Screening and Intervention Can Help Improve Treatment for Alcohol Addiction

Studies have shown that while an estimated 3,000,000 young people need help for an alcohol abuse problem, only 17 percent of youth actually get the treatment they need. In an interview with Coalitions Online, Dr. Mark Willenbring, Director of the Division of Treatment and Recovery Research for the National Institute on Alcohol Abuse and Alcoholism (NIAAA), explains how screening and referrals by primary care doctors can help change that, and how community coalitions can play a role.

Q. Are enough people obtaining the treatment they need for alcohol addiction?
A. Certainly not. About one-third of adults in the United States have an alcohol use disorder (abuse or dependence; AUD) at some point in their lives, yet only about one in ten ever receives professional treatment.

Q. What are the primary barriers to treatment?
A. Most people who meet the criteria for an AUD do not perceive a need for treatment, feeling that “they’re not that bad yet.” This suggests that there is a high threshold before seeking treatment, which may indicate that currently available treatment is too stigmatizing or unappealing. Among those who do seek treatment, there are practical barriers such as lack of transportation or child care, lack of insurance coverage or being unable to stop working to receive treatment.

Q. Why are people reluctant to seek treatment?
A. There is such a negative stigma attached to admission to a treatment program, and it has many enduring negative consequences related to employment, insurance, and so forth. In addition, I believe that most people do not find group counseling to be a very appealing form of treatment, and people may fear loss of autonomy. Finally, treatment has costs, in terms of time, travel, co-payments and loss of income.

Q. How can we change that?
A. The average age of onset for alcohol use disorders is 21 years. The average age of first treatment is about 10 years later, so we want treatment to be more acceptable, available and to attract people at earlier and less severe stages of the illness. One way to do that would be to make less intensive treatment available through our general medical and primary care system. So, for example, somebody who is employed, is reasonably functional, but is coming home every night and drinking 10 drinks a night, would go to their family doctor and say “I’m drinking too much and I think I might be dependent.” Their doctor would then screen them, give them some brief counseling and prescribe them medication. This is the same way it is done for most cases of depression. Doctors would then refer people who are more severely addicted to addiction specialists.

Q. Do primary care doctors currently screen patients for alcohol problems?
A. Not enough. In most outpatient medical practices, about 10-15 percent of patients are drinking above recommended guidelines, yet in a recent study of primary care practices, patients with alcohol dependence received the recommended quality of care, including assessment and referral to treatment, only about 10 percent of the time. Psychiatrists in general do not do better, even though the proportion of their patients who are drinking heavily is higher than in primary care.

Q. What kind of impact do you think it would have if primary care doctors started identifying and treating heavy drinking and AUDs?
A. We might be able to get more than 10 percent of cases of alcohol dependence treated! The primary goal is to reduce the numbers of people with the disorders through prevention and treatment. Most patients don’t object to being screened for alcohol use by clinicians and are open to hearing advice afterward. In fact, most primary care patients who screen positive for heavy drinking or alcohol use disorders are motivated to change their drinking. The whole idea is to reach more people earlier in their illness, while providing more sophisticated treatment for people with the chronic severe form of the illness.

Q. Are there other things that can help get more young people into treatment?
A. While more research is needed, some studies suggest that newer technologies to deliver health messages and even treatment are attractive to young people. Also, many young heavy drinkers are likely to respond to facilitated self-change strategies and brief counseling. We ought to make that type of tool available everywhere—on the Internet, cell phones, 800 numbers, employee health programs and schools. If we could even drop the new incidence of alcohol dependence by 10-20 percent, it would have a huge effect.

Q. What are some of the newer options for treatments for people suffering from AUDs?
A. We hope that newer medications to treat alcohol dependence, when combined with brief medical counseling, can be used by primary care physicians and general psychiatrists to treat patients who are less severely dependent than those who come to treatment programs. The newest medication to show effectiveness is topiramate, a drug used to treat epilepsy and migraine headaches. Two studies show that it works in alcohol dependence, and it is not necessary to stop drinking before starting it. Another one that has been around for some time is naltrexone, which reduces the reward involved with alcohol. This has been shown to reduce relapse to heavy drinking in the first 12 weeks by about 30 percent. Naltrexone comes in oral and also in an extended injectible form that requires a monthly injection. Other medications include acamprosate and disulfiram.

Q. What can community organizations, like CADCA coalitions, do to help remove barriers to treatment?
A. CADCA coalitions can help make information about facilitated self change and counseling widely available. They can put pressure on employers to make sure that screening and brief intervention, as well as medications for alcohol dependence, are covered in insurance plans. They can implement city-wide awareness campaigns about what heavy drinking is and where to get help. They can help make doctors aware of the new codes available from Medicare that can be used to get paid for screening and intervention services. It’s also important that coalitions work with their state governments and insurance companies to ensure that they accept the new Medicare codes, so that doctors in their states can use them. I also recommend that they make sure every primary care doctor and pediatrician in town has a copy of the NIAAA’s updated Clinicians Guide, Helping Patients Who Drink Too Much, which is available at www.niaaa.nih.gov.

Dr. Mark Willenbring is the Director of the Division of Treatment and Recovery Research for the National Institute on Alcohol Abuse and Alcoholism (NIAAA). This article is part of CADCA's second editorial series in Coalitions Online featuring national experts from the NIAAA.