Primary care is the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community. (Institute of Medicine, 1996)

By any measure, effectively treating a primary care patient's substance abuse problem is addressing a significant "personal health care need." Alcohol-related disorders, for example, occur in up to 26 percent of general medical clinic patients, a prevalence rate similar to those for such other chronic diseases as hypertension and diabetes (Fleming and Barry, 1992).

While not specific to the primary care setting, the most recent National Household Survey on Drug Abuse estimates that 12.8 million Americans, or 6.1 percent of the population age 12 and older, currently use illicit drugs, while about 32 million Americans (15.8 percent of the population) had engaged in binge or heavy drinking (five or more drinks on the same occasion at least once in the previous month) (Substance Abuse and Mental Health Services Administration, 1996b).

Using estimates from the Institute of Medicine (Institute of Medicine, 1990), a Robert Wood Johnson Foundation report calculated that about 5 million users of illicit drugs and 18 million people with alcohol use problems need treatment, but only one fourth of them receive it (Institute for Health Policy, 1993).

Accurately gauging the costs of substance use problems, like estimating costs for heart disease or cancer, is difficult. This figure grows or shrinks by billions of dollars depending on the economic assumptions used.

The costs to abusers, their families, and society at large, however, are indisputably enormous and encompass health care costs, premature mortality, workers' compensation claims, reduced productivity, crime, suicide, domestic violence, and child abuse.

Some 100,000 people die each year in the United States as a result of alcohol; illicit drug abuse and related acquired immunodeficiency syndrome (AIDS) deaths account for at least another 12,000 deaths (Rice et al., 1990;Stinson et al., 1993; Rosenberg et al., 1996).

Every man, woman, and child in America pays nearly $1,000 annually to cover the costs of unnecessary health care, extra law enforcement, motor vehicle crashes, crime, and lost productivity due to substance abuse (Institute for Health Policy, 1993).

Furthermore, an "analysis of the epidemiological evidence reveals that 72 conditions requiring hospitalizations are wholly or partially attributable to substance abuse" (Center on addiction and Substance Abuse, 1993, p. 21).

Nearly one quarter of Americans say that "drinking has been a cause of trouble in their family" (Institute for Health Policy, 1993, p. 40). A forthcoming study based on criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (American Psychiatric Association, 1994a) estimates that 52.9 percent of Americans age 18 and older have a family history of alcoholism among first- or second-degree relatives *(Dawson and Grant, in press).

In short, substance use disorders are simply too pervasive and too costly to be ignored.

Fortunately, not only is effective specialty treatment available for problem drinkers, alcoholics, and illicit drug users, but brief interventions, which can be done in a primary care setting, can substantially reduce hazardous drinking, a behavior that has enormous negative effects on public health (Kahan et al., 1995).

In a report on the financially driven changes in health care, the Institute of Medicine highlighted the growing need for primary care clinicians to diagnose and treat a range of problems previously addressed by specialists (Institute of Medicine, 1996).

While not focused specifically on substance abuse, the report credits the "trust and partnership" that exists between primary care clinicians and patients as a key argument for expanding the role of primary care clinicians in screening for early disease detection, managing chronic diseases, and coordinating care among all those involved in providing patient services.

The American Medical Association's Guidelines for Adolescent Preventive Services (GAPS) recommends patient education, anticipatory guidance, and early intervention strategies to reduce adolescent patients' use of alcohol and other drugs (Elster and Kuznets, 1994). Likewise, the American Academy of Pediatrics advises pediatricians to include anticipatory guidance on substance abuse to all children and adolescents.

In support of these recommendations, universities are implementing medical and nursing school curriculum modules while specialty organizations, including the National Nurses' Society on Addictions, the American Society of Addiction Medicine, the Association for Medical Education and Research on Substance Abuse, the American Association of Obstetricians and Gynecologists, and the Drug and Alcohol Nurses Association, are promoting faculty development and the development of core competencies and practice standards for intervening with and treating substance abuse problems.

In this era of managed care, the primary care clinician's responsibility is expanding. As the gatekeeper charged with ensuring the provision of comprehensive care, the primary care clinician will almost certainly provide some type of alcohol- or other drug-related service. Basic skills in identifying and diagnosing patients who are chemically dependent will become essential.

Clinicians in areas with limited substance abuse resources may be responsible for assessments, while those trained in addiction medicine may be providing a range of treatment services.

Regardless of how extensively involved clinicians become, those who are familiar with the medical complications of substance abuse and are able to relate them to other comorbid illnesses will be better equipped to deliver adequate care.

Alcohol Use Among Primary Care Patients

Since more Americans abuse alcohol than illicit drugs, primary care clinicians will encounter substantially more patients with alcohol problems than with drug problems (although many patients who abuse alcohol also abuse illicit drugs or prescription drugs and vice versa).

