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Management of Alcoholism in the Primary Care Setting KATHARINE A. BRADLEY, MD, Seattle, Washington
Primary care physicians can play an important role in managing alcoholic patients. Identifying and treating alcoholism early, before it has interfered with patients' relationships and work, may increase the likelihood of prolonged recovery. Simple office interventions can help motivate patients to abstain and seek treatment. People who abuse alcohol and are unwilling to abstain can benefit from a recommendation to reduce their intake of alcohol. For alcohol-dependent patients who decide to stop drinking, primary care physicians often can manage withdrawal on an outpatient basis. Selecting an appropriate treatment program for each alcoholic patient is important, and referral to a specialist to assist in matching patients to treatments is often necessary. Primary care physicians also can help prevent relapse. Although disulfiram is of limited value, primary care physicians can support recovery by identifying coexistent psychosocial problems, helping patients to restructure their lives, and ensuring continuity of care. (Bradley KA: Management of alcoholism in the primary care setting. West J Med 1992 Mar; 156:273-277)
T his is the second of two articles on alcoholism in the primary care setting and focuses on the outpatient management of alcohol abuse and dependence, building on the discussions of screening and diagnosis found in the first article.' Unless otherwise stated, I again will rely on the definitions of alcohol abuse and dependence used in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, third edition, revised (DSM-III-R). In general, alcohol abuse entails continued drinking despite alcohol-related physical, social, or occupational problems or in hazardous situations, whereas alcohol dependence involves a greater disability caused by drinking, often with a history of tolerance and withdrawal. The management steps discussed in this article are summarized in Table 1.
From Diagnosis to TreatmentThe Primary Care Physician's Role Early Identification and Treatment A patient's social situation at the time of treatment can have a substantial effect on the likelihood of recovery. Of men living with a spouse or employed on entering treatment, 45% and 31%, respectively, were abstinent at 8 years, compared with 21% of those in a "skid row" setting.2 Thus, by identifying and treating alcohol abuse early, before it has interfered with patients' jobs and relationships, physicians may improve their patients' chances for recovery. Motivating Patients Patient motivation appears to be a key ingredient in successful recovery from alcoholism and one that can be influenced by primary care physicians. Measures that increase patients' perceptions of the risk of drinking, especially information regarding the severity of their drinking-related problems, have been shown to significantly improve patient motivation to abstain.3 4 For instance, presenting-in a supportive, nonconfrontational manner-the risk and realities of
cirrhosis to an alcoholic person with abnormal liver function test results might motivate that patient to seek treatment. Several studies have shown that clear advice and follow-up, particularly after discussion ofthe serious nature of the problem, also increase patient motivation and consequent behavior change.3`7 When patients miss appointments, letters or phone calls from their physicians have a notable effect on motivation to return and comply with treatment recommendations.3 Finally, because waiting to begin alcoholism treatment apparently decreases motivation, primary care physicians probably can improve treatment results by facilitating rapid entry into treatment once a patient is willing.3 Substantial research also suggests that physician empathy plays an important role in patient motivation and treatment results. In contrast, confrontive behaviors have been found to TABLE 1.- PrimaryCre Provider's Role in Manaing Potiets With AlcWholism * Identify and treat alcoholism as early as possible * Increase patient motivation with specific feedback about the probltern,lar adviiceto abtain, cose:nd persistent fbllow-up, and an * Advi alcohol-abusing patients unwilling to abstain to at least reduce their alcohol intake * Peribe benzodiazepines and evaluate patients daily when with-
drawal is present': Matchpatientsto appropriate treatment programs, often in consultation with specialits * Occasionally, prescribe disulfiram to promote abstinence in appropriate patients * l*ntify and mag coexistentpchosial problems * Advise patients to participate in' Alcoholics Anonymous or other *
relapse prevention programs following treatment * Encourage patients to restructure their lives by developing new habits, new social supports, and new community involvements * Ensure continuity of care by scheduling regularfollow-up visits, contacting patients after missedzappointments, and being receptive and supportive toward relapsed patients
From the Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle. This article is Part 2 of a two-part series. Part 1, "Screening and Diagnosis of Alcoholism in the Primary Care Setting," was published in the February 1992 issue. This work was supported in part by NRSA grant No. 5T32PE10002-04. Reprint requests to Katharine A. Bradley, MD, NRSA Primary Care Fellow, HQ-24, Department of Medicine, University of Washington, Seattle, WA 98195.
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ABBREVIATIONS USED IN TEXT AA = Alcoholics Anonymous DSM-III-R = Diagnostic and Statistical Manual of Mental Disorders, third edition, revised
increase patient resistance and their drinking.3'4 Thus, it seems likely that primary care physicians can influence alcoholic patients' motivation to abstain simply by displaying such qualities as respect, caring, understanding, and an ac-
tive desire to help.3
Controlled Drinking Versus Abstinence The available evidence suggests that alcohol-dependent patients rarely, if ever, revert to normal drinking, although there has been considerable controversy in this area. In the 1970s Sobell and Sobell claimed that alcohol-dependent patients could successfully learn and maintain controlled drinking, but their work was discredited by a careful review of their patients and study results.8 Several reports by the Rand Corporation claimed to document nonproblem drinking in alcoholic persons, but those with alcohol dependence at any time in the study were likely to have continued drinking problems.9 Likewise, Vaillant found that once patients had been dependent on alcohol, they were unlikely to control their drinking without abstinence.10 Abstinence should therefore be the cornerstone of any management strategy for
alcohol-dependent patients. Some patients who abuse alcohol, on the other hand, appear able to return to nonproblem drinking. Vaillant found that, over eight years, almost half of the alcoholic persons he studied reverted to social drinking, while only a third became dependent on alcohol. Likewise, the patients in the Rand studies who reverted to controlled drinking were usually nondependent problem drinkers. Vaillant's work and the Rand studies preceded the DSM-III definitions of alcohol abuse and dependence, but their definitions were similar enough that it is reasonable to assume some overlap between their patients and those who meet DSM-III-R criteria for alcohol abuse.1' Thus, while the proportion of alcohol-abusing patients who return to social drinking can be debated, the fact that some do is difficult to dispute. Given this evidence, how should we manage alcohol abuse in general medical practice? The standard of care is that the management of all alcohol abuse, like dependence, should be founded on abstention. This is the best approach because abstinence is the safest way to avoid both the physical, social, and occupational costs of alcohol abuse and the risk of progression to dependence. Many patients will not be willing to stop drinking or enter treatment when first presented with a diagnosis of alcohol abuse, however, and these patients should be advised to cut down. There are several possible benefits of advising controlled drinking in this population. A recommendation for controlled drinking-no more than two drinks a day-can serve as a diagnostic strategy. In patients unable to control their intake, a trial of controlled drinking may overcome denial about an alcohol problem, and subsequently some patients may be willing to abstain and enter treatment.'2 In patients who are able to control their intake, decreasing the they drink can decrease morbidity. A British study found that after general practitioners recommended controlled drinking, the quantity of alcohol consumed by "examount
cessive drinkers" (over 35 drinks a week for men) decreased significantly and was reflected in significant decreases in blood pressure and aspartate aminotransferase (AST, formerly SGOT) at 12 months.5 In addition to the possible medical benefits of controlled drinking, discussions of a patient's successes and failures can help maintain an open dialogue and a therapeutic relationship between the physician and the patient, allowing physicians to continue to urge abstinence as additional alcohol-related problems arise. For these reasons, I think that after firmly recommending abstinence and after a frank discussion with patients about the serious risks of continued drinking, alcohol-abusing patients who refuse to stop drinking should be advised to reduce their intake. This approach is not recommended for patients who are alcohol-dependent, because it is unlikely that they would be able to control the amount they drink. Many alcohol treatment specialists and persons affiliated with Alcoholics Anonymous (AA) will strongly disagree with any management approach that includes controlled drinking. 10"13 It should be stressed that I am not recommending such a strategy as the preferred treatment, but rather as a second choice with potential therapeutic benefits. This circumstance seems analogous to one where a patient with a life-threatening infection refuses to stay in the hospital. Although the recommended treatment is intravenous antibiotics, when the patient leaves against medical advice most physicians would, as the best possible substitute, prescribe oral antibiotics and arrange follow-up. In this spirit, primary care physicians should recommend controlled drinking to patients who abuse, and refuse to abstain from, alcohol.
