Addressing alcohol problems within the regular health care setting, and outside of specialized treatment

Most people with alcohol disorders do not enter specialized treatment; they are seen in regular health-care or social services, which is generally reflected by their poor treatment outcomes.   Given this reality, participants in a roundtable discussion at the June 2005 annual meeting of the Research Society of Alcoholism in Santa Barbara, California deliberated the need to address alcohol problems during routine health care.   Proceedings are published in the February issue of Alcoholism: Clinical & Experimental Research.

“Alcohol problems are really common, roughly one in every 10 or 11 people drink too much, and the consequences cost us all,” said William R. Miller, Distinguished Professor of psychology and psychiatry at the University of New Mexico, and chair of the discussion.   “You have about a 40 percent chance of being in an alcohol-related vehicular crash, anywhere from a fender-bender to a fatal crash, at least once in your lifetime.  For every dollar spent to purchase alcoholic beverages, Americans incur about two dollars in social and health care costs.  Averaged across the population, that’s about $1000 per year for every U.S. adult, whether or not they themselves drink.  For those who are directly affected by their own problem drinking or that of a family member, the costs are much higher.”

Key proceedings were:

-   Screening and brief interventions within a health-care setting can be especially effective for individuals who have low-to-moderate alcohol problems.  

“Most people who drink too much don’t think of themselves as having ‘a problem,’ let alone being an ‘alcoholic,’” said Miller.   “They are therefore unlikely to seek specialist treatment unless required to do so by family or the courts.  Consequently, people do not usually enter specialist treatment or even A.A. until their alcohol problems and dependence have become quite serious.  They do, however, tend to see a physician at least once a year.  Accordingly, health-care providers have the best opportunity to screen for and address heavy drinking before it takes a severe toll on the person and their family.”

-   When choosing an intervention model, programs and providers should ensure that patient confidentiality is protected, whether or not the particular components chosen are covered by federal legislation.  

“Records from substance-abuse treatment are required by federal law to be much more carefully protected than regular health-care records,” said Miller.  

- With the recent approval of a third medication ( acamprosate) by the Federal Drug Administration (in addition to disulfiram and naltrexone), pharmacotherapies for alcoholism may soon become part of mainstream medical practice.

-   Trauma centers can provide an excellent opportunity for alcohol-disorder screening and intervention.

“About half of the injuries severe enough to require admission to a Level One trauma center are somehow related to drinking,” said Miller.   “What many people do not realize is that those who are admitted once with alcohol-related traumatic injuries are at high risk to be injured again.  The short time spent in a trauma center thus provides a unique opportunity to help people reduce their risk of future traumatic injury.”

-   “ Telehealth” (interactive audio-video) and telephone (interactive audio) sessions can serve as successful long-distance delivery modes for motivational interviewing, especially for rural populations.  

“People who live in America’s vast rural or frontier areas often have difficulty getting to health care,” said Miller. “Access to substance abuse treatment is particularly limited and, even if available, people are often reluctant to be seen going there because of small-town confidentiality concerns.   Being able to receive ongoing confidential counseling by telephone, or being able to go to a health center and having a private face-to-face confidential consultation with a professional located hundreds of miles away, can give rural citizens immediate access to state-of-the-art treatment services while protecting their anonymity.  Motivational interviewing is one form of treatment particularly amenable to delivery in this way because it is relatively brief and has a strong track record of effectiveness.”

- The development of effective brief interventions for addictive disorders is an essential step toward improving public health, but it must be followed by the distribution and adoption of these interventions.

“Screening sounds more complicated than it is,” said Miller, “it’s just asking a few simple questions as part of health-care visits.  When there is indication of heavy or problem drinking, there are some brief counseling procedures that a physician or nurse can provide, as well as referral to specialist services as needed.   Through simple screening and brief counseling methods, health-care professionals can make a substantial difference in their patients’ health.”

- The rates of adoption of alcohol screening and brief intervention (ASBI) strategies for heavy drinkers within primary-care settings remain low.

“Thinking has changed over the years,” said Miller, “in that many people [now] regard drinking as a health issue much like smoking, diet and exercise.   As with smoking, we have already seen huge reductions in alcohol use in the U.S. population, relative to the 1960s and 1970s.   There are also effective procedures that can be used within the time constraints of primary health care and family practice, and people are much more willing to talk to their doctor about their drinking than to go off to a specialist treatment program.  This symposium is just one small part of a larger effort to get this message out into the health-care community.”

Miller added that he would like to see more experimentation with a “hybrid approach” for addressing alcohol problems within primary care.   “At one extreme is referring the patient out to a specialist program,” he explained, “but most people don’t go.  At the other extreme is asking primary care physicians to [provide] alcohol counseling.   That can be effective, but most physicians are already pressed to get everything done in the short time they have with each patient.  In between is another option:  to have a behavioral health specialist on site to address alcohol problems and avoid the obstacles of a stigmatized treatment program.”

Funding for this Addiction Science Made Easy project is provided by the Addiction Technology Transfer Center National Office, under the cooperative agreement from the Center for Substance Abuse Treatment of SAMHSA.

Articles were written based on the following published research:

Baca, C.; Compton, W. M.; Ernst, D.; Manuel, J. K.; Pringle, B.; Schermer, C. R.; Weiss, R. D.; Willenbring, M. L.; Zweben, A.   (January 2006).    Addressing substance abuse in health care settings.   Alcoholism: Clinical & Experimental Research.   30(1):