Increasing Prevalence of Alcohol Use Disorders: Meeting the Challenge in Primary Care

Abstract

I n a national study of alcohol consumption, DSM-IV alcohol use disorders (AUD) increased significantly in most socioeconomic and demographic groups from 2001/2002 to 2012/2013. 1 Over this period, the prevalence of AUD rose from 8.5% to 12.7% of the population, or an estimated 29.9 million Americans. The rise in AUD reflects not only diverse socioeconomic factors, but also the failure of the health care system to diagnose and address this condition despite significant associated morbidity and mortality. 2 Access to specialty care for AUD has been notoriously poor, and demand has far outstripped capacity. 3 A logical approach to meet this demand is to increase the role of primary care in managing AUD by prescribing effective medication for this common condition. However, surprisingly little research has been conducted on factors influencing the willingness of primary care physicians to prescribe these medications. The rigorous qualitative study by Williams and colleagues in this issue of JGIM offers valuable insight on initiatives designed to promote primary care treatment of AUD. 4 As is typical of qualitative studies, the sample size is small-24 clinicians from five primary care clinics within one large VA system-because enrollment ended when new information was no longer being elicited. The authors' analysis revealed barriers to treating AUD that echo those that have been described previously, 5 including poor training , limited organizational support, belief that specialists provide this care, and the stigma of alcohol addiction. Conversely, themes reflecting facilitators included interest in learning how to prescribe AUD medications, the value of consultation or onsite shared care from addiction specialists , and integrated behavioral health support. Intriguing additional insights emerged from the authors' use of a social marketing framework to distinguish respondents who were more willing (or interested) to address a behavior or activity from those who were less willing. More receptive clinicians regarded medications for AUD as an important initial step in managing AUD, and noted that onsite primary care management may be better accepted and less stigmatizing than specialty care. Unwilling clinicians were skeptical about the effectiveness of medications for AUD and concerned about the excessive time needed to manage AUD along with associated psychosocial problems in the context of other heavy clinical demands. A recurring theme was the need for access to specialty support, especially within the primary care practice, not only for assistance with managing medications to treat AUD, but also for behavioral counseling. Multiple federal agencies have been promoting comprehensive, integrated care for alcohol and substance use. The Substance Abuse and Mental Health Services Administration offers resources for professionals regarding medication-assisted therapy for alcohol use, while the Agency for Healthcare Research and Quality's Academy for Integrating Behavioral Health and Primary Care and the Veterans Health Administration have been promoting primary care models that integrate mental health/behavioral counseling to deliver more holistic care. Currently, financial support for these integrated models of care, especially in the community, is limited, but the move toward accountable care organizations may make this expenditure worthwhile, especially considering the costly complications associated with AUD. 2 However, in many community-based settings, access to behavioral and addiction specialty services is extremely limited. With increasing congressional interest in supporting telehealth, as demonstrated by a variety of new bills under consideration, it is possible to envision a day when compensation will be offered for addiction and behavioral specialists to provide remote consultation to primary care clinicians as well as directly to patients. The value of telehealth support for primary care clinicians in disease management has been