Daniel C. Vinson, MD, MSPH

Episodic heavy drinking, like alcoholism and drug addiction, is increasingly recognized as a medical problem that primary care physicians can, and should, address.¹ But it is rarely the chief reason for an office visit. Nor is it a subject patients are likely to bring up.

However, patients are generally willing to talk to a trusted doctor who asks about their use (or misuse) of alcohol or other substances. And primary care physicians can do much to help—with brief interventions, a growing armamentarium of pharmacotherapy, and referrals as needed. In the pages that follow, you’ll find easy-to-use screening tools and effective intervention strategies.

SCREENING NEEDN'T BE TIME-CONSUMING

Screening for substance use isn’t difficult. In fact, it can usually be accomplished with 2 targeted questions—one for alcohol use and one for drugs.

Alcohol. Two single-question screens to detect hazardous drinking have been validated, despite having different parameters. Ask either:

Q: When was the last time you had more than ____ drinks (4 for women and 5 for men) in one day?

Q: How many times in the past year have you had ___ or more drinks (4 for women and 5 for men) in one day?

For the first question, any answer within the past 3 months is a positive screen for hazardous drinking.² For the second, anything other than zero is positive.^3,4

Initial screening can also be done with the AUDIT-C (TABLE), a validated short (3-question) version of the Alcohol Use Disorders Identification Test that can be self-administered.^5,6

Drugs. Only one single-question screen for drug use has been validated:

Q: How many times in the past year have you used an illegal drug or taken a prescription medication for nonmedical reasons?

Any answer other than never is a positive screen for hazardous drug use.⁷

CASE Jason F, a healthy and fit 28-year-old, has been your patient, along with his family, for years. He’s in your office because of a knee injury he incurred while running, and you take a moment to ask him, for the first time, how much he drinks and whether he takes drugs. His answer—that he drinks 3 or 4 times a week and often has multiple drinks at parties or nights out with the guys—takes you a bit by surprise.

Now what?

Watch the video

TABLE

3-question AUDIT-C screen for alcohol dependence^5,6

TELL ME MORE ABOUT IT

It is important to respond to a positive screen by requesting more information. In the conversation that ensues, the patient may provide the details you need to determine whether the drinking or drug use is indicative of a diagnosable substance use disorder, an umbrella term for alcohol or drug abuse and alcohol or drug dependence.

Alcohol or drug abuse vs dependence. Criteria for alcohol or drug abuse in the Diagnostic and Statistical Manual of Mental Disorders, 4th ed, text revision (DSM-IV-TR) include risky behavior, such as drinking and driving; problems with work and/or close relationships; or run-ins with the law, such as an arrest for driving while intoxicated. Criteria for alcohol or drug dependence include the inability to cut down or stop using the substance; evidence of tolerance and withdrawal; spending more time ingesting the substance; increasing attention to substance use while interest in other activities diminishes; and continued use despite recurrent problems.⁸

Tools zero in on extent of problem

To learn more about your patient’s situation, consider using the following criteria and tools:

DSM criteria. Ask the following 2 questions, which are among DSM-IV-TR criteria for alcohol dependence:

1. How many times in the last year have you had a lot more to drink than you intended?
2. How many times in the last year have you been drinking in situations where it could have been hazardous, where you could have caused an accident or gotten hurt?

Any answer other than zero to either question is suggestive of a substance use disorder. In exploratory analyses, this approach had positive likelihood ratios of 4.7 to 16 and negative likelihood ratios of 0.05 to 0.30.^9,10

Although the above questions refer to alcohol use, they could be revised to learn more about a patient’s use of marijuana or other drugs, as well. (There are few tools for the assessment of drug use, because any illegal or nonmedical use of controlled substances has clear risks of major harm.)

CAGE. Another tool that is effective in assessing alcohol use is the 4-question CAGE—an acronym for Cut down, Annoyed, Guilty, and Eye opener:

• Have you ever felt that you should cut down on your drinking?
• Have people annoyed you by criticizing your drinking?
• Have you ever felt bad or guilty about your drinking?
• Have you ever had a drink in the morning to get rid of a hangover?

One meta-analysis found that a positive CAGE test—ie, a positive response to one or more of the questions—had a sensitivity of 0.85 and a specificity of 0.78 in identifying alcohol dependence in a primary care setting (using DSM criteria as the gold standard).¹¹

AUDIT. This 10-item tool, a longer version of the AUDIT-C (available at http://www.medstudentlearning.com/node/6556), can also be used to determine the extent of alcohol use. This test provides detailed information about the quantity and frequency of alcohol use; however, it does not clearly distinguish between hazardous drinking and alcohol use disorders.¹²

If the patient is a teen

Assessment methods can be adjusted without difficulty to fit the age of the patient. The National Institute on Alcohol Abuse and Alcoholism has published the Alcohol Screening and Brief Intervention for Youth: A Practitioner’s Guide, available at http://www.niaaa.nih.gov/Publications/EducationTrainingMaterials/Pages/YouthGuide.aspx. The 6-question CRAFFT (for Car, Relax, Alone, Forget, Friends, Trouble) is a validated tool designed to assess adolescents’ use of both alcohol and drugs (http://www.ceasar-boston.org/clinicians/crafft.php).^13,14

CASE You give Mr. F the CAGE test, and he answers No to all 4 questions. You conclude that while his drinking may be hazardous, he does not appear to have alcohol abuse or dependence.

FOLLOW UP WITH A BRIEF INTERVENTION

For decades, evidence has shown that brief interventions are often effective in helping hazardous drinkers like Mr. F cut back to safer levels.^15-18 In some cases, the impact has been great enough to reduce health care and societal costs for up to 4 years¹⁹ and to cut the risk of alcohol-related death by about half.²⁰ As a result, the US Preventive Services Task Force has given a B rating to counseling to reduce alcohol misuse by primary care providers.²¹ (There is less evidence that brief interventions are effective for drug problems,²² or in settings other than primary care.²³)

Treat drug/alcohol problems

If you determine that your patient is engaging in hazardous alcohol or drug use or has a diagnosable substance use disorder, you do not have to drop everything else or treat it as an acute event. What matters is long-term success, which is best achieved by partnering with the patient.

Start by approaching drug and alcohol problems as you would a case of newly elevated blood pressure. Bring up the problem, seeking to engage the patient in addres- sing it.

If he or she does not agree to quit or cut back on drinking the first time you broach the subject, don’t be surprised or discouraged. Keep in mind that patients do not always respond positively to advice about handling chronic medical conditions either, particularly at first, and that you’ll be working together over time. What’s important, in the jargon of the Stages of Change model,²⁴ is to help the patient move from precontemplation to contemplation, and perhaps beyond that to planning or action.

Use motivational interviewing to partner with patients

Motivational interviewing is useful in helping patients change health-related behaviors. The technique, which is not hard to learn or apply, is based on the recognition that a simple shift in style toward a guiding (rather than directive) approach can often reap benefits that are immediately apparent. ^25-28

Motivational Interviewing: Helping People Change (3rd ed, by William R. Miller and Stephen Rollnick; Guilford Press, 2013) is an excellent resource for clinicians who wish to master this technique. An online tutorial in screening and brief intervention for alcohol or drug misuse is available free at https://adept.missouri.edu. Video demonstrations of motivational interviewing to address these issues are also available here ; to access them, click on “Training”, then on “Go to SBIRT videos”).

CASE Before Mr. F’s visit is concluded, you initiate a conversation about alcohol use, stating: “As your doctor, I’m concerned that the amount of alcohol you’re drinking could be hazardous to your health. I recommend that you cut down to no more than 4 drinks in any one day and to no more than 14 drinks a week.” You make it clear that change is up to him, and ask what he thinks about what you’ve said.

You also schedule a return visit in one month, at which time you will continue the conversation.

PHARMACOTHERAPY IS A USEFUL TOOL

Increasingly, alcohol and drug dependence—like other chronic conditions—can be effectively addressed with medication.

Drugs to treat alcohol dependence

Naltrexone. A daily dose of naltrexone, starting at 25 mg daily for a few days and going as high as 100 mg/d, can help patients with alcohol dependence limit their drinking to safe levels (number needed to treat [NNT]=9).²⁹ This will reduce the risk of alcohol-related harm while the patient considers quitting.

The most common adverse effect is nausea, but a low starting dose may alleviate it. Naltrexone, also available as a 380-mg intramuscular (IM) depot injection once every 4 weeks, is an opioid antagonist and should not be given to any patient who’s taking opioids.

A 2010 Cochrane review found only 4 trials of naltrexone IM, and failed to show significant reductions in drinking.²⁹ But post hoc analyses of trials of both oral and IM naltrexone found that those in which compliance was assured (either by direct observation or IM administration) had better outcomes than those in which it was not.³⁰ Another post hoc analysis found that patients whose alcohol dependence was more severe derived greater benefits from the drug than those who were less severely affected.³¹

Acamprosate. Two 333-mg pills tid can help newly abstinent drinkers remain alcohol-free (NNT=9).^32,33 The most common adverse effect is diarrhea, which may subside with continued use.

Combining acamprosate and naltrexone does not appear to be more effective than either drug alone. In a recently published meta-analysis comparing the 2 drugs, those taking acamprosate had slightly better rates of abstinence from alcohol, while naltrexone was slightly better in reducing heavy drinking.³⁴

Disulfiram Unlike naltrexone and acamprosate, which work by altering the brain’s reward circuits, disulfiram blocks metabolism of ethanol, leading to the accumulation of a toxic metabolite and its punishing syndrome. The major problem with the drug is noncompliance, which can be addressed by enlisting the help of a caregiver or partner to ensure that it is taken daily. ^35-37

Other medications that have been tested (though not approved by the US Food and Drug Administration [FDA]) as a treatment for alcohol dependence include:

• topiramate, which has been found to have modest efficacy in increasing the number of abstinent days and decreasing heavy-drinking days;³⁸
• baclofen, which has shown efficacy in small clinical trials;³⁹ and
• ondansetron, which has been shown to effectively treat early-onset alcohol dependence.^40,41

For patients with depression and alcohol dependence, the combination of naltrexone and sertraline has been found to be superior to either drug by itself—and to have fewer adverse effects. ⁴² Gabapentin and lorazepam have been compared in treating alcohol withdrawal, with gabapentin resulting in greater efficacy and fewer adverse effects than lorazepam.^43,44

Pharmacotherapy for drug abuse, dependence

For methamphetamine abuse and dependence. Two randomized clinical trials have studied medications for methamphetamine abuse and dependence. In one small study, topiramate did not increase the proportion of patients who achieved abstinence, but in a post hoc subgroup analysis, it did appear to help newly abstinent patients avoid relapse.⁴⁵

In another study, mirtazapine significantly decreased the proportion of patients whose weekly urine tests were positive for methamphetamine (from 73% to 44%); no significant change was found among those on placebo.⁴⁶

Both drugs were well tolerated, but compliance was low in both trials despite weekly counseling. Each has only one clinical trial to support its use, and neither has FDA approval for addiction treatment.

For marijuana dependence. In a study of 50 people seeking treatment for marijuana dependence, gabapentin 400 mg 3 times a day significantly improved the proportion reporting no cannabis use and whose urine tested negative for the drug.⁴⁷

Another recent trial randomized adolescents dependent on cannabis to placebo or N-acetylcysteine 1200 mg twice a day. Those on the active drug were 2.4 times more likely than those on placebo to have negative urine tests with a number needed to treat of 7.⁴⁸ Both trials ran for about 3 months. Neither drug is FDA approved to treat marijuana dependence.

