Alcohol Use Disorders in Primary Health Care: What Do We Know and Where Do We Go?
To analyze the current paradigm and clinical practice for dealing with alcohol use disorders (AUD) in primary health care.
Analyses of guidelines and recommendations, reviews and meta-analyses.
Many recommendations or guidelines for interventions for people with alcohol use problems in primary health care, from hazardous alcohol use to AUD, can be summarized in the SBIRT principle: screening for alcohol use and alcohol-related problems, brief interventions for hazardous and in some cases harmful alcohol use, referral to specialized treatment for people with AUD. However, while there is some evidence that these procedures are effective in reducing alcohol use levels, they are rarely applied in clinical practice in primary health care, and no interventions are initiated, even if the primary care physician had detected problems or AUD.
Rather than asking primary health care physicians to conduct interventions which are not typical for medical doctors, the researchers recommend treatment initiation for AUD at the primary health care level. AUD should be treated like hypertension, i.e. with regular checks for alcohol consumption, advice for behavioral interventions in case of consumption exceeding thresholds, and pharmaceutical assistance in case the behavioral interventions were not successful. Minimally, alcohol consumption should be screened for in all situations where there is a co-morbidity with alcohol being a potential cause (such as hypertension, insomnia, depression or anxiety disorders).
A paradigm shift is proposed for dealing with alcohol use disorders in primary health care, where initiation for treatment for AUD is seen as the central element.
Background and key issues addressed
Alcohol use disorders (AUD) are prevalent around the world (Rehm et al., 2009; World Health Organization, 2014), especially in high-income countries with small Muslim populations. In 2012 the prevalence of AUD for adults (defined as 15 years of age and older based on ICD 10) (World Health Organization, 1993) was 4.2% for the total adult population (a 1.8% prevalence of the harmful use of alcohol and a 2.3% prevalence of alcohol dependence—people with alcohol dependence and harmful use were only included under dependence), 7.1% for the adult male population and 1.2% for the adult female population (World Health Organization, 2014). In high-income non-Muslim countries, where less than 50% of the population identified as Muslim, the prevalence of AUD was 7.2% for the total adult population (a 3.2% prevalence of the harmful use of alcohol and a 4.0% prevalence of alcohol dependence), 11.4% for the adult male population and 3.2% for the adult female population.
For primary health care (PHC) samples, the prevalence of AUD is even higher for several reasons (Üstün and Sartorius, 1995; Ansseau et al., 2004; Manthey et al., in press).
- First, PHC samples comprise patients, and as heavy use of alcohol and AUD are associated with many disease and injury categories attended for in PHC, prevalence of heavy use and AUD should be higher among PHC patients. The most prominent PHC disease categories associated with heavy alcohol use are hypertension, insomnia, liver problems, depression and anxiety disorders (Chakravorty et al., 2013; Rehm et al., 2015c;).
- Second, the age distribution of PHC patients over-represents people 40 years and older; in this age group, in many countries, alcohol dependence has the highest prevalence, at least for severe dependence (Rehm et al., 2005; an exception is the USA—Rehm et al., 2014b—where prevalence of AUD is highest in younger adults; for a critical discussion of the USA see Caetano and Babor, 2006).
- Third, many of the people not responding or outside the sampling frame for general population surveys (Shield and Rehm, 2012) can be found in PHC; and this includes people without a permanent living address in some instances.
From recognition to effective forms of intervention
Given the high prevalence of AUD in PHC, the main question concerns how these patients should be handled, and what empirical evidence there is for different forms of interventions and their clinical application. Before reporting on potential interventions, separated in screening, brief advice, treatment and referral to specialized care, the researchers first answer the question, whether PHC physicians can recognize people with AUD. For all discussion in all sections, the researchers consider systematic reviews and meta-analysis first, and, if not available, we report large-scale studies.