Inpatient Versus Outpatient Detoxification Historically, detoxification involved withdrawal from alcohol in an inpatient setting, making a hospital stay the first step of rehabilitation. A randomized, controlled study of 164 patients with mild-to-moderate withdrawal symptoms and no active medical or psychological problems found outpatient detoxification to be safe and effective. 14 Outpatient detoxification included daily visits to the clinic where patients were evaluated for withdrawal symptoms and placed on benzodiazepine therapy over three to five days. Both inpatients and outpatients were referred to AA for long-term rehabilitation. Despite the fact that many participants had unstable social situations, there were no complications of outpatient withdrawal. Furthermore, in spite of a higher attrition rate among outpatients, both settings appeared equally effective with respect to abstinence, sobriety, alcohol-related problems, recurrent need for detoxification, and entry into long-term rehabilitation at six months. Inpatient detoxification was 9 to 20 times more expensive, including lost opportunity costs. 14 Although the study may have been biased by minor differences in the two randomly selected groups and lacked the power to detect small differences in results, the findingslarge differences in cost and a lack of any differences in outpatient complications or results-support outpatient management of mild to moderate alcohol withdrawal. Such patients should be seen daily by the physician or a surrogate and evaluated for withdrawal symptoms to be treated with benzodiazepine therapy. Inpatient detoxification remains appropriate, however, when withdrawal is complicated by seizures or other medical or psychiatric problems, and perhaps when a patient has failed previous outpatient detoxification or requests inpatient management.
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The Role of Medications in Detoxification Although it has been suggested that alcoholic persons can safely withdraw without medication,"5 evidence in animals and humans suggests that untreated withdrawal may predispose patients to withdrawal seizures and cognitive defects.16 Therefore, benzodiazepines should be considered for all withdrawing patients. Although opinions differ regarding the benefits of short- or long-acting benzodiazepines, the short-acting varieties (oxazepam or lorazepam) are metabolized primarily by glucuronidation and may be safer for the elderly and for patients with liver disease. If diazepam is used, a starting dose of 10 to 20 mg with repeated doses of 5 mg every four to six hours as needed to control symptoms can be prescribed the first day, decreasing the total daily dose by half each day thereafter. 17 ,B-Blockers, which mask the sympathetic discharge of withdrawal, have been shown to speed the return to normal of vital signs, substantially decrease the length of hospital stay, and decrease benzodiazepine requirements. 18 Although a recent inpatient trial reported no complications from treatment with atenolol,18 there have been previous reports of increased delirium tremens in withdrawing patients treated with propranolol.19 Therefore, until further data have accumulated, fl-blockers are probably best reserved for the inpatient setting where patients can be monitored closely. Even in these patients, $-blockers probably should be used as an adjunct to, not instead of, benzodiazepines because of the possible sequelae of untreated withdrawal mentioned previously. Treatment Programs Studies of alcoholism treatment programs have been plagued by multiple definitions of alcoholism, heterogeneous treatment populations, bias because of self-referral, the relapsing and remitting nature of the disease, attrition, and a short duration of follow-up. Nevertheless, some general conclusions about treatment can be made. No single alcoholism treatment-behavioral, psychotherapeutic, aversion, pharmacologic, or self-help-has welldocumented short- or long-term benefits for all patients. Likewise, the intensity (residential versus nonresidential) and duration of treatment have not been shown to alter patients' outcomes in controlled studies.4 Moreover, studies of pooled data, comparing treatment to no treatment, have been unable to show clear-cut treatment benefits.9' 1020-22 Nevertheless, an extensive review of the literature by a subcommittee of the Institutes of Medicine concluded that "a variety of specific treatment methods have been associated with increased improvement, relative to no treatment or alternative treatments, in controlled studies."4 Additionally, there is evidence that alcoholism treatment programs have overall cost benefits to society.21 23 For these reasons, primary care physicians are advised to refer alcohol-abusing and alcoholdependent patients for treatment. Selecting a Treatment Program Matching patients to the individual treatments that are most likely to prove successful for them is a challenge. Demographic variables (such as age, sex, and marital status), psychological factors (such as psychiatric diagnoses, selfimage, and locus of control), severity of alcoholism, and antecedents to drinking have all been found to affect the results of specific patient-treatment matches.24 For example, patients who are socially unstable (for example, homeless or
unemployed) or those with severe alcohol dependence or coexistent psychopathology may have more success in residential programs, whereas socially stable persons appear to do well in less costly nonresidential treatment settings.4 Data on matching alcoholic patients to treatment programs are incomplete at this time, and there are no easily accessible guidelines for use by primary care physicians, although both issues are being addressed by the Institutes of Medicine.24 In the meantime, clinicians can refer patients to specialists-social workers, alcoholism counselors, or mental health professionals with knowledge of alcoholism treatment resources-to be evaluated and matched to a suitable treatment option. In some localities publicly supported matching programs are available, and ideally more will be evolving.24 The National Council of Alcoholism has offices in many cities and can also assist in such matching. Alcoholics Anonymous One of the most accessible and widely recommended treatment programs is AA. Begun by two alcoholic persons, AA is a network of self-help groups offering free, daily meetings. In AA meetings alcoholic persons are guided by others recovering from alcoholism through 12 suggested steps. These steps have been described as a "quasireligious expression of the process of change seen in psychotherapy, . . . [involving] accepting the diagnosis . . . , believing that recovery is possible, undergoing a period of self-exploration, and finally translating this self-knowledge into appropriate interpersonal behavior."25 Despite extensive anecdotal reports of the value of AA, there are only three controlled studies of its effectiveness, and the results have been mixed.4 Nevertheless, the fact that AA is remarkably successful at attracting alcoholic persons to recovery, is free, and appears to be effective for relapse prevention make it an important resource for primary care physicians and their patients.4 Alcoholics Anonymous groups differ, each with a character of its own. Some are open to the public, others are closed. Once patients agree to attend, having them call for information from the physician's office will ensure that the referral is completed. Patients should be encouraged to try several open meetings and return to discuss their impressions with the referring physician before deciding "it's not for them."25 Relapse Prevention The Role ofDrugs in Abstinence Disulfiram (Antabuse) has a limited role in maintaining abstinence. It allows alcohol-abusing patients to make the decision not to drink once a day, postponing impulses to drink five to seven days, and has been shown to reduce the frequency of alcohol consumption over the short run. In a 1989 position paper, the American College of Physicians stated that supervised administration of disulfiram is probably effective in voluntary treatment of outpatients and compulsory treatment for violent or criminal patients, and that self-administration of disulfiram was possibly effective, especially in motivated, older, socially stable alcoholic persons.26 Another study, however, found no benefit of disulfiram with respect to total abstinence, time to first drink, employment, or social stability over one year, although patients treated with disulfiram did have fewer drinking days.27 The alcohol-disulfiram reaction is usually mild, including flushing, headache, nausea, and vomiting, beginning
