Pharmacologic Management of Alcohol Use Disorders in the Primary Care Setting

• Objective: To examine the rationale and evidence to support pharmacotherapies to treat alcohol problems in the primary care setting. • Methods: Qualitative review of the literature. • Results: Problem alcohol consumption is a prevalent problem in the United States and results in significant morbidity and mortality. In recent years, new pharmacologic treatments have been approved by the U.S. Food and Drug Administration to help health care providers treat patients with alcohol problems. The available research has shown that disulfiram, naltrexone, and acamprosate are effective for treating patients with alcohol problems. Certain patient characteristics promote enhanced outcomes for each medication. Whether combinations of pharmacotherapies or combinations of pharmacotherapy with nonpharmacotherapy enhance outcomes for problem drinkers are active research topics. • Conclusion: Primary care providers should strongly consider the use of pharmacologic treatment as an adjunct to nonpharmacologic therapy to help patients reduce or eliminate alcohol consumption. An estimated 18 million adults in the United States meet diagnostic criteria for alcohol abuse or alcohol dependence, and many more persons drink alcohol in amounts that place them at risk for alcohol-related harm [1]. The National Institutes of Health defines at-risk or hazardous drinking as consuming more than 14 standard drinks per week (men) or more than 7 drinks per week (women and persons > 65 years) [2]. While estimates vary, as many as 20% of outpatients presenting to primary care are hazardous drinkers [3–5]. Hazardous drinkers and those with alcohol abuse or alcohol dependence (alcohol use disorders [AUDs]) collectively experience the consequences of “problem drinking.” The medical, social, and societal consequences of problem drinking are not insignificant. Problem drinking increases the risk for other medical complications such as certain cancers, neuropsychiatric diseases, cardiovascular diseases, and gastrointestinal diseases [6]. Furthermore, problem drinking reduces patients’ adherence to medical and psychiatric treatments and may narrow the potential treatment of other illnesses (eg, hepatitis) [7]. In the United States, the estimated annual economic burden of alcohol problems exceeds $100 billion [8]. Based on the consequences of problem drinking, several authorities have advocated that physicians, especially primary care physicians, play a greater role in screening and treating patients with problem drinking. For example, the National Institute on Alcohol Abuse and Alcoholism (NIAAA) encourages all primary care and mental health clinicians to incorporate AUD screening, brief intervention, and treatment referral into their practices [2]. The Institute of Medicine, U.S. Preventive Services Task Force, and Centers for Disease Control and Prevention have made similar recommendations [9,10]. To assist busy clinicians in screening for and treating problem drinking, the NIAAA recently published a 30-page monograph, “Helping patients who drink too much: a clinician’s guide,” which provides screening, assessment, and brief intervention support materials (downloadable at http://pubs.niaaa.nih.gov/publications/ practitioner/cliniciansguide2005/guide.pdf) [2]. While nonpharmacologic treatment has been the mainstay of treatment for problem drinking, recent scientific advances have encouraged the use of pharmacologic treatments. Pharmacologic treatments for problem drinking can serve as an effective adjunct to nonpharmacologic treatments to help patients reduce or eliminate alcohol consumption. The advance in the understanding of the neurobiology of alcohol dependence and success of pharmacotherapy in other addictions has supported the use of pharmacotherapy to help in the treatment of problem drinking [11]. Unfortunately, pharmacologic treatments have not been widely used [12]. The lack of awareness among clinicians that effective pharmacotherapy options exist is a primary reason for low utilization of pharmacotherapy in clinical practice [13]. The purpose of this review is to examine the rationale and evidence to support pharmacotherapies to treat alcohol From the University of Pittsburgh School of Medicine and Center for Research on Health Care, and Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA.