Effectiveness of Treatment in General Medicine Patients With Drinking Problems.

Alcohol is the most frequently used and abused substance in the United States. Eighty percent of adult Americans drink some alcohol (Clark and Midanik 1982), and as many as 20 percent of Americans either are experiencing alcohol-related social, legal, financial, or medical problems or are at risk for developing these problems because of their drinking (Bradley et al. 1993). Although most of these people do not seek counseling for their drinking, many will visit a general internist or family physician for routine health care in any given year. These visits provide the physician with a unique opportunity to intervene and make a difference in the patient's life.This article reviews the prevalence of drinking problems among patients in primary health care settings and the physician's role in helping many of these individuals to change their drinking behaviors.PREVALENCE OF DRINKING PROBLEMSInvestigations conducted in both general medicine and family medicine practice settings have shown that as many as 40 percent of patients have current or past serious problems with drinking (Cleary et al. 1988; Buchsbaum et al. 1991). Figure 1, based on a randomly chosen sample of 453 patients, demonstrates the extent of drinking problems in one inner-city general medicine practice (Buchsbaum et al. 1991). (Figure 1 omitted) The data were collected through formal interviews according to the Diagnostic Interview Schedule (DIS), a diagnostic instrument that is based on the Diagnostic and Statistical Manual of Mental Disorders, Third Edition (DSM-III; American Psychiatric Association 1980). The DSM-III diagnostic criteria for alcohol abuse or dependence highlight the behavioral, medical, and social consequences of excessive or uncontrolled drinking. In the sample, 12 percent of the patients met the diagnostic criteria for active alcohol dependence or abuse, and 3 percent, although "subthreshold" for a formal DSM-III diagnosis, were harming themselves 6y their pattern of drinking and were classified as "problem drinkers."An additional 30 percent of the patients were identified as previous problem, alcohol-abusing, or alcohol-dependent drinkers.In addition to these patients with serious alcohol-related problems, an equal or higher number of patients are drinking in a manner that places them at risk for experiencing adverse medical or social complications such as liver disease or marital discord. These patients also could benefit from a physician's attention to their drinking habits. To identify them as well as those patients with obvious signs of alcohol abuse, the physician can consider using three diagnostic categories: hazardous drinking, harmful drinking, and dependent drinking.Hazardous drinking (also sometimes called at-risk drinking) refers to a pattern or level of drinking that, if continued, puts the patient at risk for adverse social, medical, or psychological consequences (Babor and Grant 1992). This category includes people who drink more than 14 drinks(1) per week or more than 5 drinks per drinking session (Bradley et al. 1993). Many of them are not aware that their drinking represents a hazard. Harmful drinking is a category based on the World Health Organization's International Classification of Diseases. It is defined as a drinking behavior that has already resulted in adverse consequences. This definition shares diagnostic elements with the alcohol abuse diagnosis as defined in the DSM scheme. Finally, dependent drinking refers to a pattern of drinking that is characterized by symptoms of withdrawal upon discontinuation. This term refers to a diagnosis based on DSM criteria.The relative proportions of these disorders in a given medical practice depend on the location of the practice and its patient composition. In settings characterized by high levels of economic indigence such as inner cities, alcohol dependence may be more common than harmful and hazardous drinking. In non-inner-city primary care populations, on the other hand, hazardous and harmful drinking combined are more common than dependent drinking (Skinner 1990). …