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about 5 minutes after ingestion and lasting 30 to 180 minutes. The potential complications of the drug are many (Table 2).28-3o Occasional severe reactions have included myocardial infarction, congestive heart failure, arrhythmia, seizure, and death.29 These more severe reactions usually occur at doses of at least 500 mg per day after multiple drinks and may be associated with concurrent use of sympatholytic or psychotropic drugs.30 Any ethanol-containing medication or substance (including 15 ml of over-the-counter cough syrup, cutaneously applied rubbing alcohol, and paraldehyde) can cause a reaction.29,31 Because of disulfiram's teratogenic effects, pregnancy is an absolute contraindication to its use. Relative contraindications include cardiac or metabolic diseases; pulmonary, hepatic, or renal insufficiency; neuropathy, organic mental disorders, depression, personality disorders, psychosis, or concurrent administration of sympatholytic or psychotropic medications.29-31
Patients who are started on disulfiram therapy must be educated about the risks of drinking, of taking other medications, possible side effects, and the fact that pregnancy is absolutely contraindicated. Disulfiram should be started at 250 mg per day, and administration should be supervised if possible. Patients should carry identification stating that they are taking the drug. Under no circumstances should the disulfiram-alcohol reaction be provoked deliberately, as was previously recommended as a form of aversion therapy. Trials with disulfiram implants have shown erratic blood levels; implants are not currently recommended.4 Lithium, which had been shown in early studies to prolong abstinence, was no better than placebo in a recent Veterans Administration cooperative study of depressed and nondepressed alcoholic patients.32 It has no place in the treatment of chronic alcoholism. No other drugs currently available in the United States are of proven use in promoting abstinence.4 Managing Coexistent Psychosocial Problems Coexistent psychiatric illness often predisposes patients to relapse,33 and primary care physicians can help identify and treat it. Untreated depression has a documented adverse effect on outcome in alcoholic men,34 and treating depression that persists after a patient is sober might help maintain remission.4 Therefore, if depression lasts beyond the early weeks of abstinence, a primary care physician should consider initiating specific antidepressant therapy with either medication or referral for psychotherapy. Similarly, stress management training may help maintain abstinence, especially in patients with coexisting anxiety.4
Social and family problems are also thought to contribute to relapse, and there is evidence that specific interventions aimed at these problems improve long-term results. For instance, behavioral marital therapy has been shown to decrease treatment dropout and relapse rates, while social skills training appears to improve results in alcoholic persons lack-
ing these skills.4 By being alert for concomitant social problems, primary care physicians can refer recovering alcoholic patients for specialized assistance when indicated. Restructuring Patients' Lives Vaillant has identified four conditions that contribute to stable abstinence after treatment: a substitute nonchemical dependency, new social supports, inspirational group mem-
ALCOHOLISM IN PRIMARY CARE CARE ALCOHOLISM
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TABLE 2.-Possible CompliaOns of Disulfiram
PRIMARY
herapy':
de Effects Gastrointestinal upset Fatigue and sedation Dermatitis Hypertension: IMpotence ifnreased ive"r functintest results Depression and psychosis and cholesterol level. Body odor and halitosis
Peripheral neuropath*y optic neuritis, and polyneuritis Fulminant. or cholestatic hepatitis-
Drug Interactions Increases the halfli* of phenytoin and coumadin Potentiates metronidazole and isoniazid,- including possible neuro-; toxicity and hepatic toxicity When taken with ypatholytics or monoam:ine oxidase inhibitorsmay cause severe hypotension Results of Overdose Alone-primarily nervous system dysfunction. With alcohol-tachardia, hypotension,arrhythmia, myocardial infarction, stroke, and death Teratogenic Effects Primarily limb abnormal:Ities "Fom Physician' Desk Reference,28 Bames.29 and Sellers et al.30
bership, and compulsory treatment.2 He hypothesizes that these conditions help impose structure on recovering alcoholic patients' lives, thereby interfering with any tendency to drink.2 According to Vaillant, AA often fulfills three of these conditions. Attending AA meetings may serve as a substitute addiction; other AA members offer new social support; and the group's philosophy, reflected in the 12 steps, provides spiritual support.2 Additionally, such conditions are often incorporated into aftercare programs aimed at preventing relapse. For patients unwilling to attend AA meetings or other aftercare programs, primary care physicians can use Vaillant's findings to help patients remain sober. Specifically, a regular schedule of follow-up appointments, perhaps accompanied by a calendar with each date marked, might mimic some of the effects of compulsory treatment programs. Such structured follow-up has been shown independently to improve abstinence rates.4 Advising patients to develop new exercise programs, hobbies, or other routines might foster nonchemical dependencies, which supports abstinence. Encouraging patients to join a religious or other community organization might lead to new social supports and provide inspirational group membership. Continuity of Care Alcoholism is a chronic relapsing and remitting disease, and, despite the best of intentions, most recovering alcoholic persons experience at least one relapse. While eventually paraprofessional caseworkers might provide continuity of care for these patients,35 primary care physicians can help fill this important niche. Primary care physicians can build a foundation for continuity of care by discussing the relapsing nature of the disease openly with recovering alcoholic patients. The frank discussion of relapse as a feature of the disease can help decrease a patient's sense of personal failure when relapse occurs. Moreover, the explicit articulation of a physician's willingness and expectation to care for a patient with alcoholism, if
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relapse occurs, might encourage the patient to