Though most people who consume alcoholic beverages do not experience problems related to their use, primary care clinicians can expect that 15 to 20 percent of their male patients and 5 to 10 percent of their female patients will be at risk for or already are experiencing related medical, legal, or psychosocial problems.

These problems include unresponsive diabetes, arrests for "driving under the influence," problems with job or school, or family or marital difficulties. Figure 1-1 presents the current prevalence of alcohol use and problems in primary care settings for patients over the age of 18 (Manwell et al., in press).

Levels of Use

The nature and intensity of alcohol-related problems vary according to consumption: Above two to three drinks a day, there is a clear dose-response curve. The higher the levels of consumption, the greater the risk of negative health effects including cirrhosis, cancer, heart disease, stroke, traumatic injury, and depression.

For this reason, the National Institute on Alcohol Abuse and Alcoholism recommends that patients who currently drink adhere to the following:

Men -- No more than two drinks per day
Women -- No more than one drink per day
Men and women over age 65 -- No more than one drink per day (National Institute on Alcohol Abuse and Alcoholism, 1995b)

It is important for primary care clinicians to know patients' drinking levels in order to gauge their potential risk for developing problems. Levels also can be discussed with patients in the context of general health problems where they provide a nonstigmatizing opportunity to share valuable risk reduction information

For example, just as a clinician may point out to patients with blood pressure higher than 140/90 that they are at risk for cardiovascular problems secondary to hypertension, people who consume more than two drinks per day should be told that they are at risk for heart and liver disease.

When presented this way, information about levels may help motivate nonproblem drinkers and abstainers to maintain healthy habits, while offering those at risk for problems an incentive to reduce the amount of alcohol they consume.

Frequency of Problems Related to Use

To determine a patient's risk level, however, the clinician must consider more than consumption levels. Definitions of low-risk and at-risk use are based on the relationship between a given quantity of alcohol used and a number of health effects.

Recognizing at-risk drinkers in particular can be difficult. Researchers have investigated indicators other than consumption levels in an effort to determine other risk factors.

Low-risk drinkers consume less than an average of one to two drinks per day, do not drink more than three to four drinks per occasion, and do not drink in high-risk situations (e.g., while pregnant, driving a car, or taking medication that interacts with alcohol).

At-risk drinkers occasionally exceed recommended guidelines for use. While they are at risk for such alcohol-related problems as burns, motor vehicle crashes, or falls because of their drinking habits, at-risk drinkers may never experience negative consequences as a result of their alcohol use and represent a prime target for preventive, educational efforts by primary care clinicians.

A number of environmental, interpersonal, psychobehavioral, and biogenetic risk factors (e.g., social norms conducive to use, family and marital conflict, early onset of use, and inherited susceptibility) have been identified and are summarized in Figure 1-2(Hawkins et al., 1985;Kandel et al., 1986;Newcomb and Bentler, 1988;Heath et al., 1989; *Brook and Brook, 1990; Landry et al., 1991a;Landry, 1994).

The American Psychiatric Association's DSM-IV classifies mental disorders (including substance-related disorders) to help clinicians make useful diagnoses and to guide scientists' research.

Although this approach works best when there are clear boundaries between types of disorders, categories within disorders cited in the DSM-IV are not necessarily discrete or static.

Moreover, all individuals suffering from the same disorder are not necessarily alike (American Psychiatric Association, 1995). When the DSM-IV refers to such diagnostic levels as substance abuse and dependence, it views them as points on a continuum on which patients' use may vary.

The DSM-IV's dependence is roughly equal to the term alcoholic, and abuse is synonymous with problem drinkers. The latter is seen more than the former in primary care (Kahan et al., 1995).

These nondependent but problematic drinkers account for the "majority of alcohol-related morbidity and mortality in the general population" (U.S. Preventive Services Task Force, 1996, p. 567;Institute of Medicine, 1990).

As a group, problem drinkers experience a range of alcohol-related problems from a "driving under the influence" citation to loss of job or family disruption.

It is important for clinicians to understand, however, that problem drinkers, unlike alcoholics, often respond to clinician counseling and brief intervention efforts (see Chapter 3) and do not always require a referral to specialized treatment.

Alcoholic or dependent drinkers meet at least three of the seven DSM-IV criteria for substance dependence: drinking more than intended; wanting to stop drinking; spending a great deal of time procuring alcohol; giving up social or occupational activities because of alcohol; drinking despite the physical or psychological problems it causes; and, in some cases, experiencing physical dependence as manifested by tolerance to alcohol's effects and withdrawal symptoms.

Figure 1-3 illustrates the relationship between level and frequency of use and the development of alcohol problems (Skinner, 1992).

   Continued - see source document:

From SAMHSA/CSAT Treatment Improvement Protocols
TIP 24: A Guide to Substance Abuse Services for Primary Care Clinicians