For opioid dependence. As maintenance medication for patients dependent on opioids, both methadone and buprenorphine have been shown to reduce the use of illicit opioids, lower mortality, and improve retention compared with treatment without medication.⁴⁹ Methadone would be a better choice than buprenorphine, which is a partial agonist with a ceiling on both its good (eg, stopping craving) and bad (eg, overdose risk) effects. In an open-label observational study of patients’ preferences, those who chose methadone maintenance over buprenorphine were twice as likely to remain in treatment.⁵⁰ Both drugs are FDA-approved for treating opioid dependence.

Methadone is a full agonist that can be given for opioid dependence only in a federally licensed methadone maintenance clinic. It has been shown to reduce the use of other opioids, reduce criminal behaviors,⁵¹ improve function in many areas,⁵² and reduce mortality.⁵³ In a cohort study of Massachusetts Medicaid data, methadone reduced mortality, which was 75% higher among those receiving abstinence-based treatment.^52,54

Buprenorphine (alone and in combination with naloxone), effectively reduces the use of illicit opioids and improves functional status.^55-57

Naltrexone, an opioid antagonist, may be effective in the treatment of opioid dependence. As with disulfiram for alcohol dependence, a major limitation of naltrexone for opioid dependence is noncompliance. But once a patient has been on oral naltrexone, he or she can be switched to naltrexone IM, which can be administered every 4 weeks. A Cochrane review published in 2011 found no evidence that naltrexone was superior to placebo, ⁵⁸ but since then another randomized clinical trial has been published that found naltrexone 380 mg IM every 4 weeks was superior to IM placebo. Patients on naltrexone were more likely to remain in treatment and have opioid-free urine tests, and reported less craving for opioids.⁵⁹ Both oral and depot injection naltrexone are FDA approved for treatment of opioid dependence. No comparisons of naltrexone vs either methadone or buprenorphine have been published.

To learn more about pharmacotherapy for opioid dependence, see “Diagnosing and treating opioid dependence” (J Fam Pract. 2012;61:588-596).

DEALING WITH THE CHALLENGES

As noted earlier, some patients with substance use disorders, like some patients with depression or hypertension, respond well to care and counseling, and some do not. Just as with other conditions, consultation with a specialist often helps.

A major difference in arranging consultations for patients with substance use disorders, however, is that clinicians who specialize in substance abuse and dependence often work in health care systems that are largely, or entirely, separate from those in which primary care physicians typically work. This, plus the stigma that surrounds problems with substance use, presents barriers to patients, who may shy away from going across town or to another city to see a provider they don’t know for a problem they’re either resistant to “owning” or ashamed of.

Yet it is possible to reach across this divide and make it easier for patients. One way to do that might be to partner with a local alcohol- and drug-treatment program so that your patients are referred, not to a faceless agency, but rather to a specific clinician; you might even call the provider while the patient is in your office so they can “meet.” Another approach, taken by some multispecialty practices, is to add psychotherapists to the staff so that patients can simply walk down the hall to obtain the mental health care they need.

Reaching across this divide is also a useful strategy for primary care physicians, who may welcome opportunities to meet with someone from a local treatment agency, not just for referrals but to learn more about treating patients with substance use problems. The Patient Protection and Affordable Care Act, which cites substance use disorders as one of 6 chronic health conditions that primary care medical homes are expected to address, may lead to better integration of health care systems that address physical health, as well as mental health and substance use disorders.

Episodic heavy drinking, like alcoholism and drug addiction, is increasingly recognized as a medical problem that primary care physicians can, and should, address.¹ But it is rarely the chief reason for an office visit. Nor is it a subject patients are likely to bring up.

However, patients are generally willing to talk to a trusted doctor who asks about their use (or misuse) of alcohol or other substances. And primary care physicians can do much to help—with brief interventions, a growing armamentarium of pharmacotherapy, and referrals as needed. In the pages that follow, you’ll find easy-to-use screening tools and effective intervention strategies.

SCREENING NEEDN'T BE TIME-CONSUMING

Screening for substance use isn’t difficult. In fact, it can usually be accomplished with 2 targeted questions—one for alcohol use and one for drugs.

Alcohol. Two single-question screens to detect hazardous drinking have been validated, despite having different parameters. Ask either:

Q: When was the last time you had more than ____ drinks (4 for women and 5 for men) in one day?

Q: How many times in the past year have you had ___ or more drinks (4 for women and 5 for men) in one day?

For the first question, any answer within the past 3 months is a positive screen for hazardous drinking.² For the second, anything other than zero is positive.^3,4

Initial screening can also be done with the AUDIT-C (TABLE), a validated short (3-question) version of the Alcohol Use Disorders Identification Test that can be self-administered.^5,6

Drugs. Only one single-question screen for drug use has been validated:

Q: How many times in the past year have you used an illegal drug or taken a prescription medication for nonmedical reasons?

Any answer other than never is a positive screen for hazardous drug use.⁷

CASE Jason F, a healthy and fit 28-year-old, has been your patient, along with his family, for years. He’s in your office because of a knee injury he incurred while running, and you take a moment to ask him, for the first time, how much he drinks and whether he takes drugs. His answer—that he drinks 3 or 4 times a week and often has multiple drinks at parties or nights out with the guys—takes you a bit by surprise.

Now what?

Watch the video

TABLE

3-question AUDIT-C screen for alcohol dependence^5,6

TELL ME MORE ABOUT IT

It is important to respond to a positive screen by requesting more information. In the conversation that ensues, the patient may provide the details you need to determine whether the drinking or drug use is indicative of a diagnosable substance use disorder, an umbrella term for alcohol or drug abuse and alcohol or drug dependence.

Alcohol or drug abuse vs dependence. Criteria for alcohol or drug abuse in the Diagnostic and Statistical Manual of Mental Disorders, 4th ed, text revision (DSM-IV-TR) include risky behavior, such as drinking and driving; problems with work and/or close relationships; or run-ins with the law, such as an arrest for driving while intoxicated. Criteria for alcohol or drug dependence include the inability to cut down or stop using the substance; evidence of tolerance and withdrawal; spending more time ingesting the substance; increasing attention to substance use while interest in other activities diminishes; and continued use despite recurrent problems.⁸

Tools zero in on extent of problem

To learn more about your patient’s situation, consider using the following criteria and tools:

DSM criteria. Ask the following 2 questions, which are among DSM-IV-TR criteria for alcohol dependence:

1. How many times in the last year have you had a lot more to drink than you intended?
2. How many times in the last year have you been drinking in situations where it could have been hazardous, where you could have caused an accident or gotten hurt?

Any answer other than zero to either question is suggestive of a substance use disorder. In exploratory analyses, this approach had positive likelihood ratios of 4.7 to 16 and negative likelihood ratios of 0.05 to 0.30.^9,10

Although the above questions refer to alcohol use, they could be revised to learn more about a patient’s use of marijuana or other drugs, as well. (There are few tools for the assessment of drug use, because any illegal or nonmedical use of controlled substances has clear risks of major harm.)

CAGE. Another tool that is effective in assessing alcohol use is the 4-question CAGE—an acronym for Cut down, Annoyed, Guilty, and Eye opener:

• Have you ever felt that you should cut down on your drinking?
• Have people annoyed you by criticizing your drinking?
• Have you ever felt bad or guilty about your drinking?
• Have you ever had a drink in the morning to get rid of a hangover?

One meta-analysis found that a positive CAGE test—ie, a positive response to one or more of the questions—had a sensitivity of 0.85 and a specificity of 0.78 in identifying alcohol dependence in a primary care setting (using DSM criteria as the gold standard).¹¹

AUDIT. This 10-item tool, a longer version of the AUDIT-C (available at http://www.medstudentlearning.com/node/6556), can also be used to determine the extent of alcohol use. This test provides detailed information about the quantity and frequency of alcohol use; however, it does not clearly distinguish between hazardous drinking and alcohol use disorders.¹²

If the patient is a teen

Assessment methods can be adjusted without difficulty to fit the age of the patient. The National Institute on Alcohol Abuse and Alcoholism has published the Alcohol Screening and Brief Intervention for Youth: A Practitioner’s Guide, available at http://www.niaaa.nih.gov/Publications/EducationTrainingMaterials/Pages/YouthGuide.aspx. The 6-question CRAFFT (for Car, Relax, Alone, Forget, Friends, Trouble) is a validated tool designed to assess adolescents’ use of both alcohol and drugs (http://www.ceasar-boston.org/clinicians/crafft.php).^13,14

CASE You give Mr. F the CAGE test, and he answers No to all 4 questions. You conclude that while his drinking may be hazardous, he does not appear to have alcohol abuse or dependence.

FOLLOW UP WITH A BRIEF INTERVENTION

For decades, evidence has shown that brief interventions are often effective in helping hazardous drinkers like Mr. F cut back to safer levels.^15-18 In some cases, the impact has been great enough to reduce health care and societal costs for up to 4 years¹⁹ and to cut the risk of alcohol-related death by about half.²⁰ As a result, the US Preventive Services Task Force has given a B rating to counseling to reduce alcohol misuse by primary care providers.²¹ (There is less evidence that brief interventions are effective for drug problems,²² or in settings other than primary care.²³)

Treat drug/alcohol problems

If you determine that your patient is engaging in hazardous alcohol or drug use or has a diagnosable substance use disorder, you do not have to drop everything else or treat it as an acute event. What matters is long-term success, which is best achieved by partnering with the patient.

Start by approaching drug and alcohol problems as you would a case of newly elevated blood pressure. Bring up the problem, seeking to engage the patient in addres- sing it.

If he or she does not agree to quit or cut back on drinking the first time you broach the subject, don’t be surprised or discouraged. Keep in mind that patients do not always respond positively to advice about handling chronic medical conditions either, particularly at first, and that you’ll be working together over time. What’s important, in the jargon of the Stages of Change model,²⁴ is to help the patient move from precontemplation to contemplation, and perhaps beyond that to planning or action.

Use motivational interviewing to partner with patients

Motivational interviewing is useful in helping patients change health-related behaviors. The technique, which is not hard to learn or apply, is based on the recognition that a simple shift in style toward a guiding (rather than directive) approach can often reap benefits that are immediately apparent. ^25-28

Motivational Interviewing: Helping People Change (3rd ed, by William R. Miller and Stephen Rollnick; Guilford Press, 2013) is an excellent resource for clinicians who wish to master this technique. An online tutorial in screening and brief intervention for alcohol or drug misuse is available free at https://adept.missouri.edu. Video demonstrations of motivational interviewing to address these issues are also available here ; to access them, click on “Training”, then on “Go to SBIRT videos”).

CASE Before Mr. F’s visit is concluded, you initiate a conversation about alcohol use, stating: “As your doctor, I’m concerned that the amount of alcohol you’re drinking could be hazardous to your health. I recommend that you cut down to no more than 4 drinks in any one day and to no more than 14 drinks a week.” You make it clear that change is up to him, and ask what he thinks about what you’ve said.

You also schedule a return visit in one month, at which time you will continue the conversation.