6. Edwards G, Orford J, Egert S, et al: Alcoholism: A controlled trial of treatment and advice. J Stud Alcohol 1977; 38:1004-1031 7. Chick J, Lloyd G, Crombie E: Counseling problem drinkers in medical wards: A controlled study. Br Med J 1985; 290:965-967 8. Pendery ML, Maltzman IM, West LJ: Controlled drinking by alcoholics? New findings and re-evaluation of a major affirmative study. Science 1982; 217:169-175 9. Polich JM, Armor DJ, Braiker HB: The Course of Alcoholism: Four Years After Treatment. Santa Monica, Calif, Rand, 1980 10. Vaillant GE: The Natural History of Alcoholism. Cambridge, Mass, Harvard University Press, 1983 11. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 3d Ed, revised. Washington, DC, American Psychiatric Association, 1987 12. Bigby JA: Negotiating treatment and monitoring recovery, chap 7, In Barnes HN, Aronson MD, Delbanco TL (Eds): Alcoholism-A Guide for the Primary Care Physician. New York, NY, Springer-Verlag, 1987, pp 66-72 13. Wallace J: Controlled drinking, treatment effectiveness, and the disease model of addiction. J Psychoactive Drugs 1990; 22:261-284 14. Hayashida M, Alterman Al, McLellan AT, et al: Comparative effectiveness and costs of inpatient and outpatient detoxification of patients with mild to moderate alcohol withdrawal syndrome. N Engi J Med 1989; 320:358-365 15. Whitfield CL, Thompson G, Lamb A, Spencer V, Pfeifer M, Browning-Ferrando M: Detoxification of 1,024 alcoholic patients without psychoactive drugs. JAMA 1978; 239:1409-1410 16. Tabakoff B: Treatment of alcoholism (Letter). N Engl J Med 1989; 321:400 17. Abrams A: Outpatient treatment of withdrawal, chap 9, In Barnes HN, Aronson MD, Delbanco TL (Eds): Alcoholism-A Guide for the Primary Care Physician. New York, NY, Springer-Verlag, 1987, pp 78-82 18. Kraus ML, Gottlieb LD, Horwitz RI, Anscher M: Randomized clinical trial of atenolol in patients with alcohol withdrawal. N Engl J Med 1985; 313:905-909 19. Bush B: Management of the alcoholic inpatient, chap 10, In Barnes HN, Aronson MD, Delbanco TL (Eds): Alcoholism-A Guide for the Primary Care Physician. New York, NY, Springer-Verlag, 1987, pp 83-89 20. Emrick CD: A review of psychologically oriented treatment of alcoholism. J Stud Alcohol 1975; 36:88-99 21. Saxe L, Dougherty D, Esty K: The effectiveness and cost of alcoholism treatment, chap 11, In Mendelson JH, Mello NK (Eds): The Diagnosis and Treatment of Alcoholism, 2nd Ed. New York, NY, McGraw Hill, 1985; pp 485-540 22. McLellan AT, Luborsky L, O'Brien CP, Woody GE, Druley KA: Is treatment for substance abuse effective? JAMA 1982; 247:1423-1428 23. Holder HD, Blose JO: Alcoholism treatment and total health care utilization and costs. JAMA 1986; 256:1456-1460 24. Institutes of Medicine: Matching, chap 11, In Broadening the Base of Treatment for Alcohol Problems: A Report of the Committee for the Study of Treatment and Rehabilitation for Alcoholism. Washington, DC, National Academy Press, 1990, pp 279-296 25. O'Neill SF, Barnes H: Alcoholics Anonymous, chap 11, In Barnes HN, Aronson MD, Delbanco TL (Eds): Alcoholism-A Guide for the Primary Care Physician. New York, NY, Springer-Verlag, 1987, pp 93-101 26. Wright C, Moore RD: Disulfiram treatment of alcoholism-Position paper of the American College of Physicians. Ann Intern Med 1989; 111:943-945 27. Fuller RK, Branchey L, Brightwell DR, et al: Disulfiram treatment of alcoholism: A VA cooperative study. JAMA 1986; 256:1449-1455 28. Physicians' Desk Reference. Oradell, NJ, Medical Economics Company, 1990 29. Barnes HN: The use of disulfiram, chap 8, In Barnes HN, Aronson MD, Delbanco TL (Eds): Alcoholism-A Guide for the Primary Care Physician. New York, NY, Springer-Verlag, 1987, pp 73-77 30. Sellers EM, Naranjo CA, Peachey JE: Drugs to decrease alcohol consumption. N EngI J Med 1981; 305:1255-1262 31. Kwentes J, Major LF: Disulfiram in the treatment of alcoholism: A review. J Stud Alcohol 1979; 40:428-441 32. Dorus W, Ostrow DG, Anton R, et al: Lithium treatment of depressed and nondepressed alcoholics. JAMA 1989; 262:1646-1652 33. Schuckit MA: The clinical implications of primary diagnostic groups among alcoholics. Arch Gen Psychiatry 1985; 42:1043-1048 34. Rounsaville BJ, Dolinsky ZS, Babor TF, Meyer RE: Psychopathology as a predictor of treatment outcome in alcoholics. Arch Gen Psychiatry 1987; 44:505-513 35. Institutes of Medicine: Implementing the vision: Toward treatment systems, chap 13, In Broadening the Base of Treatment for Alcohol Problems: A Report of the Committee for the Study of Treatment and Rehabilitation for Alcoholism. Washington, DC, National Academy Press, 1990, pp 329-343 36. Rund DA, Summers WK, Levin M: Alcohol use and psychiatric illness in emergency patients. JAMA 1981; 245:1240-1241
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contact the primary care physician at such times,
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rather than
seeking care elsewhere because of shame or guilt. There are several potential benefits of such continuity of care. As discussed earlier, follow-up with an empathic physician can increase motivation for abstinence. In addition, an actively drinking patient would benefit by encountering a respectful physician familiar with that patient's previous desire and effort to abstain. The primary care physician might help motivate the patient to again abstain by asking about the events leading up to recurrent drinking and expressing optimism about the patient's ability to stop drinking again. The physician also could prescribe benzodiazepine therapy if needed to treat withdrawal. Frequent follow-up would help structure a patient's early days of sobriety. In contrast, relapsed alcoholic patients who seek treatment for trauma, withdrawal, or medical conditions in acute care settings are more likely to encounter a hostile environment in which the management of their primary problem, alcoholism, may not
be addressed.36
Conclusion
Primary care physicians can play an important role in managing alcoholism. Alcohol-abusing patients can be identified early, before they become socially isolated or unemployed, perhaps improving their prognosis. Several simple interventions, easily incorporated into brief medical visits, can increase patient motivation, a key determinant of the results of treatment of alcoholism. Alcohol-abusing patients who are unwilling to abstain can be advised to limit their drinking, thereby decreasing morbidity while overcoming denial about their alcohol problem. Once patients decide to abstain, detoxification, if necessary, can often be supervised safely in an outpatient setting. Matching these patients to an appropriate treatment program and maintaining close follow-up improve the likelihood of subsequent recovery, especially if attention is focused on relapse prevention. Perhaps most important to the successful management of alcoholism in the primary care setting, however, is the intrinsic benefit of a respectful, empathic, and ongoing relationship between an optimistic physician and an alcoholic patient. REFERENCES
Bradley KA: Screening and diagnosis of alcoholism in the primary care setting. West J Med 1992; 156:166-171 2. Vaillant GE: What can long-term follow-up teach us about relapse and prevention of relapse in addiction? Br J Addict 1988; 83:1147-1157 3. Miller WR: Motivation for treatment: A review with emphasis on alcoholism. Psychol Bull 1985; 98:84-107 4. Institutes of Medicine: Treatment modalities: Process and outcome, Appendix B, In Broadening the Base of Treatment for Alcohol Problems: A Report of the Committee for the Study ofTreatment and Rehabilitation for Alcoholism. Washington, DC, National Academy Press, 1990, pp 511-538 5. Wallace P, Cutler S, Haines A: Randomized controlled trial of general practitioner intervention in patients with excessive alcohol consumption. Br Med J 1988; 297:663-668 1.
