The Primary Care Practitioner's Role in the Prevention and Management of Alcohol Problems.

Primary care practitioners encounter a spectrum (figure 1) of alcohol-related problems.(Figure 1 omitted) At one end are patients with severe alcohol dependence; at the other end are patients with hazardous patterns of alcohol consumption but no identifiable adverse consequences of drinking. In between are patients with a diverse array of alcohol-related problems.Until recently, practitioners have focused largely on diagnosing alcohol disorders and referring patients with established alcohol abuse and dependence (for definitions of terms used in this article, see p. 99) to treatment specialists to prevent additional alcohol problems and minimize disability (Barnes et al. 1987). This type of intervention can be thought of as tertiary prevention (see the sidebar, p. 100). Recent research, however, has demonstrated that counseling patients with hazardous drinking patterns or mild alcohol-related problems that do not meet diagnostic criteria for alcohol disorders, or secondary prevention, also is effective in primary care settings (Bien et al. 1993). Although the efficacy of advising all patients about safe drinking practices, or primary prevention, is not known, it is practiced in some primary care settings (e.g., obstetrics).This article describes the roles of primary care practitioners in the identification and management of alcohol problems and suggests ways that practitioners can improve the prevention of alcohol problems in primary care settings.EPIDEMIOLOGY OF ALCOHOL DISORDERSAlcohol Abuse and DependenceThese disorders are common in primary care settings. Their prevalence ranges from 11 to 20 percent in general medical clinics (Bradley 1992), 8 to 16 percent in family practice clinics (Leckman et al. 1984; Schorling et al. 1994), and 12 to 16 percent in obstetrics and gynecology practices (Halliday et al. 1986; Russell and Bigler 1979). Their prevalence in emergency departments is nearly 20 percent (Rund et al. 1981). Although few general pediatric patients meet the criteria for alcohol abuse or dependence (Duggan et al. 1991), an estimated one in eight children in the United States has a parent with a drinking problem (Kemper 1992).Known risk factors for alcohol abuse and dependence include gender, age, family history, and ethnicity. Men are three to four times more likely than women to develop drinking problems (Bradley 1992). In men, heavy drinking often begins in the teenage years, with the risk of alcohol-related problems reaching a peak in the early twenties (Bradley 1992). Women tend to develop drinking problems at a slightly older age than men, but medical complications tend to occur at similar ages in men and women (Blume 1986). Youth who begin to use alcohol before age 16 (Smith 1993), or those with antisocial behavior (Vaillant 1983), are more likely to develop alcohol problems.A genetic or cultural predisposition clearly places some people at higher risk than others (Schuckit 1985; Vaillant 1983). Men with two or more alcoholic relatives are about three times more likely to become alcohol dependent than those without (Vaillant 1983). Northern Europeans (Vaillant 1983) and some Native American groups (Institute of Medicine [IOM] 1990) also are at increased risk of developing drinking problems.HAZARDOUS DRINKINGAvailable evidence suggests that hazardous drinking is relatively common among primary care patients. Saunders and colleagues (1993a) reported that 19 percent of patients who drank alcohol consumed potentially hazardous amounts. Russell and Bigler (1979) found 19 percent of women in a gynecology practice to be heavy drinkers. Although the prevalence of hazardous drinking among pediatric primary care patients is not known, one-third of high school seniors engage in binge drinking at least every 2 weeks (Smith 1993).Epidemiologic studies have identified several patterns of drinking that place people at increased risk for alcohol problems. …