PHARMACOTHERAPY IS A USEFUL TOOL

Increasingly, alcohol and drug dependence—like other chronic conditions—can be effectively addressed with medication.

Drugs to treat alcohol dependence

Naltrexone. A daily dose of naltrexone, starting at 25 mg daily for a few days and going as high as 100 mg/d, can help patients with alcohol dependence limit their drinking to safe levels (number needed to treat [NNT]=9).²⁹ This will reduce the risk of alcohol-related harm while the patient considers quitting.

The most common adverse effect is nausea, but a low starting dose may alleviate it. Naltrexone, also available as a 380-mg intramuscular (IM) depot injection once every 4 weeks, is an opioid antagonist and should not be given to any patient who’s taking opioids.

A 2010 Cochrane review found only 4 trials of naltrexone IM, and failed to show significant reductions in drinking.²⁹ But post hoc analyses of trials of both oral and IM naltrexone found that those in which compliance was assured (either by direct observation or IM administration) had better outcomes than those in which it was not.³⁰ Another post hoc analysis found that patients whose alcohol dependence was more severe derived greater benefits from the drug than those who were less severely affected.³¹

Acamprosate. Two 333-mg pills tid can help newly abstinent drinkers remain alcohol-free (NNT=9).^32,33 The most common adverse effect is diarrhea, which may subside with continued use.

Combining acamprosate and naltrexone does not appear to be more effective than either drug alone. In a recently published meta-analysis comparing the 2 drugs, those taking acamprosate had slightly better rates of abstinence from alcohol, while naltrexone was slightly better in reducing heavy drinking.³⁴

Disulfiram Unlike naltrexone and acamprosate, which work by altering the brain’s reward circuits, disulfiram blocks metabolism of ethanol, leading to the accumulation of a toxic metabolite and its punishing syndrome. The major problem with the drug is noncompliance, which can be addressed by enlisting the help of a caregiver or partner to ensure that it is taken daily. ^35-37

Other medications that have been tested (though not approved by the US Food and Drug Administration [FDA]) as a treatment for alcohol dependence include:

• topiramate, which has been found to have modest efficacy in increasing the number of abstinent days and decreasing heavy-drinking days;³⁸
• baclofen, which has shown efficacy in small clinical trials;³⁹ and
• ondansetron, which has been shown to effectively treat early-onset alcohol dependence.^40,41

For patients with depression and alcohol dependence, the combination of naltrexone and sertraline has been found to be superior to either drug by itself—and to have fewer adverse effects. ⁴² Gabapentin and lorazepam have been compared in treating alcohol withdrawal, with gabapentin resulting in greater efficacy and fewer adverse effects than lorazepam.^43,44

Pharmacotherapy for drug abuse, dependence

For methamphetamine abuse and dependence. Two randomized clinical trials have studied medications for methamphetamine abuse and dependence. In one small study, topiramate did not increase the proportion of patients who achieved abstinence, but in a post hoc subgroup analysis, it did appear to help newly abstinent patients avoid relapse.⁴⁵

In another study, mirtazapine significantly decreased the proportion of patients whose weekly urine tests were positive for methamphetamine (from 73% to 44%); no significant change was found among those on placebo.⁴⁶

Both drugs were well tolerated, but compliance was low in both trials despite weekly counseling. Each has only one clinical trial to support its use, and neither has FDA approval for addiction treatment.

For marijuana dependence. In a study of 50 people seeking treatment for marijuana dependence, gabapentin 400 mg 3 times a day significantly improved the proportion reporting no cannabis use and whose urine tested negative for the drug.⁴⁷

Another recent trial randomized adolescents dependent on cannabis to placebo or N-acetylcysteine 1200 mg twice a day. Those on the active drug were 2.4 times more likely than those on placebo to have negative urine tests with a number needed to treat of 7.⁴⁸ Both trials ran for about 3 months. Neither drug is FDA approved to treat marijuana dependence.

For opioid dependence. As maintenance medication for patients dependent on opioids, both methadone and buprenorphine have been shown to reduce the use of illicit opioids, lower mortality, and improve retention compared with treatment without medication.⁴⁹ Methadone would be a better choice than buprenorphine, which is a partial agonist with a ceiling on both its good (eg, stopping craving) and bad (eg, overdose risk) effects. In an open-label observational study of patients’ preferences, those who chose methadone maintenance over buprenorphine were twice as likely to remain in treatment.⁵⁰ Both drugs are FDA-approved for treating opioid dependence.

Methadone is a full agonist that can be given for opioid dependence only in a federally licensed methadone maintenance clinic. It has been shown to reduce the use of other opioids, reduce criminal behaviors,⁵¹ improve function in many areas,⁵² and reduce mortality.⁵³ In a cohort study of Massachusetts Medicaid data, methadone reduced mortality, which was 75% higher among those receiving abstinence-based treatment.^52,54

Buprenorphine (alone and in combination with naloxone), effectively reduces the use of illicit opioids and improves functional status.^55-57

Naltrexone, an opioid antagonist, may be effective in the treatment of opioid dependence. As with disulfiram for alcohol dependence, a major limitation of naltrexone for opioid dependence is noncompliance. But once a patient has been on oral naltrexone, he or she can be switched to naltrexone IM, which can be administered every 4 weeks. A Cochrane review published in 2011 found no evidence that naltrexone was superior to placebo, ⁵⁸ but since then another randomized clinical trial has been published that found naltrexone 380 mg IM every 4 weeks was superior to IM placebo. Patients on naltrexone were more likely to remain in treatment and have opioid-free urine tests, and reported less craving for opioids.⁵⁹ Both oral and depot injection naltrexone are FDA approved for treatment of opioid dependence. No comparisons of naltrexone vs either methadone or buprenorphine have been published.

To learn more about pharmacotherapy for opioid dependence, see “Diagnosing and treating opioid dependence” (J Fam Pract. 2012;61:588-596).

DEALING WITH THE CHALLENGES

As noted earlier, some patients with substance use disorders, like some patients with depression or hypertension, respond well to care and counseling, and some do not. Just as with other conditions, consultation with a specialist often helps.

A major difference in arranging consultations for patients with substance use disorders, however, is that clinicians who specialize in substance abuse and dependence often work in health care systems that are largely, or entirely, separate from those in which primary care physicians typically work. This, plus the stigma that surrounds problems with substance use, presents barriers to patients, who may shy away from going across town or to another city to see a provider they don’t know for a problem they’re either resistant to “owning” or ashamed of.

Yet it is possible to reach across this divide and make it easier for patients. One way to do that might be to partner with a local alcohol- and drug-treatment program so that your patients are referred, not to a faceless agency, but rather to a specific clinician; you might even call the provider while the patient is in your office so they can “meet.” Another approach, taken by some multispecialty practices, is to add psychotherapists to the staff so that patients can simply walk down the hall to obtain the mental health care they need.

Reaching across this divide is also a useful strategy for primary care physicians, who may welcome opportunities to meet with someone from a local treatment agency, not just for referrals but to learn more about treating patients with substance use problems. The Patient Protection and Affordable Care Act, which cites substance use disorders as one of 6 chronic health conditions that primary care medical homes are expected to address, may lead to better integration of health care systems that address physical health, as well as mental health and substance use disorders.

Episodic heavy drinking, like alcoholism and drug addiction, is increasingly recognized as a medical problem that primary care physicians can, and should, address.¹ But it is rarely the chief reason for an office visit. Nor is it a subject patients are likely to bring up.

However, patients are generally willing to talk to a trusted doctor who asks about their use (or misuse) of alcohol or other substances. And primary care physicians can do much to help—with brief interventions, a growing armamentarium of pharmacotherapy, and referrals as needed. In the pages that follow, you’ll find easy-to-use screening tools and effective intervention strategies.

SCREENING NEEDN'T BE TIME-CONSUMING

Screening for substance use isn’t difficult. In fact, it can usually be accomplished with 2 targeted questions—one for alcohol use and one for drugs.

Alcohol. Two single-question screens to detect hazardous drinking have been validated, despite having different parameters. Ask either:

Q: When was the last time you had more than ____ drinks (4 for women and 5 for men) in one day?

Q: How many times in the past year have you had ___ or more drinks (4 for women and 5 for men) in one day?

For the first question, any answer within the past 3 months is a positive screen for hazardous drinking.² For the second, anything other than zero is positive.^3,4

Initial screening can also be done with the AUDIT-C (TABLE), a validated short (3-question) version of the Alcohol Use Disorders Identification Test that can be self-administered.^5,6

Drugs. Only one single-question screen for drug use has been validated:

Q: How many times in the past year have you used an illegal drug or taken a prescription medication for nonmedical reasons?

Any answer other than never is a positive screen for hazardous drug use.⁷

CASE Jason F, a healthy and fit 28-year-old, has been your patient, along with his family, for years. He’s in your office because of a knee injury he incurred while running, and you take a moment to ask him, for the first time, how much he drinks and whether he takes drugs. His answer—that he drinks 3 or 4 times a week and often has multiple drinks at parties or nights out with the guys—takes you a bit by surprise.

Now what?

Watch the video

TABLE

3-question AUDIT-C screen for alcohol dependence^5,6

TELL ME MORE ABOUT IT

It is important to respond to a positive screen by requesting more information. In the conversation that ensues, the patient may provide the details you need to determine whether the drinking or drug use is indicative of a diagnosable substance use disorder, an umbrella term for alcohol or drug abuse and alcohol or drug dependence.

Alcohol or drug abuse vs dependence. Criteria for alcohol or drug abuse in the Diagnostic and Statistical Manual of Mental Disorders, 4th ed, text revision (DSM-IV-TR) include risky behavior, such as drinking and driving; problems with work and/or close relationships; or run-ins with the law, such as an arrest for driving while intoxicated. Criteria for alcohol or drug dependence include the inability to cut down or stop using the substance; evidence of tolerance and withdrawal; spending more time ingesting the substance; increasing attention to substance use while interest in other activities diminishes; and continued use despite recurrent problems.⁸

Tools zero in on extent of problem

To learn more about your patient’s situation, consider using the following criteria and tools:

DSM criteria. Ask the following 2 questions, which are among DSM-IV-TR criteria for alcohol dependence:

1. How many times in the last year have you had a lot more to drink than you intended?
2. How many times in the last year have you been drinking in situations where it could have been hazardous, where you could have caused an accident or gotten hurt?

Any answer other than zero to either question is suggestive of a substance use disorder. In exploratory analyses, this approach had positive likelihood ratios of 4.7 to 16 and negative likelihood ratios of 0.05 to 0.30.^9,10

Although the above questions refer to alcohol use, they could be revised to learn more about a patient’s use of marijuana or other drugs, as well. (There are few tools for the assessment of drug use, because any illegal or nonmedical use of controlled substances has clear risks of major harm.)

CAGE. Another tool that is effective in assessing alcohol use is the 4-question CAGE—an acronym for Cut down, Annoyed, Guilty, and Eye opener:

• Have you ever felt that you should cut down on your drinking?
• Have people annoyed you by criticizing your drinking?
• Have you ever felt bad or guilty about your drinking?
• Have you ever had a drink in the morning to get rid of a hangover?