Articles
Management of Alcoholism in the Primary Care Setting KATHARINE A. BRADLEY, MD, Seattle, Washington
Primary care physicians can play an important role in managing alcoholic patients. Identifying and treating alcoholism early, before it has interfered with patients' relationships and work, may increase the likelihood of prolonged recovery. Simple office interventions can help motivate patients to abstain and seek treatment. People who abuse alcohol and are unwilling to abstain can benefit from a recommendation to reduce their intake of alcohol. For alcohol-dependent patients who decide to stop drinking, primary care physicians often can manage withdrawal on an outpatient basis. Selecting an appropriate treatment program for each alcoholic patient is important, and referral to a specialist to assist in matching patients to treatments is often necessary. Primary care physicians also can help prevent relapse. Although disulfiram is of limited value, primary care physicians can support recovery by identifying coexistent psychosocial problems, helping patients to restructure their lives, and ensuring continuity of care. (Bradley KA: Management of alcoholism in the primary care setting. West J Med 1992 Mar; 156:273-277)
T his is the second of two articles on alcoholism in the primary care setting and focuses on the outpatient management of alcohol abuse and dependence, building on the discussions of screening and diagnosis found in the first article.' Unless otherwise stated, I again will rely on the definitions of alcohol abuse and dependence used in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders, third edition, revised (DSM-III-R). In general, alcohol abuse entails continued drinking despite alcohol-related physical, social, or occupational problems or in hazardous situations, whereas alcohol dependence involves a greater disability caused by drinking, often with a history of tolerance and withdrawal. The management steps discussed in this article are summarized in Table 1.
From Diagnosis to TreatmentThe Primary Care Physician's Role Early Identification and Treatment A patient's social situation at the time of treatment can have a substantial effect on the likelihood of recovery. Of men living with a spouse or employed on entering treatment, 45% and 31%, respectively, were abstinent at 8 years, compared with 21% of those in a "skid row" setting.2 Thus, by identifying and treating alcohol abuse early, before it has interfered with patients' jobs and relationships, physicians may improve their patients' chances for recovery. Motivating Patients Patient motivation appears to be a key ingredient in successful recovery from alcoholism and one that can be influenced by primary care physicians. Measures that increase patients' perceptions of the risk of drinking, especially information regarding the severity of their drinking-related problems, have been shown to significantly improve patient motivation to abstain.3 4 For instance, presenting-in a supportive, nonconfrontational manner-the risk and realities of
cirrhosis to an alcoholic person with abnormal liver function test results might motivate that patient to seek treatment. Several studies have shown that clear advice and follow-up, particularly after discussion ofthe serious nature of the problem, also increase patient motivation and consequent behavior change.3`7 When patients miss appointments, letters or phone calls from their physicians have a notable effect on motivation to return and comply with treatment recommendations.3 Finally, because waiting to begin alcoholism treatment apparently decreases motivation, primary care physicians probably can improve treatment results by facilitating rapid entry into treatment once a patient is willing.3 Substantial research also suggests that physician empathy plays an important role in patient motivation and treatment results. In contrast, confrontive behaviors have been found to TABLE 1.- PrimaryCre Provider's Role in Manaing Potiets With AlcWholism * Identify and treat alcoholism as early as possible * Increase patient motivation with specific feedback about the probltern,lar adviiceto abtain, cose:nd persistent fbllow-up, and an * Advi alcohol-abusing patients unwilling to abstain to at least reduce their alcohol intake * Peribe benzodiazepines and evaluate patients daily when with-
drawal is present': Matchpatientsto appropriate treatment programs, often in consultation with specialits * Occasionally, prescribe disulfiram to promote abstinence in appropriate patients * l*ntify and mag coexistentpchosial problems * Advise patients to participate in' Alcoholics Anonymous or other *
relapse prevention programs following treatment * Encourage patients to restructure their lives by developing new habits, new social supports, and new community involvements * Ensure continuity of care by scheduling regularfollow-up visits, contacting patients after missedzappointments, and being receptive and supportive toward relapsed patients
From the Division of General Internal Medicine, Department of Medicine, University of Washington, Seattle. This article is Part 2 of a two-part series. Part 1, "Screening and Diagnosis of Alcoholism in the Primary Care Setting," was published in the February 1992 issue. This work was supported in part by NRSA grant No. 5T32PE10002-04. Reprint requests to Katharine A. Bradley, MD, NRSA Primary Care Fellow, HQ-24, Department of Medicine, University of Washington, Seattle, WA 98195.
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ABBREVIATIONS USED IN TEXT AA = Alcoholics Anonymous DSM-III-R = Diagnostic and Statistical Manual of Mental Disorders, third edition, revised
increase patient resistance and their drinking.3'4 Thus, it seems likely that primary care physicians can influence alcoholic patients' motivation to abstain simply by displaying such qualities as respect, caring, understanding, and an ac-
tive desire to help.3
Controlled Drinking Versus Abstinence The available evidence suggests that alcohol-dependent patients rarely, if ever, revert to normal drinking, although there has been considerable controversy in this area. In the 1970s Sobell and Sobell claimed that alcohol-dependent patients could successfully learn and maintain controlled drinking, but their work was discredited by a careful review of their patients and study results.8 Several reports by the Rand Corporation claimed to document nonproblem drinking in alcoholic persons, but those with alcohol dependence at any time in the study were likely to have continued drinking problems.9 Likewise, Vaillant found that once patients had been dependent on alcohol, they were unlikely to control their drinking without abstinence.10 Abstinence should therefore be the cornerstone of any management strategy for
alcohol-dependent patients. Some patients who abuse alcohol, on the other hand, appear able to return to nonproblem drinking. Vaillant found that, over eight years, almost half of the alcoholic persons he studied reverted to social drinking, while only a third became dependent on alcohol. Likewise, the patients in the Rand studies who reverted to controlled drinking were usually nondependent problem drinkers. Vaillant's work and the Rand studies preceded the DSM-III definitions of alcohol abuse and dependence, but their definitions were similar enough that it is reasonable to assume some overlap between their patients and those who meet DSM-III-R criteria for alcohol abuse.1' Thus, while the proportion of alcohol-abusing patients who return to social drinking can be debated, the fact that some do is difficult to dispute. Given this evidence, how should we manage alcohol abuse in general medical practice? The standard of care is that the management of all alcohol abuse, like dependence, should be founded on abstention. This is the best approach because abstinence is the safest way to avoid both the physical, social, and occupational costs of alcohol abuse and the risk of progression to dependence. Many patients will not be willing to stop drinking or enter treatment when first presented with a diagnosis of alcohol abuse, however, and these patients should be advised to cut down. There are several possible benefits of advising controlled drinking in this population. A recommendation for controlled drinking-no more than two drinks a day-can serve as a diagnostic strategy. In patients unable to control their intake, a trial of controlled drinking may overcome denial about an alcohol problem, and subsequently some patients may be willing to abstain and enter treatment.'2 In patients who are able to control their intake, decreasing the they drink can decrease morbidity. A British study found that after general practitioners recommended controlled drinking, the quantity of alcohol consumed by "examount
cessive drinkers" (over 35 drinks a week for men) decreased significantly and was reflected in significant decreases in blood pressure and aspartate aminotransferase (AST, formerly SGOT) at 12 months.5 In addition to the possible medical benefits of controlled drinking, discussions of a patient's successes and failures can help maintain an open dialogue and a therapeutic relationship between the physician and the patient, allowing physicians to continue to urge abstinence as additional alcohol-related problems arise. For these reasons, I think that after firmly recommending abstinence and after a frank discussion with patients about the serious risks of continued drinking, alcohol-abusing patients who refuse to stop drinking should be advised to reduce their intake. This approach is not recommended for patients who are alcohol-dependent, because it is unlikely that they would be able to control the amount they drink. Many alcohol treatment specialists and persons affiliated with Alcoholics Anonymous (AA) will strongly disagree with any management approach that includes controlled drinking. 10"13 It should be stressed that I am not recommending such a strategy as the preferred treatment, but rather as a second choice with potential therapeutic benefits. This circumstance seems analogous to one where a patient with a life-threatening infection refuses to stay in the hospital. Although the recommended treatment is intravenous antibiotics, when the patient leaves against medical advice most physicians would, as the best possible substitute, prescribe oral antibiotics and arrange follow-up. In this spirit, primary care physicians should recommend controlled drinking to patients who abuse, and refuse to abstain from, alcohol.
