Can Treatment of Alcohol Use Disorder in Primary Care Be Effective?

Many patients in primary care are recognized as having alcohol use disorder (AUD), but do not receive treatment for it. Two randomized studies inform us about the promise of starting AUD treatment in primary care settings.

Bradley et al assigned 304 patients with heavy drinking (73% with AUD, heavy drinking on 61% of days) at 3 US Veterans Affairs clinics to usual care, or to alcohol nurse care management that included repeated brief motivational counseling, medication, and shared decision making about treatment options. Intervention group patients were more likely to receive medication for AUD (32% versus 8%), but the past-month proportion of heavy drinking days was similar in both groups (39% and 35%).

In the second study, Wallhed Finn et al assigned 288 patients in Sweden with DSM-IV alcohol dependence (reporting 12 heavy drinking days per month) to primary or specialist care. Primary care physicians had 1 day of training, and with shared decision making, counseled, prescribed medication, or both. Patients in both groups most commonly received both treatments. At 6 months, the reduction in alcohol use (~140–160g per week) was similar in both groups – it was not statistically different, though it also did not meet non-inferiority criteria.

Comments: Treatment of AUD in primary care, based in shared decision making, can have similar effectiveness as treatment in specialty care settings, at least for some patients. However, improving care processes (e.g., medication prescription) modestly may not be enough to improve clinical outcomes. As with any other condition, treating AUD is better than not treating it. But we need ways to get more people on effective treatments if we want to make a difference for patients with greater severity.

Richard Saitz, MD, MPH

References: Bradley KA, Bobb JF, Ludman EJ, et al. Alcohol-related nurse care management in primary care: a randomized clinical trial. JAMA Intern Med. 2018;178(5):613–621.

Wallhed Finn S, Hammarberg A, Andreasson S. Treatment for alcohol dependence in primary care compared to outpatient specialist treatment-A randomized controlled trial. Alcohol Alcohol. 2018 [Epub ahead of print]. doi: 10.1093/alcalc/agx126.