One meta-analysis found that a positive CAGE test—ie, a positive response to one or more of the questions—had a sensitivity of 0.85 and a specificity of 0.78 in identifying alcohol dependence in a primary care setting (using DSM criteria as the gold standard).¹¹

AUDIT. This 10-item tool, a longer version of the AUDIT-C (available at http://www.medstudentlearning.com/node/6556), can also be used to determine the extent of alcohol use. This test provides detailed information about the quantity and frequency of alcohol use; however, it does not clearly distinguish between hazardous drinking and alcohol use disorders.¹²

If the patient is a teen

Assessment methods can be adjusted without difficulty to fit the age of the patient. The National Institute on Alcohol Abuse and Alcoholism has published the Alcohol Screening and Brief Intervention for Youth: A Practitioner’s Guide, available at http://www.niaaa.nih.gov/Publications/EducationTrainingMaterials/Pages/YouthGuide.aspx. The 6-question CRAFFT (for Car, Relax, Alone, Forget, Friends, Trouble) is a validated tool designed to assess adolescents’ use of both alcohol and drugs (http://www.ceasar-boston.org/clinicians/crafft.php).^13,14

CASE You give Mr. F the CAGE test, and he answers No to all 4 questions. You conclude that while his drinking may be hazardous, he does not appear to have alcohol abuse or dependence.

FOLLOW UP WITH A BRIEF INTERVENTION

For decades, evidence has shown that brief interventions are often effective in helping hazardous drinkers like Mr. F cut back to safer levels.^15-18 In some cases, the impact has been great enough to reduce health care and societal costs for up to 4 years¹⁹ and to cut the risk of alcohol-related death by about half.²⁰ As a result, the US Preventive Services Task Force has given a B rating to counseling to reduce alcohol misuse by primary care providers.²¹ (There is less evidence that brief interventions are effective for drug problems,²² or in settings other than primary care.²³)

Treat drug/alcohol problems

If you determine that your patient is engaging in hazardous alcohol or drug use or has a diagnosable substance use disorder, you do not have to drop everything else or treat it as an acute event. What matters is long-term success, which is best achieved by partnering with the patient.

Start by approaching drug and alcohol problems as you would a case of newly elevated blood pressure. Bring up the problem, seeking to engage the patient in addres- sing it.

If he or she does not agree to quit or cut back on drinking the first time you broach the subject, don’t be surprised or discouraged. Keep in mind that patients do not always respond positively to advice about handling chronic medical conditions either, particularly at first, and that you’ll be working together over time. What’s important, in the jargon of the Stages of Change model,²⁴ is to help the patient move from precontemplation to contemplation, and perhaps beyond that to planning or action.

Use motivational interviewing to partner with patients

Motivational interviewing is useful in helping patients change health-related behaviors. The technique, which is not hard to learn or apply, is based on the recognition that a simple shift in style toward a guiding (rather than directive) approach can often reap benefits that are immediately apparent. ^25-28

Motivational Interviewing: Helping People Change (3rd ed, by William R. Miller and Stephen Rollnick; Guilford Press, 2013) is an excellent resource for clinicians who wish to master this technique. An online tutorial in screening and brief intervention for alcohol or drug misuse is available free at https://adept.missouri.edu. Video demonstrations of motivational interviewing to address these issues are also available here ; to access them, click on “Training”, then on “Go to SBIRT videos”).

CASE Before Mr. F’s visit is concluded, you initiate a conversation about alcohol use, stating: “As your doctor, I’m concerned that the amount of alcohol you’re drinking could be hazardous to your health. I recommend that you cut down to no more than 4 drinks in any one day and to no more than 14 drinks a week.” You make it clear that change is up to him, and ask what he thinks about what you’ve said.

You also schedule a return visit in one month, at which time you will continue the conversation.

PHARMACOTHERAPY IS A USEFUL TOOL

Increasingly, alcohol and drug dependence—like other chronic conditions—can be effectively addressed with medication.

Drugs to treat alcohol dependence

Naltrexone. A daily dose of naltrexone, starting at 25 mg daily for a few days and going as high as 100 mg/d, can help patients with alcohol dependence limit their drinking to safe levels (number needed to treat [NNT]=9).²⁹ This will reduce the risk of alcohol-related harm while the patient considers quitting.

The most common adverse effect is nausea, but a low starting dose may alleviate it. Naltrexone, also available as a 380-mg intramuscular (IM) depot injection once every 4 weeks, is an opioid antagonist and should not be given to any patient who’s taking opioids.

A 2010 Cochrane review found only 4 trials of naltrexone IM, and failed to show significant reductions in drinking.²⁹ But post hoc analyses of trials of both oral and IM naltrexone found that those in which compliance was assured (either by direct observation or IM administration) had better outcomes than those in which it was not.³⁰ Another post hoc analysis found that patients whose alcohol dependence was more severe derived greater benefits from the drug than those who were less severely affected.³¹

Acamprosate. Two 333-mg pills tid can help newly abstinent drinkers remain alcohol-free (NNT=9).^32,33 The most common adverse effect is diarrhea, which may subside with continued use.

Combining acamprosate and naltrexone does not appear to be more effective than either drug alone. In a recently published meta-analysis comparing the 2 drugs, those taking acamprosate had slightly better rates of abstinence from alcohol, while naltrexone was slightly better in reducing heavy drinking.³⁴

Disulfiram Unlike naltrexone and acamprosate, which work by altering the brain’s reward circuits, disulfiram blocks metabolism of ethanol, leading to the accumulation of a toxic metabolite and its punishing syndrome. The major problem with the drug is noncompliance, which can be addressed by enlisting the help of a caregiver or partner to ensure that it is taken daily. ^35-37

Other medications that have been tested (though not approved by the US Food and Drug Administration [FDA]) as a treatment for alcohol dependence include:

• topiramate, which has been found to have modest efficacy in increasing the number of abstinent days and decreasing heavy-drinking days;³⁸
• baclofen, which has shown efficacy in small clinical trials;³⁹ and
• ondansetron, which has been shown to effectively treat early-onset alcohol dependence.^40,41

For patients with depression and alcohol dependence, the combination of naltrexone and sertraline has been found to be superior to either drug by itself—and to have fewer adverse effects. ⁴² Gabapentin and lorazepam have been compared in treating alcohol withdrawal, with gabapentin resulting in greater efficacy and fewer adverse effects than lorazepam.^43,44

Pharmacotherapy for drug abuse, dependence

For methamphetamine abuse and dependence. Two randomized clinical trials have studied medications for methamphetamine abuse and dependence. In one small study, topiramate did not increase the proportion of patients who achieved abstinence, but in a post hoc subgroup analysis, it did appear to help newly abstinent patients avoid relapse.⁴⁵

In another study, mirtazapine significantly decreased the proportion of patients whose weekly urine tests were positive for methamphetamine (from 73% to 44%); no significant change was found among those on placebo.⁴⁶

Both drugs were well tolerated, but compliance was low in both trials despite weekly counseling. Each has only one clinical trial to support its use, and neither has FDA approval for addiction treatment.

For marijuana dependence. In a study of 50 people seeking treatment for marijuana dependence, gabapentin 400 mg 3 times a day significantly improved the proportion reporting no cannabis use and whose urine tested negative for the drug.⁴⁷

Another recent trial randomized adolescents dependent on cannabis to placebo or N-acetylcysteine 1200 mg twice a day. Those on the active drug were 2.4 times more likely than those on placebo to have negative urine tests with a number needed to treat of 7.⁴⁸ Both trials ran for about 3 months. Neither drug is FDA approved to treat marijuana dependence.

For opioid dependence. As maintenance medication for patients dependent on opioids, both methadone and buprenorphine have been shown to reduce the use of illicit opioids, lower mortality, and improve retention compared with treatment without medication.⁴⁹ Methadone would be a better choice than buprenorphine, which is a partial agonist with a ceiling on both its good (eg, stopping craving) and bad (eg, overdose risk) effects. In an open-label observational study of patients’ preferences, those who chose methadone maintenance over buprenorphine were twice as likely to remain in treatment.⁵⁰ Both drugs are FDA-approved for treating opioid dependence.

Methadone is a full agonist that can be given for opioid dependence only in a federally licensed methadone maintenance clinic. It has been shown to reduce the use of other opioids, reduce criminal behaviors,⁵¹ improve function in many areas,⁵² and reduce mortality.⁵³ In a cohort study of Massachusetts Medicaid data, methadone reduced mortality, which was 75% higher among those receiving abstinence-based treatment.^52,54

Buprenorphine (alone and in combination with naloxone), effectively reduces the use of illicit opioids and improves functional status.^55-57

Naltrexone, an opioid antagonist, may be effective in the treatment of opioid dependence. As with disulfiram for alcohol dependence, a major limitation of naltrexone for opioid dependence is noncompliance. But once a patient has been on oral naltrexone, he or she can be switched to naltrexone IM, which can be administered every 4 weeks. A Cochrane review published in 2011 found no evidence that naltrexone was superior to placebo, ⁵⁸ but since then another randomized clinical trial has been published that found naltrexone 380 mg IM every 4 weeks was superior to IM placebo. Patients on naltrexone were more likely to remain in treatment and have opioid-free urine tests, and reported less craving for opioids.⁵⁹ Both oral and depot injection naltrexone are FDA approved for treatment of opioid dependence. No comparisons of naltrexone vs either methadone or buprenorphine have been published.

To learn more about pharmacotherapy for opioid dependence, see “Diagnosing and treating opioid dependence” (J Fam Pract. 2012;61:588-596).

DEALING WITH THE CHALLENGES

As noted earlier, some patients with substance use disorders, like some patients with depression or hypertension, respond well to care and counseling, and some do not. Just as with other conditions, consultation with a specialist often helps.

A major difference in arranging consultations for patients with substance use disorders, however, is that clinicians who specialize in substance abuse and dependence often work in health care systems that are largely, or entirely, separate from those in which primary care physicians typically work. This, plus the stigma that surrounds problems with substance use, presents barriers to patients, who may shy away from going across town or to another city to see a provider they don’t know for a problem they’re either resistant to “owning” or ashamed of.

Yet it is possible to reach across this divide and make it easier for patients. One way to do that might be to partner with a local alcohol- and drug-treatment program so that your patients are referred, not to a faceless agency, but rather to a specific clinician; you might even call the provider while the patient is in your office so they can “meet.” Another approach, taken by some multispecialty practices, is to add psychotherapists to the staff so that patients can simply walk down the hall to obtain the mental health care they need.

Reaching across this divide is also a useful strategy for primary care physicians, who may welcome opportunities to meet with someone from a local treatment agency, not just for referrals but to learn more about treating patients with substance use problems. The Patient Protection and Affordable Care Act, which cites substance use disorders as one of 6 chronic health conditions that primary care medical homes are expected to address, may lead to better integration of health care systems that address physical health, as well as mental health and substance use disorders.

The leading causes of death in developed countries are heart disease and cancer, often resulting from smoking, poor diet, and lack of exercise, and excessive alcohol use.¹ Importantly, changing unhealthy behaviors—at least smoking^2,3 and excessive drinking⁴— improves health outcomes that patients care about.

Changing behavior is not easy. Moreover, smoking, drinking, and poor diet are not biomedical conditions under the clinician’s control. Brief interventions in primary care help some patients change their use of tobacco⁵ and alcohol,^6,7 but only a small minority change. Studies of diet and exercise have shown only modest impact on disease-oriented measures.^8-10 The Activity Counseling Trial, for example, showed an increase of 5% in maximal oxygen uptake, but in women only. In that clinical trial, men and women in all treatment groups reported significantly increased physical activity, but they comprised only about 3%.¹⁰ Clinician-prompted change of eating or exercise patterns is not common, easy, substantial, or lasting.