Inpatient Versus Outpatient Detoxification Historically, detoxification involved withdrawal from alcohol in an inpatient setting, making a hospital stay the first step of rehabilitation. A randomized, controlled study of 164 patients with mild-to-moderate withdrawal symptoms and no active medical or psychological problems found outpatient detoxification to be safe and effective. 14 Outpatient detoxification included daily visits to the clinic where patients were evaluated for withdrawal symptoms and placed on benzodiazepine therapy over three to five days. Both inpatients and outpatients were referred to AA for long-term rehabilitation. Despite the fact that many participants had unstable social situations, there were no complications of outpatient withdrawal. Furthermore, in spite of a higher attrition rate among outpatients, both settings appeared equally effective with respect to abstinence, sobriety, alcohol-related problems, recurrent need for detoxification, and entry into long-term rehabilitation at six months. Inpatient detoxification was 9 to 20 times more expensive, including lost opportunity costs. 14 Although the study may have been biased by minor differences in the two randomly selected groups and lacked the power to detect small differences in results, the findingslarge differences in cost and a lack of any differences in outpatient complications or results-support outpatient management of mild to moderate alcohol withdrawal. Such patients should be seen daily by the physician or a surrogate and evaluated for withdrawal symptoms to be treated with benzodiazepine therapy. Inpatient detoxification remains appropriate, however, when withdrawal is complicated by seizures or other medical or psychiatric problems, and perhaps when a patient has failed previous outpatient detoxification or requests inpatient management.
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The Role of Medications in Detoxification Although it has been suggested that alcoholic persons can safely withdraw without medication,"5 evidence in animals and humans suggests that untreated withdrawal may predispose patients to withdrawal seizures and cognitive defects.16 Therefore, benzodiazepines should be considered for all withdrawing patients. Although opinions differ regarding the benefits of short- or long-acting benzodiazepines, the short-acting varieties (oxazepam or lorazepam) are metabolized primarily by glucuronidation and may be safer for the elderly and for patients with liver disease. If diazepam is used, a starting dose of 10 to 20 mg with repeated doses of 5 mg every four to six hours as needed to control symptoms can be prescribed the first day, decreasing the total daily dose by half each day thereafter. 17 ,B-Blockers, which mask the sympathetic discharge of withdrawal, have been shown to speed the return to normal of vital signs, substantially decrease the length of hospital stay, and decrease benzodiazepine requirements. 18 Although a recent inpatient trial reported no complications from treatment with atenolol,18 there have been previous reports of increased delirium tremens in withdrawing patients treated with propranolol.19 Therefore, until further data have accumulated, fl-blockers are probably best reserved for the inpatient setting where patients can be monitored closely. Even in these patients, $-blockers probably should be used as an adjunct to, not instead of, benzodiazepines because of the possible sequelae of untreated withdrawal mentioned previously. Treatment Programs Studies of alcoholism treatment programs have been plagued by multiple definitions of alcoholism, heterogeneous treatment populations, bias because of self-referral, the relapsing and remitting nature of the disease, attrition, and a short duration of follow-up. Nevertheless, some general conclusions about treatment can be made. No single alcoholism treatment-behavioral, psychotherapeutic, aversion, pharmacologic, or self-help-has welldocumented short- or long-term benefits for all patients. Likewise, the intensity (residential versus nonresidential) and duration of treatment have not been shown to alter patients' outcomes in controlled studies.4 Moreover, studies of pooled data, comparing treatment to no treatment, have been unable to show clear-cut treatment benefits.9' 1020-22 Nevertheless, an extensive review of the literature by a subcommittee of the Institutes of Medicine concluded that "a variety of specific treatment methods have been associated with increased improvement, relative to no treatment or alternative treatments, in controlled studies."4 Additionally, there is evidence that alcoholism treatment programs have overall cost benefits to society.21 23 For these reasons, primary care physicians are advised to refer alcohol-abusing and alcoholdependent patients for treatment. Selecting a Treatment Program Matching patients to the individual treatments that are most likely to prove successful for them is a challenge. Demographic variables (such as age, sex, and marital status), psychological factors (such as psychiatric diagnoses, selfimage, and locus of control), severity of alcoholism, and antecedents to drinking have all been found to affect the results of specific patient-treatment matches.24 For example, patients who are socially unstable (for example, homeless or
unemployed) or those with severe alcohol dependence or coexistent psychopathology may have more success in residential programs, whereas socially stable persons appear to do well in less costly nonresidential treatment settings.4 Data on matching alcoholic patients to treatment programs are incomplete at this time, and there are no easily accessible guidelines for use by primary care physicians, although both issues are being addressed by the Institutes of Medicine.24 In the meantime, clinicians can refer patients to specialists-social workers, alcoholism counselors, or mental health professionals with knowledge of alcoholism treatment resources-to be evaluated and matched to a suitable treatment option. In some localities publicly supported matching programs are available, and ideally more will be evolving.24 The National Council of Alcoholism has offices in many cities and can also assist in such matching. Alcoholics Anonymous One of the most accessible and widely recommended treatment programs is AA. Begun by two alcoholic persons, AA is a network of self-help groups offering free, daily meetings. In AA meetings alcoholic persons are guided by others recovering from alcoholism through 12 suggested steps. These steps have been described as a "quasireligious expression of the process of change seen in psychotherapy, . . . [involving] accepting the diagnosis . . . , believing that recovery is possible, undergoing a period of self-exploration, and finally translating this self-knowledge into appropriate interpersonal behavior."25 Despite extensive anecdotal reports of the value of AA, there are only three controlled studies of its effectiveness, and the results have been mixed.4 Nevertheless, the fact that AA is remarkably successful at attracting alcoholic persons to recovery, is free, and appears to be effective for relapse prevention make it an important resource for primary care physicians and their patients.4 Alcoholics Anonymous groups differ, each with a character of its own. Some are open to the public, others are closed. Once patients agree to attend, having them call for information from the physician's office will ensure that the referral is completed. Patients should be encouraged to try several open meetings and return to discuss their impressions with the referring physician before deciding "it's not for them."25 Relapse Prevention The Role ofDrugs in Abstinence Disulfiram (Antabuse) has a limited role in maintaining abstinence. It allows alcohol-abusing patients to make the decision not to drink once a day, postponing impulses to drink five to seven days, and has been shown to reduce the frequency of alcohol consumption over the short run. In a 1989 position paper, the American College of Physicians stated that supervised administration of disulfiram is probably effective in voluntary treatment of outpatients and compulsory treatment for violent or criminal patients, and that self-administration of disulfiram was possibly effective, especially in motivated, older, socially stable alcoholic persons.26 Another study, however, found no benefit of disulfiram with respect to total abstinence, time to first drink, employment, or social stability over one year, although patients treated with disulfiram did have fewer drinking days.27 The alcohol-disulfiram reaction is usually mild, including flushing, headache, nausea, and vomiting, beginning
