Another possibility is that the current definitions of AUDs are flawed and that individuals who can actually control their drinking are misclassified as dependent. Under the current definitions of AUDs, if the same initial therapeutic approach is appropriate for patients with alcohol abuse or dependence, it may not be important for primary care clinicians to ascertain precise alcohol-related diagnoses for problem drinkers. A practical point, however, is that patients should be assessed for potential alcohol withdrawal before they are advised to cut down or stop their drinking.
There were some notable differences between those dependent subjects who did receive treatment for their drinking and those who did not. The higher frequency of attempts at strategies that proved unhelpful by those who received treatment may indicate that some dependent patients seek treatment only after attempts at self-treatment fail. The higher frequency of family and emotional problems among those who received treatment is compatible with the notion that more severely affected individuals receive treatment more often than those with milder disorders. These findings support the notion that dependent patients need not be referred immediately for treatment.
Suggested Strategies
For some of the subjects, medical disorders and medical contraindications to drinking were influential in their remissions. Therefore, clinicians are advised to educate patients about any special medical risks of continued excessive drinking. We also found that family and emotional issues were often more important than biomedical factors in eliciting reduced drinking. Thus, a narrow counseling focus on the biomedical consequences and risks of drinking may miss opportunities with many patients. Primary care clinicians may enhance the effectiveness of their alcohol counseling by reflecting back the more personal psychosocial consequences or risks of drinking.
When helping patients devise strategies to modify their drinking, primary care clinicians should consider helping patients to set rules of limitation and avoidance for themselves, since such rules were helpful for many of the subjects in this study. Clinicians should also assess patients’ barriers to reducing their drinking. Exposure to others who drink and family dysfunction may be key barriers. Simple brainstorming and problem-solving techniques may help patients realize how they can minimize their contact with others who drink. Family dysfunction that interferes with a patient’s attempts to reduce drinking could be addressed with similar brief techniques, and referrals for individual psychotherapy or family therapy might be useful.
These suggestions adhere to an approach for counseling problem drinkers called “motivational interviewing” or “motivational enhancement therapy.” This approach stems partly from Carl Rogers’s theory that behavioral change is fostered by unconditional positive regard, nonpossessive warmth, and genuine concern.24 Applying diagnostic labels, such as “alcohol abuse” and “alcoholism” and issuing directives, such as mandating abstinence, are avoided. Instead, for patients who have not committed themselves to modifying their drinking, clinicians help them recognize and weigh the advantages and disadvantages of drinking in the context of their goals and values. For those who have committed themselves to modifying their drinking, clinicians can help them construct, implement, evaluate, and refine their plans for change. The results of Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity) suggest that motivational interviewing is as effective, and perhaps more efficient, than cognitive-behavioral coping skills therapy and 12-step facilitation therapy.25
Brief interventions that adhere to the principles of motivational interviewing are effective in reducing drinking by alcohol abusers.3,4 Since it is apparent that many alcohol-dependent primary care patients can remit without specialized treatment, a brief intervention may be sufficient to prompt remission in others who do not remit independently. Randomized controlled trials are needed to assess the effectiveness of brief interventions for alcohol-dependent primary care patients.
Conclusions
Our study suggests that AUDs in remission are common in primary care, that many patients with AUDs will remit without formal treatment, that some patients improve spontaneously without intention, and that many dependent patients can remain free of alcohol-related problems with moderate drinking. Many primary care clinicians may be unduly pessimistic about AUDs. Primary care clinicians who understand the factors that promote remission and can apply appropriate counseling techniques may be able to help primary care patients remit from AUDs without formal treatment.
Acknowledgments
Our study was supported by a grant from the National Institute on Drug Abuse (DA-07334) and the Department of Family Medicine, University of Wisconsin Medical School. The authors acknowledge Dr Kym Erbes, Sabrina Holmquist, and Scott Klein for their dedication and perseverance in data collection.