The interventions used in those studies were intensive. The study by van der Veen and colleagues in this issue of JFP examined an approach that is more feasible in family practice. They referred patients to a dietitian only when the patient was ready to change; 60 of 71 patients in the intervention group met that criterion. After 1 to 3 10-min visits with the family physician and 3 visits to the dietitian totaling about 1 hour, change in self-reported fat consumption was modest and changes in body measurements small. The intervention group on average gained 0.2 kg over 12 months, and the control group lost 0.6 kg.

What should practicing clinicians do? Our ability to help patients with eating and activity issues is limited, but we can still respond in helpful ways. First, change takes time. Obesity and sedentary lifestyles, like tobacco and alcohol problems, are chronic issues. We should not be surprised if an hour with a dietitian effects only small changes.

Second, even those small changes can be meaningful. Some people given an intervention will change more than others. For them the outcomes may be considerably improved. Furthermore, small changes distributed over many people may benefit a population significantly.¹¹

Third, if we are to find answers to family medicine’s important questions, then we need to be involved in generating those answers (and in identifying the specific research questions). Addressing questions identified in practice by studying interventions in practice is the core idea of practice-based research. The study by van der Veen et al is an example; more such work is needed.

Finally, poor dietary choices, inactivity, and obesity are environmental issues. Addressing them with individual patients is necessary, but not likely to be sufficient. As a national consensus panel concluded, “Exertion has been systematically engineered out of most occupations and lifestyles.”¹²

Re-engineering our lives to increase activity and decrease calories and fat will require societal change. Cultures change, just as persons do: over time, often with great effort, and sometimes in surprising ways. Family physicians with insight and creativity are needed to help find those ways.

CORRESPONDENCE
Dan Vinson, MD, MSPH, Department of Family and Community Medicine, M231 Health Sciences, University of Missouri-Columbia, Columbia, MO 65212. Email: vinsond@health.missouri.edu.

The leading causes of death in developed countries are heart disease and cancer, often resulting from smoking, poor diet, and lack of exercise, and excessive alcohol use.¹ Importantly, changing unhealthy behaviors—at least smoking^2,3 and excessive drinking⁴— improves health outcomes that patients care about.

Changing behavior is not easy. Moreover, smoking, drinking, and poor diet are not biomedical conditions under the clinician’s control. Brief interventions in primary care help some patients change their use of tobacco⁵ and alcohol,^6,7 but only a small minority change. Studies of diet and exercise have shown only modest impact on disease-oriented measures.^8-10 The Activity Counseling Trial, for example, showed an increase of 5% in maximal oxygen uptake, but in women only. In that clinical trial, men and women in all treatment groups reported significantly increased physical activity, but they comprised only about 3%.¹⁰ Clinician-prompted change of eating or exercise patterns is not common, easy, substantial, or lasting.

The interventions used in those studies were intensive. The study by van der Veen and colleagues in this issue of JFP examined an approach that is more feasible in family practice. They referred patients to a dietitian only when the patient was ready to change; 60 of 71 patients in the intervention group met that criterion. After 1 to 3 10-min visits with the family physician and 3 visits to the dietitian totaling about 1 hour, change in self-reported fat consumption was modest and changes in body measurements small. The intervention group on average gained 0.2 kg over 12 months, and the control group lost 0.6 kg.

What should practicing clinicians do? Our ability to help patients with eating and activity issues is limited, but we can still respond in helpful ways. First, change takes time. Obesity and sedentary lifestyles, like tobacco and alcohol problems, are chronic issues. We should not be surprised if an hour with a dietitian effects only small changes.

Second, even those small changes can be meaningful. Some people given an intervention will change more than others. For them the outcomes may be considerably improved. Furthermore, small changes distributed over many people may benefit a population significantly.¹¹

Third, if we are to find answers to family medicine’s important questions, then we need to be involved in generating those answers (and in identifying the specific research questions). Addressing questions identified in practice by studying interventions in practice is the core idea of practice-based research. The study by van der Veen et al is an example; more such work is needed.

Finally, poor dietary choices, inactivity, and obesity are environmental issues. Addressing them with individual patients is necessary, but not likely to be sufficient. As a national consensus panel concluded, “Exertion has been systematically engineered out of most occupations and lifestyles.”¹²

Re-engineering our lives to increase activity and decrease calories and fat will require societal change. Cultures change, just as persons do: over time, often with great effort, and sometimes in surprising ways. Family physicians with insight and creativity are needed to help find those ways.

CORRESPONDENCE
Dan Vinson, MD, MSPH, Department of Family and Community Medicine, M231 Health Sciences, University of Missouri-Columbia, Columbia, MO 65212. Email: vinsond@health.missouri.edu.

The leading causes of death in developed countries are heart disease and cancer, often resulting from smoking, poor diet, and lack of exercise, and excessive alcohol use.¹ Importantly, changing unhealthy behaviors—at least smoking^2,3 and excessive drinking⁴— improves health outcomes that patients care about.

Changing behavior is not easy. Moreover, smoking, drinking, and poor diet are not biomedical conditions under the clinician’s control. Brief interventions in primary care help some patients change their use of tobacco⁵ and alcohol,^6,7 but only a small minority change. Studies of diet and exercise have shown only modest impact on disease-oriented measures.^8-10 The Activity Counseling Trial, for example, showed an increase of 5% in maximal oxygen uptake, but in women only. In that clinical trial, men and women in all treatment groups reported significantly increased physical activity, but they comprised only about 3%.¹⁰ Clinician-prompted change of eating or exercise patterns is not common, easy, substantial, or lasting.

The interventions used in those studies were intensive. The study by van der Veen and colleagues in this issue of JFP examined an approach that is more feasible in family practice. They referred patients to a dietitian only when the patient was ready to change; 60 of 71 patients in the intervention group met that criterion. After 1 to 3 10-min visits with the family physician and 3 visits to the dietitian totaling about 1 hour, change in self-reported fat consumption was modest and changes in body measurements small. The intervention group on average gained 0.2 kg over 12 months, and the control group lost 0.6 kg.

What should practicing clinicians do? Our ability to help patients with eating and activity issues is limited, but we can still respond in helpful ways. First, change takes time. Obesity and sedentary lifestyles, like tobacco and alcohol problems, are chronic issues. We should not be surprised if an hour with a dietitian effects only small changes.

Second, even those small changes can be meaningful. Some people given an intervention will change more than others. For them the outcomes may be considerably improved. Furthermore, small changes distributed over many people may benefit a population significantly.¹¹

Third, if we are to find answers to family medicine’s important questions, then we need to be involved in generating those answers (and in identifying the specific research questions). Addressing questions identified in practice by studying interventions in practice is the core idea of practice-based research. The study by van der Veen et al is an example; more such work is needed.

Finally, poor dietary choices, inactivity, and obesity are environmental issues. Addressing them with individual patients is necessary, but not likely to be sufficient. As a national consensus panel concluded, “Exertion has been systematically engineered out of most occupations and lifestyles.”¹²

Re-engineering our lives to increase activity and decrease calories and fat will require societal change. Cultures change, just as persons do: over time, often with great effort, and sometimes in surprising ways. Family physicians with insight and creativity are needed to help find those ways.

CORRESPONDENCE
Dan Vinson, MD, MSPH, Department of Family and Community Medicine, M231 Health Sciences, University of Missouri-Columbia, Columbia, MO 65212. Email: vinsond@health.missouri.edu.

Brief physician intervention with problem drinkers can be effective in primary care practice: Patients who receive it are twice as likely to moderate their alcohol intake as patients in a control group.^1-4 Most problem drinkers, however, go unrecognized and untreated in medical encounters.^5,6 Two separate surveys found that only 39% of patients reported being asked by their physician about their alcohol use.^7,8 Several barriers to widespread adoption of brief physician-based intervention techniques have been hypothesized, including time constraints and physician reluctance to impose a new agenda on the patient;^9-11 but the quantitative effects of those barriers on current physician practice have not been empirically explored.

In research trials brief interventions with problem drinkers have required one or more office visits, each lasting from 5 to 15 minutes.^2,3 In those studies, patients were screened at one visit, and those identified as problem drinkers were recruited for the study by research personnel. If assigned to the intervention group, they returned for another office visit. This 2-stage approach (screening and intervention at separate visits) may miss some patients. In the Wisconsin study,² 30% of those patients willing to participate failed to complete the baseline interview, and 22% of those assigned to the intervention group did not keep the subsequent appointment. Furthermore, physicians may find the requirement of a second visit too burdensome. In a study in Scotland, half the general practitioners who were invited to participate did not join the study because they felt that a 10-minute intervention was too time consuming.¹² These problems could be partially addressed by opportunistic intervention (screening and doing the brief intervention at the same office visit), but an Australian study¹³ found even that approach unsuccessful.

A better understanding of current alcohol-related discussions in primary care may facilitate adoption of brief interventions with problem drinkers, and we know of no study that has described them. We designed our study to describe the frequency, duration, intensity, and triggers of alcohol-related discussions in primary care routine practice. Then in a before-after design, we investigated changes in alcohol-related discussions with the addition of systematic screening of all adult patients for problem drinking, and then again after the clinicians received training in brief interventions with problem drinkers.

Methods

The Ambulatory Sentinel Practice Network (ASPN) included primary care clinicians in the United States and Canada; 86% were family physicians, and most of the rest were nurse practitioners and physician assistants. ASPN conducted more than 40 studies that spanned a broad spectrum of clinical and health services research that informed both clinical practice and health care policy.¹⁴ A comparison of key characteristics of ASPN patients with a probability sample of US family physicians participating in the 1991 National Ambulatory Care Survey suggests minimal selection bias associated with voluntary participation in ASPN.¹⁵

We recruited volunteer clinicians to collect data about alcohol-involved visits for 1 week without change in their routine practice (Phase 1). Clinicians recorded data about any patient they knew had an alcohol problem or if they discussed alcohol for any reason. On a pocket-sized card,¹⁶ they noted the patient’s age and sex, the type of visit (acute self-limited illness, acute serious, chronic illness, obstetrical care, or health maintenance), whether the presenting complaint seemed related to alcohol, whether the clinician had any previous knowledge or suspicion of an alcohol problem, what triggered the alcohol-related discussion, how long it lasted (<2, 2 to 4, 4 to 8, or >8 minutes), and how intense it was for the clinician and for the patient (coded as no, mild to moderate, or marked intensity).

Clinicians who completed Phase 1 were invited to participate in a second week of data collection, this time with the addition of routine screening of all adult patients presenting for care (Phase 2). As in Phase 1, data were recorded for any patient who had a known alcohol problem, any patient with whom the clinician discussed alcohol, and any patient who had a positive screening result for problem drinking. The screening question—“When was the last time you had more than 5 drinks on one occasion?”¹⁷—was asked between questions regarding tobacco and seat belt use. An answer indicating any time within the past 3 months was considered a positive screening result for problem drinking.