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about 5 minutes after ingestion and lasting 30 to 180 minutes. The potential complications of the drug are many (Table 2).28-3o Occasional severe reactions have included myocardial infarction, congestive heart failure, arrhythmia, seizure, and death.29 These more severe reactions usually occur at doses of at least 500 mg per day after multiple drinks and may be associated with concurrent use of sympatholytic or psychotropic drugs.30 Any ethanol-containing medication or substance (including 15 ml of over-the-counter cough syrup, cutaneously applied rubbing alcohol, and paraldehyde) can cause a reaction.29,31 Because of disulfiram's teratogenic effects, pregnancy is an absolute contraindication to its use. Relative contraindications include cardiac or metabolic diseases; pulmonary, hepatic, or renal insufficiency; neuropathy, organic mental disorders, depression, personality disorders, psychosis, or concurrent administration of sympatholytic or psychotropic medications.29-31
Patients who are started on disulfiram therapy must be educated about the risks of drinking, of taking other medications, possible side effects, and the fact that pregnancy is absolutely contraindicated. Disulfiram should be started at 250 mg per day, and administration should be supervised if possible. Patients should carry identification stating that they are taking the drug. Under no circumstances should the disulfiram-alcohol reaction be provoked deliberately, as was previously recommended as a form of aversion therapy. Trials with disulfiram implants have shown erratic blood levels; implants are not currently recommended.4 Lithium, which had been shown in early studies to prolong abstinence, was no better than placebo in a recent Veterans Administration cooperative study of depressed and nondepressed alcoholic patients.32 It has no place in the treatment of chronic alcoholism. No other drugs currently available in the United States are of proven use in promoting abstinence.4 Managing Coexistent Psychosocial Problems Coexistent psychiatric illness often predisposes patients to relapse,33 and primary care physicians can help identify and treat it. Untreated depression has a documented adverse effect on outcome in alcoholic men,34 and treating depression that persists after a patient is sober might help maintain remission.4 Therefore, if depression lasts beyond the early weeks of abstinence, a primary care physician should consider initiating specific antidepressant therapy with either medication or referral for psychotherapy. Similarly, stress management training may help maintain abstinence, especially in patients with coexisting anxiety.4
Social and family problems are also thought to contribute to relapse, and there is evidence that specific interventions aimed at these problems improve long-term results. For instance, behavioral marital therapy has been shown to decrease treatment dropout and relapse rates, while social skills training appears to improve results in alcoholic persons lack-
ing these skills.4 By being alert for concomitant social problems, primary care physicians can refer recovering alcoholic patients for specialized assistance when indicated. Restructuring Patients' Lives Vaillant has identified four conditions that contribute to stable abstinence after treatment: a substitute nonchemical dependency, new social supports, inspirational group mem-
ALCOHOLISM IN PRIMARY CARE CARE ALCOHOLISM
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TABLE 2.-Possible CompliaOns of Disulfiram
PRIMARY
herapy':
de Effects Gastrointestinal upset Fatigue and sedation Dermatitis Hypertension: IMpotence ifnreased ive"r functintest results Depression and psychosis and cholesterol level. Body odor and halitosis
Peripheral neuropath*y optic neuritis, and polyneuritis Fulminant. or cholestatic hepatitis-
Drug Interactions Increases the halfli* of phenytoin and coumadin Potentiates metronidazole and isoniazid,- including possible neuro-; toxicity and hepatic toxicity When taken with ypatholytics or monoam:ine oxidase inhibitorsmay cause severe hypotension Results of Overdose Alone-primarily nervous system dysfunction. With alcohol-tachardia, hypotension,arrhythmia, myocardial infarction, stroke, and death Teratogenic Effects Primarily limb abnormal:Ities "Fom Physician' Desk Reference,28 Bames.29 and Sellers et al.30
bership, and compulsory treatment.2 He hypothesizes that these conditions help impose structure on recovering alcoholic patients' lives, thereby interfering with any tendency to drink.2 According to Vaillant, AA often fulfills three of these conditions. Attending AA meetings may serve as a substitute addiction; other AA members offer new social support; and the group's philosophy, reflected in the 12 steps, provides spiritual support.2 Additionally, such conditions are often incorporated into aftercare programs aimed at preventing relapse. For patients unwilling to attend AA meetings or other aftercare programs, primary care physicians can use Vaillant's findings to help patients remain sober. Specifically, a regular schedule of follow-up appointments, perhaps accompanied by a calendar with each date marked, might mimic some of the effects of compulsory treatment programs. Such structured follow-up has been shown independently to improve abstinence rates.4 Advising patients to develop new exercise programs, hobbies, or other routines might foster nonchemical dependencies, which supports abstinence. Encouraging patients to join a religious or other community organization might lead to new social supports and provide inspirational group membership. Continuity of Care Alcoholism is a chronic relapsing and remitting disease, and, despite the best of intentions, most recovering alcoholic persons experience at least one relapse. While eventually paraprofessional caseworkers might provide continuity of care for these patients,35 primary care physicians can help fill this important niche. Primary care physicians can build a foundation for continuity of care by discussing the relapsing nature of the disease openly with recovering alcoholic patients. The frank discussion of relapse as a feature of the disease can help decrease a patient's sense of personal failure when relapse occurs. Moreover, the explicit articulation of a physician's willingness and expectation to care for a patient with alcoholism, if
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relapse occurs, might encourage the patient to
