Alcohol Use Disorders in Primary Health Care

Abstract and Introduction

Abstract

Aims: To analyze the current paradigm and clinical practice for dealing with alcohol use disorders (AUD) in primary health care.

Methods: Analyses of guidelines and recommendations, reviews and meta-analyses.

Results: Many recommendations or guidelines for interventions for people with alcohol use problems in primary health care, from hazardous drinking 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 drinking, referral to specialized treatment for people with AUD. However, while there is some evidence that these procedures are effective in reducing drinking 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, we 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).

Conclusions: A paradigm shift is proposed for dealing with problematic alcohol consumption in primary health care, where initiation for treatment for AUD is seen as the central element.

Introduction: Prevalence of Alcohol use Disorders in Primary Health Care Settings

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 (World Health Organization, 2014; for recent regional publications from high-income countries see: Europe, specifically for EU countries Rehm et al., 2015d; for Russia: World Health Organization, 2014; Americas, for the USA: Grant et al., 2015; for Canada: Pearson et al., 2013, http://www.statcan.gc.ca/pub/82-624-x/2013001/article/c-g/11855-c-g-02-eng.htm; for Chile: Vicente et al., 2004; Asia, for Japan: Ishikawa et al., 2015; for South Korea: Han et al., 2015; Oceania for Australia: Teesson et al., 2010). 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; http://www.nationaldrugstrategy.gov.au/internet/drugstrategy/publishing.nsf/Content/FE16C454A782A8AFCA2575BE002044D0/$File/mono71.pdf). 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.

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, we will first answer the question, whether PHC physicians can recognize people with AUD. For all discussion in all sections, we consider systematic reviews and meta-analysis first, and, if not available, we report large-scale studies.

Authors and Disclosures

Jürgen Rehm^1,2,3,4,5,6,*, Peter Anderson^7,8, Jakob Manthey⁴, Kevin D. Shield^1,3, Pierluigi Struzzo^9,10, Marcin Wojnar^11,12 and Antoni Gual^13,14,15

¹Centre for Addiction and Mental Health (CAMH), 33 Russell Street, Toronto, ON M5S 2S1, Canada, ²Campbell Family Mental Health Research Institute, CAMH, 250 College Street, Toronto, ON M5T 1R8, Canada, ³Institute of Medical Science (IMS), University of Toronto, Medical Sciences Building, 1 King's College Circle, Room 2374, Toronto, ON M5S 1A8, Canada, ⁴Institute for Clinical Psychology and Psychotherapy, TU Dresden, Chemnitzer Str. 46, 01187 Dresden, Germany, ⁵Department of Psychiatry, University of Toronto, 250 College Street, 8th Floor, Toronto, ON M5T 1R8, Canada, ⁶Dalla Lana School of Public Health, University of Toronto, 155 College Street, 6th Floor, Toronto, ON M5T 3M7, Canada, ⁷Institute of Health & Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne NE2 4AX, UK, ⁸Faculty of Health, Medicine and Life Sciences, Maastricht University, P. Debyeplein 1, 6221 HA Maastricht, Netherlands, ⁹Department of Life Sciences, University of Trieste, Via Weiss 2 – Pal. Q – 34128 Trieste, Italy, ¹⁰Center for Study and Research in General Practice (Ceformed), Via Galvani 1, 34074 Monfalcone, GO, Italy, ¹¹Department of Psychiatry, Medical University of Warsaw, Nowowiejska 27, 00-665 Warsaw, Poland, ¹²Department of Psychiatry and Addiction Research Center, University of Michigan, 4250 Plymouth Rd, Ann Arbor, MI 48109, USA, ¹³Addictions Unit, Psychiatry Department, Neurosciences Institute, Hospital Clinic, Carrer Villarroel 170, 08036 Barcelona, Spain (Catalonia), ¹⁴Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Carrer Rosselló 149, 08036 Barcelona, Spain (Catalonia) and ¹⁵Red de Trastornos Adictivos (RTA – RETICS), Instituto de Salud Carlos III, Calle Sinesio Delgado, 4, 28029 Madrid, Spain

*Corresponding author
CAMH, 33 Russell Street, Toronto, ON M5S 2S1, Canada. Tel.: +1-416-535-8501; Fax: +1-416-595-6068; E-mail: jtrehm@gmail.com

Authors' Contributions
Study concept and design: J.R. and P.A. Drafting of the manuscript: J.R. Critical revision of the manuscript for important intellectual content: all authors. Statistical analysis (own calculations): J.M. and K.D.S. Approval of the final manuscript: all authors.

Conflict of Interest Statement
A.G.: reports grants and personal fees from Lundbeck and D&A Pharma during the conduct of the study and grants from TEVA and personal fees from AbbVie outside the submitted work. J.M.: reports receiving personal fees from Lundbeck, outside of the submitted work. J.R.: reports grants, personal fees and travel support from Lundbeck outside of the submitted work. K.D.S.: no potential conflict of interest stated. M.W.: reports personal fees from AOP Orphan, Berlin Chemie, Janssen, Lundbeck, D&A Pharma, Reckitt Benckiser outside the submitted work. P.A.: no potential conflict of interest stated. P.S.: reports grants from University of Dresden and being primary care board member for Lundbeck outside the submitted work.