We invited clinicians who participated in Phase 2 to receive training in brief interventions with problem drinkers. We mailed them a copy of The Physicians’ Guide to Helping Patients with Alcohol Problems¹⁸ and a videotaped lecture illustrating the steps in that guide. We also telephoned each participating clinician to address any concerns or perceived barriers and to practice brief intervention skills. Following training, each clinician collected card data for a third week (Phase 3), that included routine screening of all adult patients as in Phase 2. The 3 weeks of data collection were not consecutive in any practice, and each phase was not done in the same week across practices.

In comparing data from clinicians participating in more than one phase of card data collection, we assessed statistical significance with confidence interval analysis and with nonparametric tests (chi square, Fisher exact, and Mann-Whitney U) because most distributions were skewed.¹⁹

Results

A total of 114 clinicians collected data in Phase 1. During that week (which varied among practices), they saw a total of 7695 patients and had an alcohol-related discussion with 732 of them (9.5% of all visits). Among those 732 patients, the average age was 40 years (standard deviation = 18); 52.1% were women. Of the visits at which alcohol was discussed, 40% were for health maintenance, 28% for chronic illness, and 23% for acute self-limited illness. The clinician had previously seen the patient in 69% of the cases.

Nineteen clinicians participated in both Phases 1 and 2. They saw 1685 patients in Phase 1 and 1719 in Phase 2. Compared with clinicians who did not participate, more of the participants’ Phase 1 alcohol-related discussions were with patients they knew or suspected had an alcohol problem (34% vs 15%, P <.001 by chi square). Their alcohol-related discussions were longer (P = .008 by Mann-Whitney U), more likely to be prompted by their own concern (29% vs 20%) and were perceived as having greater intensity for the patient (6% perceived as having marked intensity vs 1%). However, the proportion of visits during which those 19 clinicians discussed alcohol was not significantly different from clinicians in Phase 1 who did not participate in Phase 2.

Table 1 shows comparisons of Phase 1 and Phase 2 for the 19 clinicians who completed data collection for both. Although we had anticipated a significant increase in the frequency, duration, and perceived intensity of alcohol-related discussions, the results from the first 2 phases were surprisingly similar. The addition of routine screening was associated with a shift in the triggers noted, especially from “clinician screening” to “primary prevention,” a decrease in the proportion that occurred in health maintenance visits, and an increase in the proportion in acute-care visits. Notably, of the 168 patients who had a positive screening result for problem drinking, the clinician did not discuss alcohol with 61, usually because of discussions at previous visits or a lack of time. The clinician had no previous knowledge or suspicion of an alcohol problem in 41 of those 61 instances; approximately one fourth (41 of 168) of the positive screening results were unexpected but were not addressed at the screening visit.

Of the 19 clinicians who participated in Phases 1 and 2, 15 participated in Phase 3 Table 2. We anticipated that training would increase the frequency and duration of alcohol-related discussions with patients who had a positive screening result and decrease the clinicians’ perceived discomfort with the intervention. Although these 15 clinicians were slightly more likely to address a positive screening result in Phase 3 than in Phase 2, the difference was not statistically significant. The discussions, however, were significantly longer. This was especially evident if the discussion was in response to a positive screening result: only 32% of those discussions lasted longer than 2 minutes in Phase 2, 58% in Phase 3 (P <.001). However, only 26% lasted longer than 4 minutes, and “not enough time” was checked more often in Phase 3 than in Phase 2 as a reason for not addressing a positive screening result.

In Phase 2, 70% of the screening was done by office assistants, compared with 57% in Phase 3 (P = .03). However, the screener did not significantly affect the characteristics of alcohol-related discussions, such as duration and intensity. Although 2 of the participating clinicians reported missing the screening of some patients, the clinicians reported only one patient who refused screening of the 3391 patients seen during these 2 phases of our study. Data were recorded on the pocket-sized card after each visit in approximately 40%, at the end of each day in another 40%, and at the end of the week in about 20% in both Phase 1 and 2; data were recorded somewhat closer to the visit in Phase 3 (60% after each visit, 33% each day).

Discussion

In all phases of this study, the primary care clinicians discussed alcohol with approximately 10% of their patients, usually at their own initiation. Relatively few discussions (approximately 1 out of 5) were prompted by the clinician’s concern about a possible alcohol problem, and even fewer were initiated by a patient or concerned family member. Unlike the successful 5- to 15-minute interventions published in the literature, these alcohol-related discussions were remarkably short. In Phase 1, considering only the 19 clinicians who also participated in Phase 2, 93% of the alcohol-related discussions were shorter than 4 minutes, even when they were prompted by the clinician’s concern.

We thought routine screening would increase the frequency of alcohol-related discussions, shift the focus from clinicians doing their own screening to intervening with identified problem drinkers, and make the discussions longer and more uncomfortable. But routine screening made almost no difference in alcohol-related discussions. Clinicians reported shifts in the triggers for alcohol-related discussions and the types of patient visits during which alcohol was discussed, but we found no significant changes in the duration or intensity of alcohol-related discussions.

In Phase 3, after the physicians received training in identifying and intervening with problem drinkers, alcohol-related discussions were significantly longer. When initiated in response to a positive screening result, most discussions were longer than 2 minutes, but only 26% lasted longer than 4 minutes, still shorter than effective brief interventions.^1,2

Our findings are, in some respects, generalizable to other primary care clinicians. The proportion of visits in which alcohol was discussed in our study was similar to the 9% reported by the Direct Observation of Primary Care study.²⁰ This was the first study of problem drinking by ASPN, and the patients were comparable with those seen in the National Ambulatory Medical Care Survey.¹⁵

The reasons for the lack of change with the addition of routine screening remain unclear; we suggest 3 possibilities. First, these clinicians may have already known their patients well; adding routine screening gave them little additional information. However, the most commonly cited reason for not discussing alcohol with patients who had a positive screening result was a lack of time. Second, most clinicians had their office assistant screen patients, and more discussions might have taken place had the clinicians done the screening and used a positive response as an opportunity to engage the patient in a conversation about drinking. The duration of discussions prompted by clinician concern, however, was similar across all 3 phases of our study. Third, time constraints may have limited clinicians’ ability to respond to an unexpectedly positive screening result. A lack of time was given as a reason for not discussing a positive screening result with 22 of 61 patients in Phase 2, 17 of 30 in Phase 3. Notably and also contrary to our expectations, clinician discomfort with screening-prompted discussions was no greater than with those in Phase 1, suggesting that adding routine screening seldom creates an awkward situation for the clinician.

Although training was associated with longer discussions, the changes from Phase 2 (before training) to Phase 3 (after training) were smaller than we anticipated. Further exploration is warranted, but as documented by Stange and colleagues,²⁰ an ordinary office visit deals with a multitude of issues. The lack of substantial change in alcohol-related discussions may simply be because of the crowded agenda of the primary care office visit.

We do not know the content or outcome of the alcohol-related discussions during the 3 phases of data collection or how many of those who screened positive actually had at-risk drinking, an alcohol-use disorder, both, or neither. Of those who had a negative screening result yet had an alcohol-related discussion, 5 of the 34 discussions in Phase 2 and 15 of the 44 in Phase 3 were prompted by clinician concern. We suspect some of these patients had false-negative screening results, and we do not know how many other problem drinkers were missed by the screening question.

Limitations

The 19 clinicians who participated in both Phase 1 and Phase 2 were demonstrably different from the Phase 1—only participants. Their alcohol-related discussions were longer, and more of those discussions were triggered by clinician concern. Assuming that the physicians who did not participate in Phase 2 were similar to family physicians in general, our findings are likely to show greater clinician concern about problem drinking and longer alcohol-related discussions than would be true nationally.

Also, all our data were from physician self-reports. Patient report, chart review, or observation by a third person would probably demonstrate differences. Given the lag between encounters and data recording for some clinicians, recall of alcohol-related discussions may have faded, and even those clinicians who recorded data after each visit might have missed some. However, this would be true of data collection in all 3 phases of our study, and the magnitude of bias would be similar. Furthermore, the phases were not contiguous for any practice, and we doubt there were any substantial learning or fatigue effects that might have changed the accuracy of data collection from one phase to another.

Conclusions

Alcohol use is a common topic of discussion in primary care, and the clinicians in this study usually felt comfortable addressing it. The duration of these discussions, however, was almost always shorter than the effective brief interventions with problem drinkers in all published clinical trials. Whether a 2-minute intervention would be successful is a matter for future empirical research, but it is clear that either brief interventions need to be substantially shorter, or the approach to alcohol problems in primary care needs to be changed. Furthermore, it is clear that simply adding routine screening to primary care practice is not sufficient to change clinician behavior significantly. Screening with a single question, however, was almost universally acceptable to patients and did not increase discomfort for the clinicians. And training the clinicians in recognition of and brief intervention with problem drinkers was effective in increasing the duration of the discussions.

Acknowledgments

We received funding from the Alcoholic Beverage Medical Research Foundation. During the study, Dr. Vinson was supported by a Generalist Physician Faculty Scholars Program grant from the Robert Wood Johnson Foundation.

Brief physician intervention with problem drinkers can be effective in primary care practice: Patients who receive it are twice as likely to moderate their alcohol intake as patients in a control group.^1-4 Most problem drinkers, however, go unrecognized and untreated in medical encounters.^5,6 Two separate surveys found that only 39% of patients reported being asked by their physician about their alcohol use.^7,8 Several barriers to widespread adoption of brief physician-based intervention techniques have been hypothesized, including time constraints and physician reluctance to impose a new agenda on the patient;^9-11 but the quantitative effects of those barriers on current physician practice have not been empirically explored.

In research trials brief interventions with problem drinkers have required one or more office visits, each lasting from 5 to 15 minutes.^2,3 In those studies, patients were screened at one visit, and those identified as problem drinkers were recruited for the study by research personnel. If assigned to the intervention group, they returned for another office visit. This 2-stage approach (screening and intervention at separate visits) may miss some patients. In the Wisconsin study,² 30% of those patients willing to participate failed to complete the baseline interview, and 22% of those assigned to the intervention group did not keep the subsequent appointment. Furthermore, physicians may find the requirement of a second visit too burdensome. In a study in Scotland, half the general practitioners who were invited to participate did not join the study because they felt that a 10-minute intervention was too time consuming.¹² These problems could be partially addressed by opportunistic intervention (screening and doing the brief intervention at the same office visit), but an Australian study¹³ found even that approach unsuccessful.

A better understanding of current alcohol-related discussions in primary care may facilitate adoption of brief interventions with problem drinkers, and we know of no study that has described them. We designed our study to describe the frequency, duration, intensity, and triggers of alcohol-related discussions in primary care routine practice. Then in a before-after design, we investigated changes in alcohol-related discussions with the addition of systematic screening of all adult patients for problem drinking, and then again after the clinicians received training in brief interventions with problem drinkers.

Methods

The Ambulatory Sentinel Practice Network (ASPN) included primary care clinicians in the United States and Canada; 86% were family physicians, and most of the rest were nurse practitioners and physician assistants. ASPN conducted more than 40 studies that spanned a broad spectrum of clinical and health services research that informed both clinical practice and health care policy.¹⁴ A comparison of key characteristics of ASPN patients with a probability sample of US family physicians participating in the 1991 National Ambulatory Care Survey suggests minimal selection bias associated with voluntary participation in ASPN.¹⁵

We recruited volunteer clinicians to collect data about alcohol-involved visits for 1 week without change in their routine practice (Phase 1). Clinicians recorded data about any patient they knew had an alcohol problem or if they discussed alcohol for any reason. On a pocket-sized card,¹⁶ they noted the patient’s age and sex, the type of visit (acute self-limited illness, acute serious, chronic illness, obstetrical care, or health maintenance), whether the presenting complaint seemed related to alcohol, whether the clinician had any previous knowledge or suspicion of an alcohol problem, what triggered the alcohol-related discussion, how long it lasted (<2, 2 to 4, 4 to 8, or >8 minutes), and how intense it was for the clinician and for the patient (coded as no, mild to moderate, or marked intensity).

