treatment and referral reflected evidence-based guidance. Health services have an important role to contribute in identifying and managing alcohol disorders and more work is needed to exploit the opportunities to deliver evidence-based treatments for these patients.

  • Generalized anxiety disorder is under-recognized in clinical practice in patients with alcohol dependence in France

    Violaine Charriau, M'hammed Elyakoubi, Bruno Millet, Dominique Drapier, Didier Robin, Romain Moirand

    Alcohol 2013, Volume 47, pages 15–19

    Editor's comment:
    Generalized anxiety disorder and alcohol dependence frequently occur together and there is a strong and significant association between the two. However, in their study, the authors found that generalized anxiety disorder in alcohol-dependent patients was under-recognized. The most important implication for clinical practice is that under-diagnosis leads to the absence of a specific treatment of this disorder, which could in turn cause relapses of alcohol, used as an auto-medication. Generalized anxiety disorder is a chronic disabling disorder, which complicates the evolution of alcohol dependence and for which codified therapeutic strategies do exist.