Making a Difference with Patients Who Drink Too Much
Am Fam Physician. 2009 Jul 1;80(1):21-22.
Patients often present to family physicians with a range of modifiable behaviors that influence the incidence, course, and outcomes of acute and chronic illnesses. Physicians know that smoking, poor diet, and physical inactivity are risk factors that can be addressed with patients. However, most medical education programs have only recently begun to teach students how to conduct brief interventions for behavior change. These interventions usually begin with an assessment of the patient's current behaviors and whether he or she is interested in making a change.
Less attention has been devoted to assessing patients' use of alcohol, which is the third leading preventable cause of illness and mortality in the United States.1 Heavy drinking contributes to many health problems, and often complicates or compromises treatment. Simple and effective tools for addressing alcohol use are available for physicians, as described in the article by Willenbring and colleagues in this issue.2
It is curious that primary care physicians treat the acute and chronic consequences of heavy drinking (e.g., withdrawal, injuries, gastrointestinal bleeding from gastritis or esophageal varices, liver disease, neuropathies, dementia), but do not routinely address the prevention of alcohol-related disease. In the era of managed care, physicians are already stressed by time demands and practice requirements. Yet, surely a major and prevalent risk factor such as alcohol use deserves physicians' attention.
The reasons for this neglect stem, in part, from two misconceptions. First, physicians perceive patients' heavy drinking as a condition to be addressed only by addiction specialists.3 However, the barriers to specialist care are substantial, and only a minority of patients ever receive it. Patients with alcohol problems or at risk of alcohol problems are most likely to be seen in primary care or hospital settings, where evaluation and treatment can begin.
Second, we as a society have failed to recognize all but the most severe drinking problems, in part because of the stereotypes of alcoholism and the associated social stigma. With many health conditions, such as diabetes and hypertension, early intervention allows physicians to diagnose and treat accordingly. It is time for excessive alcohol use to be added to these conditions. It has long been recognized that alcohol problems occur along a continuum of severity,4 and that earlier intervention improves outcomes and prevents more serious complications. In addition to its chronic effects, heavy drinking also increases patients' risk of acute events and injuries.
Recent research has shown that physicians do not need to wait for patients to be ready to change their drinking habits.5 Openness to change is a product of physician-patient conversation. Physicians often recognize that confronting and pushing patients to change can backfire, producing defensiveness. Methods that build partnership and respect patient autonomy, such as motivational interviewing, can be used effectively within the context of primary care to enhance positive changes in health behavior.5,6 Like smokers, most heavy drinkers know at some level that they are harming themselves. Through motivational interviewing, the physician can use an empathic style, rather than an authoritative or argumentative approach, to help patients understand the discrepancy between their personal goals and their current drinking behavior. This can ultimately elicit the patient's own reasons for change.
A new development that is being explored is providing billable, on-site consultations by a behavioral health specialist in the primary care setting. The behavioral health specialist would have more time and training to counsel patients in behavior change. They would also assist with a range of practical concerns and chronic illnesses that rely on behavior change for better health. On-site service facilitates these referrals and consultations within physician practices and systems of care. A pilot project addressing the logistics of treating substance abuse in the primary care setting was published in the International Journal of Integrated Care.7 It emphasizes the integration of care across health care systems, including primary care, specialty care, and physical and mental health services.7
There is a great opportunity for primary care physicians to recognize at-risk alcohol consumption and practice early intervention. By engaging patients in brief interventions and providing behavioral health specialist consultations, physicians can help reduce the morbidity and mortality of harmful alcohol use.
1. Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000 [published correction appears in JAMA. 2005;293(3):293–294]. JAMA. 2004;291(10):1238–1245.
2. Willenbring ML, Huang SW, Gardner MB. Helping patients who drink too much: an evidence-based guide for primary care physicians. Am Fam Physician. 2009;80(1):44–50.
3. McLellan AT, Lewis DC, O'Brien CP, Kleber HD. Drug dependence, a chronic medical illness: implications for treatment, insurance, and outcomes evaluation. JAMA. 2000;284(13):1689–1695.
4. Institute of Medicine Committee on Treatment of Alcohol Problems. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: National Academies Press; 1990.
5. Rollnick S, Miller WR, Butler CC. Motivational Interviewing in Health Care: Helping Patients Change Behavior. New York, NY: The Guilford Press; 2008.
6. Hettema J, Steele J, Miller WR. Motivational interviewing. Annu Rev Clin Psychol. 2005;1:91–111.
7. Ernst D, Miller WR, Rollnick S. Treating substance abuse in primary care: a demonstration project. Int J Integr Care. 2007;7:e36.
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