Clinicians who completed Phase 1 were invited to participate in a second week of data collection, this time with the addition of routine screening of all adult patients presenting for care (Phase 2). As in Phase 1, data were recorded for any patient who had a known alcohol problem, any patient with whom the clinician discussed alcohol, and any patient who had a positive screening result for problem drinking. The screening question—“When was the last time you had more than 5 drinks on one occasion?”¹⁷—was asked between questions regarding tobacco and seat belt use. An answer indicating any time within the past 3 months was considered a positive screening result for problem drinking.

We invited clinicians who participated in Phase 2 to receive training in brief interventions with problem drinkers. We mailed them a copy of The Physicians’ Guide to Helping Patients with Alcohol Problems¹⁸ and a videotaped lecture illustrating the steps in that guide. We also telephoned each participating clinician to address any concerns or perceived barriers and to practice brief intervention skills. Following training, each clinician collected card data for a third week (Phase 3), that included routine screening of all adult patients as in Phase 2. The 3 weeks of data collection were not consecutive in any practice, and each phase was not done in the same week across practices.

In comparing data from clinicians participating in more than one phase of card data collection, we assessed statistical significance with confidence interval analysis and with nonparametric tests (chi square, Fisher exact, and Mann-Whitney U) because most distributions were skewed.¹⁹

Results

A total of 114 clinicians collected data in Phase 1. During that week (which varied among practices), they saw a total of 7695 patients and had an alcohol-related discussion with 732 of them (9.5% of all visits). Among those 732 patients, the average age was 40 years (standard deviation = 18); 52.1% were women. Of the visits at which alcohol was discussed, 40% were for health maintenance, 28% for chronic illness, and 23% for acute self-limited illness. The clinician had previously seen the patient in 69% of the cases.

Nineteen clinicians participated in both Phases 1 and 2. They saw 1685 patients in Phase 1 and 1719 in Phase 2. Compared with clinicians who did not participate, more of the participants’ Phase 1 alcohol-related discussions were with patients they knew or suspected had an alcohol problem (34% vs 15%, P <.001 by chi square). Their alcohol-related discussions were longer (P = .008 by Mann-Whitney U), more likely to be prompted by their own concern (29% vs 20%) and were perceived as having greater intensity for the patient (6% perceived as having marked intensity vs 1%). However, the proportion of visits during which those 19 clinicians discussed alcohol was not significantly different from clinicians in Phase 1 who did not participate in Phase 2.

Table 1 shows comparisons of Phase 1 and Phase 2 for the 19 clinicians who completed data collection for both. Although we had anticipated a significant increase in the frequency, duration, and perceived intensity of alcohol-related discussions, the results from the first 2 phases were surprisingly similar. The addition of routine screening was associated with a shift in the triggers noted, especially from “clinician screening” to “primary prevention,” a decrease in the proportion that occurred in health maintenance visits, and an increase in the proportion in acute-care visits. Notably, of the 168 patients who had a positive screening result for problem drinking, the clinician did not discuss alcohol with 61, usually because of discussions at previous visits or a lack of time. The clinician had no previous knowledge or suspicion of an alcohol problem in 41 of those 61 instances; approximately one fourth (41 of 168) of the positive screening results were unexpected but were not addressed at the screening visit.

Of the 19 clinicians who participated in Phases 1 and 2, 15 participated in Phase 3 Table 2. We anticipated that training would increase the frequency and duration of alcohol-related discussions with patients who had a positive screening result and decrease the clinicians’ perceived discomfort with the intervention. Although these 15 clinicians were slightly more likely to address a positive screening result in Phase 3 than in Phase 2, the difference was not statistically significant. The discussions, however, were significantly longer. This was especially evident if the discussion was in response to a positive screening result: only 32% of those discussions lasted longer than 2 minutes in Phase 2, 58% in Phase 3 (P <.001). However, only 26% lasted longer than 4 minutes, and “not enough time” was checked more often in Phase 3 than in Phase 2 as a reason for not addressing a positive screening result.

In Phase 2, 70% of the screening was done by office assistants, compared with 57% in Phase 3 (P = .03). However, the screener did not significantly affect the characteristics of alcohol-related discussions, such as duration and intensity. Although 2 of the participating clinicians reported missing the screening of some patients, the clinicians reported only one patient who refused screening of the 3391 patients seen during these 2 phases of our study. Data were recorded on the pocket-sized card after each visit in approximately 40%, at the end of each day in another 40%, and at the end of the week in about 20% in both Phase 1 and 2; data were recorded somewhat closer to the visit in Phase 3 (60% after each visit, 33% each day).

Discussion

In all phases of this study, the primary care clinicians discussed alcohol with approximately 10% of their patients, usually at their own initiation. Relatively few discussions (approximately 1 out of 5) were prompted by the clinician’s concern about a possible alcohol problem, and even fewer were initiated by a patient or concerned family member. Unlike the successful 5- to 15-minute interventions published in the literature, these alcohol-related discussions were remarkably short. In Phase 1, considering only the 19 clinicians who also participated in Phase 2, 93% of the alcohol-related discussions were shorter than 4 minutes, even when they were prompted by the clinician’s concern.

We thought routine screening would increase the frequency of alcohol-related discussions, shift the focus from clinicians doing their own screening to intervening with identified problem drinkers, and make the discussions longer and more uncomfortable. But routine screening made almost no difference in alcohol-related discussions. Clinicians reported shifts in the triggers for alcohol-related discussions and the types of patient visits during which alcohol was discussed, but we found no significant changes in the duration or intensity of alcohol-related discussions.

In Phase 3, after the physicians received training in identifying and intervening with problem drinkers, alcohol-related discussions were significantly longer. When initiated in response to a positive screening result, most discussions were longer than 2 minutes, but only 26% lasted longer than 4 minutes, still shorter than effective brief interventions.^1,2

Our findings are, in some respects, generalizable to other primary care clinicians. The proportion of visits in which alcohol was discussed in our study was similar to the 9% reported by the Direct Observation of Primary Care study.²⁰ This was the first study of problem drinking by ASPN, and the patients were comparable with those seen in the National Ambulatory Medical Care Survey.¹⁵

The reasons for the lack of change with the addition of routine screening remain unclear; we suggest 3 possibilities. First, these clinicians may have already known their patients well; adding routine screening gave them little additional information. However, the most commonly cited reason for not discussing alcohol with patients who had a positive screening result was a lack of time. Second, most clinicians had their office assistant screen patients, and more discussions might have taken place had the clinicians done the screening and used a positive response as an opportunity to engage the patient in a conversation about drinking. The duration of discussions prompted by clinician concern, however, was similar across all 3 phases of our study. Third, time constraints may have limited clinicians’ ability to respond to an unexpectedly positive screening result. A lack of time was given as a reason for not discussing a positive screening result with 22 of 61 patients in Phase 2, 17 of 30 in Phase 3. Notably and also contrary to our expectations, clinician discomfort with screening-prompted discussions was no greater than with those in Phase 1, suggesting that adding routine screening seldom creates an awkward situation for the clinician.

Although training was associated with longer discussions, the changes from Phase 2 (before training) to Phase 3 (after training) were smaller than we anticipated. Further exploration is warranted, but as documented by Stange and colleagues,²⁰ an ordinary office visit deals with a multitude of issues. The lack of substantial change in alcohol-related discussions may simply be because of the crowded agenda of the primary care office visit.

We do not know the content or outcome of the alcohol-related discussions during the 3 phases of data collection or how many of those who screened positive actually had at-risk drinking, an alcohol-use disorder, both, or neither. Of those who had a negative screening result yet had an alcohol-related discussion, 5 of the 34 discussions in Phase 2 and 15 of the 44 in Phase 3 were prompted by clinician concern. We suspect some of these patients had false-negative screening results, and we do not know how many other problem drinkers were missed by the screening question.

Limitations

The 19 clinicians who participated in both Phase 1 and Phase 2 were demonstrably different from the Phase 1—only participants. Their alcohol-related discussions were longer, and more of those discussions were triggered by clinician concern. Assuming that the physicians who did not participate in Phase 2 were similar to family physicians in general, our findings are likely to show greater clinician concern about problem drinking and longer alcohol-related discussions than would be true nationally.

Also, all our data were from physician self-reports. Patient report, chart review, or observation by a third person would probably demonstrate differences. Given the lag between encounters and data recording for some clinicians, recall of alcohol-related discussions may have faded, and even those clinicians who recorded data after each visit might have missed some. However, this would be true of data collection in all 3 phases of our study, and the magnitude of bias would be similar. Furthermore, the phases were not contiguous for any practice, and we doubt there were any substantial learning or fatigue effects that might have changed the accuracy of data collection from one phase to another.

Conclusions

Alcohol use is a common topic of discussion in primary care, and the clinicians in this study usually felt comfortable addressing it. The duration of these discussions, however, was almost always shorter than the effective brief interventions with problem drinkers in all published clinical trials. Whether a 2-minute intervention would be successful is a matter for future empirical research, but it is clear that either brief interventions need to be substantially shorter, or the approach to alcohol problems in primary care needs to be changed. Furthermore, it is clear that simply adding routine screening to primary care practice is not sufficient to change clinician behavior significantly. Screening with a single question, however, was almost universally acceptable to patients and did not increase discomfort for the clinicians. And training the clinicians in recognition of and brief intervention with problem drinkers was effective in increasing the duration of the discussions.

Acknowledgments

We received funding from the Alcoholic Beverage Medical Research Foundation. During the study, Dr. Vinson was supported by a Generalist Physician Faculty Scholars Program grant from the Robert Wood Johnson Foundation.

Brief physician intervention with problem drinkers can be effective in primary care practice: Patients who receive it are twice as likely to moderate their alcohol intake as patients in a control group.^1-4 Most problem drinkers, however, go unrecognized and untreated in medical encounters.^5,6 Two separate surveys found that only 39% of patients reported being asked by their physician about their alcohol use.^7,8 Several barriers to widespread adoption of brief physician-based intervention techniques have been hypothesized, including time constraints and physician reluctance to impose a new agenda on the patient;^9-11 but the quantitative effects of those barriers on current physician practice have not been empirically explored.

In research trials brief interventions with problem drinkers have required one or more office visits, each lasting from 5 to 15 minutes.^2,3 In those studies, patients were screened at one visit, and those identified as problem drinkers were recruited for the study by research personnel. If assigned to the intervention group, they returned for another office visit. This 2-stage approach (screening and intervention at separate visits) may miss some patients. In the Wisconsin study,² 30% of those patients willing to participate failed to complete the baseline interview, and 22% of those assigned to the intervention group did not keep the subsequent appointment. Furthermore, physicians may find the requirement of a second visit too burdensome. In a study in Scotland, half the general practitioners who were invited to participate did not join the study because they felt that a 10-minute intervention was too time consuming.¹² These problems could be partially addressed by opportunistic intervention (screening and doing the brief intervention at the same office visit), but an Australian study¹³ found even that approach unsuccessful.