6. Edwards G, Orford J, Egert S, et al: Alcoholism: A controlled trial of treatment and advice. J Stud Alcohol 1977; 38:1004-1031 7. Chick J, Lloyd G, Crombie E: Counseling problem drinkers in medical wards: A controlled study. Br Med J 1985; 290:965-967 8. Pendery ML, Maltzman IM, West LJ: Controlled drinking by alcoholics? New findings and re-evaluation of a major affirmative study. Science 1982; 217:169-175 9. Polich JM, Armor DJ, Braiker HB: The Course of Alcoholism: Four Years After Treatment. Santa Monica, Calif, Rand, 1980 10. Vaillant GE: The Natural History of Alcoholism. Cambridge, Mass, Harvard University Press, 1983 11. American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders, 3d Ed, revised. Washington, DC, American Psychiatric Association, 1987 12. Bigby JA: Negotiating treatment and monitoring recovery, chap 7, In Barnes HN, Aronson MD, Delbanco TL (Eds): Alcoholism-A Guide for the Primary Care Physician. New York, NY, Springer-Verlag, 1987, pp 66-72 13. Wallace J: Controlled drinking, treatment effectiveness, and the disease model of addiction. J Psychoactive Drugs 1990; 22:261-284 14. Hayashida M, Alterman Al, McLellan AT, et al: Comparative effectiveness and costs of inpatient and outpatient detoxification of patients with mild to moderate alcohol withdrawal syndrome. N Engi J Med 1989; 320:358-365 15. Whitfield CL, Thompson G, Lamb A, Spencer V, Pfeifer M, Browning-Ferrando M: Detoxification of 1,024 alcoholic patients without psychoactive drugs. JAMA 1978; 239:1409-1410 16. Tabakoff B: Treatment of alcoholism (Letter). N Engl J Med 1989; 321:400 17. Abrams A: Outpatient treatment of withdrawal, chap 9, In Barnes HN, Aronson MD, Delbanco TL (Eds): Alcoholism-A Guide for the Primary Care Physician. New York, NY, Springer-Verlag, 1987, pp 78-82 18. Kraus ML, Gottlieb LD, Horwitz RI, Anscher M: Randomized clinical trial of atenolol in patients with alcohol withdrawal. N Engl J Med 1985; 313:905-909 19. Bush B: Management of the alcoholic inpatient, chap 10, In Barnes HN, Aronson MD, Delbanco TL (Eds): Alcoholism-A Guide for the Primary Care Physician. New York, NY, Springer-Verlag, 1987, pp 83-89 20. Emrick CD: A review of psychologically oriented treatment of alcoholism. J Stud Alcohol 1975; 36:88-99 21. Saxe L, Dougherty D, Esty K: The effectiveness and cost of alcoholism treatment, chap 11, In Mendelson JH, Mello NK (Eds): The Diagnosis and Treatment of Alcoholism, 2nd Ed. New York, NY, McGraw Hill, 1985; pp 485-540 22. McLellan AT, Luborsky L, O'Brien CP, Woody GE, Druley KA: Is treatment for substance abuse effective? JAMA 1982; 247:1423-1428 23. Holder HD, Blose JO: Alcoholism treatment and total health care utilization and costs. JAMA 1986; 256:1456-1460 24. Institutes of Medicine: Matching, chap 11, In Broadening the Base of Treatment for Alcohol Problems: A Report of the Committee for the Study of Treatment and Rehabilitation for Alcoholism. Washington, DC, National Academy Press, 1990, pp 279-296 25. O'Neill SF, Barnes H: Alcoholics Anonymous, chap 11, In Barnes HN, Aronson MD, Delbanco TL (Eds): Alcoholism-A Guide for the Primary Care Physician. New York, NY, Springer-Verlag, 1987, pp 93-101 26. Wright C, Moore RD: Disulfiram treatment of alcoholism-Position paper of the American College of Physicians. Ann Intern Med 1989; 111:943-945 27. Fuller RK, Branchey L, Brightwell DR, et al: Disulfiram treatment of alcoholism: A VA cooperative study. JAMA 1986; 256:1449-1455 28. Physicians' Desk Reference. Oradell, NJ, Medical Economics Company, 1990 29. Barnes HN: The use of disulfiram, chap 8, In Barnes HN, Aronson MD, Delbanco TL (Eds): Alcoholism-A Guide for the Primary Care Physician. New York, NY, Springer-Verlag, 1987, pp 73-77 30. Sellers EM, Naranjo CA, Peachey JE: Drugs to decrease alcohol consumption. N EngI J Med 1981; 305:1255-1262 31. Kwentes J, Major LF: Disulfiram in the treatment of alcoholism: A review. J Stud Alcohol 1979; 40:428-441 32. Dorus W, Ostrow DG, Anton R, et al: Lithium treatment of depressed and nondepressed alcoholics. JAMA 1989; 262:1646-1652 33. Schuckit MA: The clinical implications of primary diagnostic groups among alcoholics. Arch Gen Psychiatry 1985; 42:1043-1048 34. Rounsaville BJ, Dolinsky ZS, Babor TF, Meyer RE: Psychopathology as a predictor of treatment outcome in alcoholics. Arch Gen Psychiatry 1987; 44:505-513 35. Institutes of Medicine: Implementing the vision: Toward treatment systems, chap 13, In Broadening the Base of Treatment for Alcohol Problems: A Report of the Committee for the Study of Treatment and Rehabilitation for Alcoholism. Washington, DC, National Academy Press, 1990, pp 329-343 36. Rund DA, Summers WK, Levin M: Alcohol use and psychiatric illness in emergency patients. JAMA 1981; 245:1240-1241
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contact the primary care physician at such times,
16
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rather than
seeking care elsewhere because of shame or guilt. There are several potential benefits of such continuity of care. As discussed earlier, follow-up with an empathic physician can increase motivation for abstinence. In addition, an actively drinking patient would benefit by encountering a respectful physician familiar with that patient's previous desire and effort to abstain. The primary care physician might help motivate the patient to again abstain by asking about the events leading up to recurrent drinking and expressing optimism about the patient's ability to stop drinking again. The physician also could prescribe benzodiazepine therapy if needed to treat withdrawal. Frequent follow-up would help structure a patient's early days of sobriety. In contrast, relapsed alcoholic patients who seek treatment for trauma, withdrawal, or medical conditions in acute care settings are more likely to encounter a hostile environment in which the management of their primary problem, alcoholism, may not
be addressed.36
Conclusion
Primary care physicians can play an important role in managing alcoholism. Alcohol-abusing patients can be identified early, before they become socially isolated or unemployed, perhaps improving their prognosis. Several simple interventions, easily incorporated into brief medical visits, can increase patient motivation, a key determinant of the results of treatment of alcoholism. Alcohol-abusing patients who are unwilling to abstain can be advised to limit their drinking, thereby decreasing morbidity while overcoming denial about their alcohol problem. Once patients decide to abstain, detoxification, if necessary, can often be supervised safely in an outpatient setting. Matching these patients to an appropriate treatment program and maintaining close follow-up improve the likelihood of subsequent recovery, especially if attention is focused on relapse prevention. Perhaps most important to the successful management of alcoholism in the primary care setting, however, is the intrinsic benefit of a respectful, empathic, and ongoing relationship between an optimistic physician and an alcoholic patient. REFERENCES
Bradley KA: Screening and diagnosis of alcoholism in the primary care setting. West J Med 1992; 156:166-171 2. Vaillant GE: What can long-term follow-up teach us about relapse and prevention of relapse in addiction? Br J Addict 1988; 83:1147-1157 3. Miller WR: Motivation for treatment: A review with emphasis on alcoholism. Psychol Bull 1985; 98:84-107 4. Institutes of Medicine: Treatment modalities: Process and outcome, Appendix B, In Broadening the Base of Treatment for Alcohol Problems: A Report of the Committee for the Study ofTreatment and Rehabilitation for Alcoholism. Washington, DC, National Academy Press, 1990, pp 511-538 5. Wallace P, Cutler S, Haines A: Randomized controlled trial of general practitioner intervention in patients with excessive alcohol consumption. Br Med J 1988; 297:663-668 1.
