Q&A: Overcoming barriers to alcohol use disorder treatment
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HHS recently announced that six institutions would split $16 million to develop strategies for primary care providers to address unhealthy alcohol use in their patients. The funding is desperately needed, according to AAFP president-elect Ada Stewart, MD.
“Primary care providers are out there trying to recognize and treat alcohol use disorder,” Stewart told Healio Primary Care. “Can we do better? Yes. But we also need resources to better help our patients.”
Although some resources are available to PCPs — including national recommendations and screening tools — almost 30% of adult ambulatory care users never receive an alcohol use assessment, according to researchers.
Healio Primary Care asked Stewart, who is also a family physician at Cooperative Health in Columbia, South Carolina, about the best approaches to screening patients for alcohol use disorder, and the barriers to identifying those patients and getting them the treatment they need. - by Janel Miller
Q: One of the frequent barriers that PCPs face in treating their patients is a short appointment with the long to-do list. What is the quickest way that clinicians identify alcohol use disorder in their patients?
A: Men can be asked, “How many times in the past year have you had five or more drinks in a day?” Women should be asked, “How many times have you had four or more drinks in a day?” According to an article in Journal of General Internal Medicine, this question has good sensitivity (between 73% and 88%) and specificity (between 74% and 100%) for detecting unhealthy alcohol use in U.S. primary care settings. If a patient’s answer is more than once, then the use of more detailed screening tools — U.S. Preventive Services Task Force recommendations, AUDIT–C, CAGE and the SASQ Screening Tool — should be used.
Q: According to a 2017 report, programs that try to reduce heavy drinking are “poorly implemented” in primary care. How can physicians successfully implement these programs ?
A: I allocate some responsibilities — like alcohol screening — to my medical assistant. Then, when I am talking to the patient, I find that if I can attach alcohol use to another disorder, such as diabetes, it may encourage the patient to get attention for their problem. PCPs may also want to consider doing what my practice does: have a licensed professional counselor on staff that can meet with patients who would benefit from counseling and, if needed, refer the patient to more extensive treatment options.
Q: A study published in the American Journal of Epidemiology showed that patients with an alcohol use disorder diagnosis were less likely to seek treatment for their alcohol use “if they perceived a higher stigma ” associated with their condition. How can PCPs overcome the barrier that stigma creates?
A: As you talk and make notes about your patients in their electronic health record, make sure you use patient-first language, such as, “This is John, who has issues with alcohol,” instead of, “This is an alcoholic patient.” You will not get anywhere by telling or describing a patient as one who drinks too much or by being accusatory.
I have also found that having a strong physician-patient relationship also really makes a difference. This makes approaches such as, “I know you’ve had some stressors in your family,” or, “I see that you’re probably drinking more than normal. Have you realized that could be a problem, or do you feel like that’s a problem?” more reasonable. When patients know they have a good relationship with their provider, they feel more open to talking with them about their problems.
PCPs also need to understand that every patient with alcohol use disorder is different. Some patients’ conditions are triggered by depression and anxiety. Others will spend a lot of money on alcohol and then find they don’t have food or housing. For still others, alcohol use disorder could be a combination of these two factors or something else. Therefore, addressing specific issues that could contribute to their alcohol abuse is also important.
References:
Anderson P, et al. Curr Psychiatry Rep. 2017;doi:10.1007/s11920-017-0837-z.
Glass JE. et al. J Gen Intern Med. 2016;doi:10.1007/s11606-016-3614-5.
Keyes KM, et al. Am J Epidemiol. 2010;doi:10.1093/aje/kwg304.
Smith PC, et al. J Gen Intern Med. 2009;doi:10.1007/s11606-009-0928-6.
Disclosure: Stewart reports no relevant financial disclosures.