A better understanding of current alcohol-related discussions in primary care may facilitate adoption of brief interventions with problem drinkers, and we know of no study that has described them. We designed our study to describe the frequency, duration, intensity, and triggers of alcohol-related discussions in primary care routine practice. Then in a before-after design, we investigated changes in alcohol-related discussions with the addition of systematic screening of all adult patients for problem drinking, and then again after the clinicians received training in brief interventions with problem drinkers.

Methods

The Ambulatory Sentinel Practice Network (ASPN) included primary care clinicians in the United States and Canada; 86% were family physicians, and most of the rest were nurse practitioners and physician assistants. ASPN conducted more than 40 studies that spanned a broad spectrum of clinical and health services research that informed both clinical practice and health care policy.¹⁴ A comparison of key characteristics of ASPN patients with a probability sample of US family physicians participating in the 1991 National Ambulatory Care Survey suggests minimal selection bias associated with voluntary participation in ASPN.¹⁵

We recruited volunteer clinicians to collect data about alcohol-involved visits for 1 week without change in their routine practice (Phase 1). Clinicians recorded data about any patient they knew had an alcohol problem or if they discussed alcohol for any reason. On a pocket-sized card,¹⁶ they noted the patient’s age and sex, the type of visit (acute self-limited illness, acute serious, chronic illness, obstetrical care, or health maintenance), whether the presenting complaint seemed related to alcohol, whether the clinician had any previous knowledge or suspicion of an alcohol problem, what triggered the alcohol-related discussion, how long it lasted (<2, 2 to 4, 4 to 8, or >8 minutes), and how intense it was for the clinician and for the patient (coded as no, mild to moderate, or marked intensity).

Clinicians who completed Phase 1 were invited to participate in a second week of data collection, this time with the addition of routine screening of all adult patients presenting for care (Phase 2). As in Phase 1, data were recorded for any patient who had a known alcohol problem, any patient with whom the clinician discussed alcohol, and any patient who had a positive screening result for problem drinking. The screening question—“When was the last time you had more than 5 drinks on one occasion?”¹⁷—was asked between questions regarding tobacco and seat belt use. An answer indicating any time within the past 3 months was considered a positive screening result for problem drinking.

We invited clinicians who participated in Phase 2 to receive training in brief interventions with problem drinkers. We mailed them a copy of The Physicians’ Guide to Helping Patients with Alcohol Problems¹⁸ and a videotaped lecture illustrating the steps in that guide. We also telephoned each participating clinician to address any concerns or perceived barriers and to practice brief intervention skills. Following training, each clinician collected card data for a third week (Phase 3), that included routine screening of all adult patients as in Phase 2. The 3 weeks of data collection were not consecutive in any practice, and each phase was not done in the same week across practices.

In comparing data from clinicians participating in more than one phase of card data collection, we assessed statistical significance with confidence interval analysis and with nonparametric tests (chi square, Fisher exact, and Mann-Whitney U) because most distributions were skewed.¹⁹

Results

A total of 114 clinicians collected data in Phase 1. During that week (which varied among practices), they saw a total of 7695 patients and had an alcohol-related discussion with 732 of them (9.5% of all visits). Among those 732 patients, the average age was 40 years (standard deviation = 18); 52.1% were women. Of the visits at which alcohol was discussed, 40% were for health maintenance, 28% for chronic illness, and 23% for acute self-limited illness. The clinician had previously seen the patient in 69% of the cases.

Nineteen clinicians participated in both Phases 1 and 2. They saw 1685 patients in Phase 1 and 1719 in Phase 2. Compared with clinicians who did not participate, more of the participants’ Phase 1 alcohol-related discussions were with patients they knew or suspected had an alcohol problem (34% vs 15%, P <.001 by chi square). Their alcohol-related discussions were longer (P = .008 by Mann-Whitney U), more likely to be prompted by their own concern (29% vs 20%) and were perceived as having greater intensity for the patient (6% perceived as having marked intensity vs 1%). However, the proportion of visits during which those 19 clinicians discussed alcohol was not significantly different from clinicians in Phase 1 who did not participate in Phase 2.

Table 1 shows comparisons of Phase 1 and Phase 2 for the 19 clinicians who completed data collection for both. Although we had anticipated a significant increase in the frequency, duration, and perceived intensity of alcohol-related discussions, the results from the first 2 phases were surprisingly similar. The addition of routine screening was associated with a shift in the triggers noted, especially from “clinician screening” to “primary prevention,” a decrease in the proportion that occurred in health maintenance visits, and an increase in the proportion in acute-care visits. Notably, of the 168 patients who had a positive screening result for problem drinking, the clinician did not discuss alcohol with 61, usually because of discussions at previous visits or a lack of time. The clinician had no previous knowledge or suspicion of an alcohol problem in 41 of those 61 instances; approximately one fourth (41 of 168) of the positive screening results were unexpected but were not addressed at the screening visit.

Of the 19 clinicians who participated in Phases 1 and 2, 15 participated in Phase 3 Table 2. We anticipated that training would increase the frequency and duration of alcohol-related discussions with patients who had a positive screening result and decrease the clinicians’ perceived discomfort with the intervention. Although these 15 clinicians were slightly more likely to address a positive screening result in Phase 3 than in Phase 2, the difference was not statistically significant. The discussions, however, were significantly longer. This was especially evident if the discussion was in response to a positive screening result: only 32% of those discussions lasted longer than 2 minutes in Phase 2, 58% in Phase 3 (P <.001). However, only 26% lasted longer than 4 minutes, and “not enough time” was checked more often in Phase 3 than in Phase 2 as a reason for not addressing a positive screening result.

In Phase 2, 70% of the screening was done by office assistants, compared with 57% in Phase 3 (P = .03). However, the screener did not significantly affect the characteristics of alcohol-related discussions, such as duration and intensity. Although 2 of the participating clinicians reported missing the screening of some patients, the clinicians reported only one patient who refused screening of the 3391 patients seen during these 2 phases of our study. Data were recorded on the pocket-sized card after each visit in approximately 40%, at the end of each day in another 40%, and at the end of the week in about 20% in both Phase 1 and 2; data were recorded somewhat closer to the visit in Phase 3 (60% after each visit, 33% each day).

Discussion

In all phases of this study, the primary care clinicians discussed alcohol with approximately 10% of their patients, usually at their own initiation. Relatively few discussions (approximately 1 out of 5) were prompted by the clinician’s concern about a possible alcohol problem, and even fewer were initiated by a patient or concerned family member. Unlike the successful 5- to 15-minute interventions published in the literature, these alcohol-related discussions were remarkably short. In Phase 1, considering only the 19 clinicians who also participated in Phase 2, 93% of the alcohol-related discussions were shorter than 4 minutes, even when they were prompted by the clinician’s concern.

We thought routine screening would increase the frequency of alcohol-related discussions, shift the focus from clinicians doing their own screening to intervening with identified problem drinkers, and make the discussions longer and more uncomfortable. But routine screening made almost no difference in alcohol-related discussions. Clinicians reported shifts in the triggers for alcohol-related discussions and the types of patient visits during which alcohol was discussed, but we found no significant changes in the duration or intensity of alcohol-related discussions.

In Phase 3, after the physicians received training in identifying and intervening with problem drinkers, alcohol-related discussions were significantly longer. When initiated in response to a positive screening result, most discussions were longer than 2 minutes, but only 26% lasted longer than 4 minutes, still shorter than effective brief interventions.^1,2

Our findings are, in some respects, generalizable to other primary care clinicians. The proportion of visits in which alcohol was discussed in our study was similar to the 9% reported by the Direct Observation of Primary Care study.²⁰ This was the first study of problem drinking by ASPN, and the patients were comparable with those seen in the National Ambulatory Medical Care Survey.¹⁵

The reasons for the lack of change with the addition of routine screening remain unclear; we suggest 3 possibilities. First, these clinicians may have already known their patients well; adding routine screening gave them little additional information. However, the most commonly cited reason for not discussing alcohol with patients who had a positive screening result was a lack of time. Second, most clinicians had their office assistant screen patients, and more discussions might have taken place had the clinicians done the screening and used a positive response as an opportunity to engage the patient in a conversation about drinking. The duration of discussions prompted by clinician concern, however, was similar across all 3 phases of our study. Third, time constraints may have limited clinicians’ ability to respond to an unexpectedly positive screening result. A lack of time was given as a reason for not discussing a positive screening result with 22 of 61 patients in Phase 2, 17 of 30 in Phase 3. Notably and also contrary to our expectations, clinician discomfort with screening-prompted discussions was no greater than with those in Phase 1, suggesting that adding routine screening seldom creates an awkward situation for the clinician.

Although training was associated with longer discussions, the changes from Phase 2 (before training) to Phase 3 (after training) were smaller than we anticipated. Further exploration is warranted, but as documented by Stange and colleagues,²⁰ an ordinary office visit deals with a multitude of issues. The lack of substantial change in alcohol-related discussions may simply be because of the crowded agenda of the primary care office visit.

We do not know the content or outcome of the alcohol-related discussions during the 3 phases of data collection or how many of those who screened positive actually had at-risk drinking, an alcohol-use disorder, both, or neither. Of those who had a negative screening result yet had an alcohol-related discussion, 5 of the 34 discussions in Phase 2 and 15 of the 44 in Phase 3 were prompted by clinician concern. We suspect some of these patients had false-negative screening results, and we do not know how many other problem drinkers were missed by the screening question.

Limitations

The 19 clinicians who participated in both Phase 1 and Phase 2 were demonstrably different from the Phase 1—only participants. Their alcohol-related discussions were longer, and more of those discussions were triggered by clinician concern. Assuming that the physicians who did not participate in Phase 2 were similar to family physicians in general, our findings are likely to show greater clinician concern about problem drinking and longer alcohol-related discussions than would be true nationally.

Also, all our data were from physician self-reports. Patient report, chart review, or observation by a third person would probably demonstrate differences. Given the lag between encounters and data recording for some clinicians, recall of alcohol-related discussions may have faded, and even those clinicians who recorded data after each visit might have missed some. However, this would be true of data collection in all 3 phases of our study, and the magnitude of bias would be similar. Furthermore, the phases were not contiguous for any practice, and we doubt there were any substantial learning or fatigue effects that might have changed the accuracy of data collection from one phase to another.

Conclusions

Alcohol use is a common topic of discussion in primary care, and the clinicians in this study usually felt comfortable addressing it. The duration of these discussions, however, was almost always shorter than the effective brief interventions with problem drinkers in all published clinical trials. Whether a 2-minute intervention would be successful is a matter for future empirical research, but it is clear that either brief interventions need to be substantially shorter, or the approach to alcohol problems in primary care needs to be changed. Furthermore, it is clear that simply adding routine screening to primary care practice is not sufficient to change clinician behavior significantly. Screening with a single question, however, was almost universally acceptable to patients and did not increase discomfort for the clinicians. And training the clinicians in recognition of and brief intervention with problem drinkers was effective in increasing the duration of the discussions.

Acknowledgments

We received funding from the Alcoholic Beverage Medical Research Foundation. During the study, Dr. Vinson was supported by a Generalist Physician Faculty Scholars Program grant from the Robert Wood Johnson Foundation.