Volume 19, Number 3, September 2008
Dr. Fulton T. Crews
Director, Bowles Center for Alcohol Studies
Prevention and treatment of alcohol problems need a new structure. Although almost all experts in the addiction field agree that alcohol dependence needs to be treated like a chronic disease, the separation of substance abuse treatment from primary medical care prevents this approach. At UNC, we have struggled with how to bring the primary medical care community into partnerships with substance abuse counselors who most often treat addiction. Addiction treatment clinics tend to have few referrals from physicians but many from the judicial system, which is not structured to prevent or deal with chronic disease. Many chronic diseases such as diabetes or heart disease have a structure of primary medical care that treats risk for disease as well as the disease itelf.
Recent advances in understanding alcohol problems have indicated that binge drinking (5+ male /4+ female drinks in 2 hours) and heavy drinking (5+/4+ drinks/day) are high risk factors for alcohol dependence, accidental death, violence, suicide, liver disease, various cancers, cardiovascular disease, pancreatitis and dementia. Reducing risk for diabetes and heart disease are major public health efforts that involve primary care physicians who check your weight and blood pressure, ask if you smoke and exercise, and treat patients who do not have disease to reduce the risk of getting disease. This can and should be done for alcohol abuse and dependence risk. It will require public health efforts, however, to change attitudes of physicians and the general public. Studies have shown that frequency of risky drinking and average daily alcohol intake are good predictors of risk for more severe alcohol problems. The predictability and probability of alcohol use disorder symptoms increase with increased daily intake and frequency of heavy drinking to criteria for abuse and dependence, e.g. quit control, withdrawal, time spent, use despite problems, neglect roles and legal issues. Legal issues usually indicate severe problems. Currently, legal issues and the judicial system are our major referral source for substance abuse clinics. These are individuals who have alcohol use disorder and need treatment. But we are not treating risk!
Studies suggest that if adolescent alcohol exposure is reduced, large groups of individuals will be protected. Furthermore, if binge and heavy drinking in those over 21 are reduced, we will protect large numbers of individuals from progressing to disease. Primary care physicians have been very powerful in reducing smoking, because it increases risk for lung cancer and heart disease. The nation is concerned about obesity because of risk for diabetes and heart disease. Binge and heavy drinking also have high risks and the power of primary care intervention is significant. We need to involve the primary care physician in reducing risk for alcohol use problems. Primary care often involves the entire family and family involvement in risk reduction can be particularly powerful and effective. Further, if physician intervention fails, physicians should have a referral structure to substance abuse treatment professionals who devote their lives to helping the afflicted and are experts at behavioral change. We are hopeful that we can make this happen in North Carolina and the impact of its success will spread across America and the World.