In the last 30 years, several calls have been made for greater physician involvement in alcohol use disorders.29–31
At a minimum, primary care physicians and psychiatrists should screen all patients for these disorders and offer referral to addiction treatment, 12-step groups, or other counseling services to patients with substance abuse or dependence. Despite several studies documenting that physicians agree such involvement is part of their responsibilities,16,20,21,32,33
physicians inconsistently screen, make the diagnosis, and offer treatment.13,34
In this nationally representative survey of primary care physicians and psychiatrists, the great majority of respondents inquired routinely about alcohol use. Fewer asked about maximum amounts of alcohol consumption or used formal alcohol screening tools (such as CAGE, AUDIT, or MAST).9
A substantial minority did not offer any intervention on a regular basis to patients with diagnosed alcohol problems.
Although the CAGE questionnaire was developed more than 25 years ago and the Institute of Medicine encouraged addressing the broad spectrum of alcohol problems a decade ago,8
screening and intervention practices remain inadequate in many medical settings. Investigations into alcohol screening practices have consistently found that most physicians ask patients about consumption, but few go beyond an initial inquiry.13,15,35
For example, a study of 134 primary care physicians from four western states and Alaska found that the majority of physicians asked standardized patients an initial question about alcohol use, but few followed up with more probative questions such as those in the CAGE questionnaire. Consequently, fewer than 50% of the physicians included alcohol abuse in the differential diagnosis for the patients scripted to consume four or more drinks per day.15
Physicians who ask superficially about alcohol use and do not assess consequences and pattern of use in a valid manner cannot distinguish between safe drinking, hazardous drinking, and alcohol abuse. Inadequate screening practices will necessarily limit opportunities for intervention.
These results suggest a complex relationship among specialty, substance abuse training, attitudes, and practices. Although internists were more likely to inquire about alcohol use, they were no more likely to intervene than family physicians.17,32
Obstetrician-gynecologists were less likely to offer intervention to patients with diagnosed alcohol problems. This latter finding is disturbing because alcohol use has risen in recent years among women of childbearing age, and women experience health consequences from problem drinking after briefer or less-intense exposure than do men.36,37
This cross-sectional study cannot discern the causal direction between psychiatrists' better practices, their greater confidence in their skills, their greater training in substance abuse issues, and less-stigmatizing attitudes. Confidence in skills and familiarity with the NIAAA guidelines9
here contributed to better screening and intervention practices. Substance abuse training may contribute to greater confidence, greater familiarity with expert recommendations, and more positive attitudes toward patients with these disorders,38
but studies of the direct influence of training on screening and treatment practices have been equivocal.13,39
Stigmatizing attitudes, long theorized to contribute to inadequate practice toward substance-abusing patients,19
here displayed little independent association with physicians' alcohol screening and intervention practices. Several studies have found that physicians with more-positive attitudes toward problem drinkers were more actively involved in their care,38,40,41
while others have not found an influence of attitudes on treatment intention.39
Further research is needed to sort out the direct and indirect influences of training and attitudes on screening and intervention practices.42
Physicians' concerns about alienating patients, either through prying into an area about which “patients don't want to be asked” or through substance-abusing patients' rejection of the diagnosis, were associated with less-optimal screening and intervention practices. Although several studies suggest that few patients are perturbed when their physicians ask about emotional or substance use problems,43–46
these findings appear to need greater dissemination among physicians. In addition, physicians' concerns about patients' objections may reflect on the physicians' own ambivalence regarding these issues. Finally, unlike previous work examining time pressure as a barrier to preventive practices,47
perceived time constraints and calculated minutes spent per patient had no detectable association with these practices.
Younger physician age, which is highly correlated with more recent graduation from medical school, was here associated with routine screening and intervention in alcohol problems. Other studies have also suggested that more recent graduation from medical school is associated with greater confidence in skills, more optimistic attitudes about treatment, and a greater willingness to intervene.17,21,33
In light of a previous report that female physicians have less-positive attitudes toward working with substance-abusing patients,48
our finding that female physicians had more-optimal screening and intervention practices raises further questions about the connection between attitudes and practices. Finally, the finding that physicians who serve more Medicaid-insured patients were less likely to offer intervention for diagnosed alcohol problems is of some concern. Low reimbursement or poor access to specialty alcoholism treatment might cause such physicians to spend less time discussing available treatment options.
The major strengths of this study are its national representation and a response rate comparable to other physician surveys.49
Still, it has several limitations. It examines reported, not actual, barriers and practices. Social desirability bias might exaggerate reports of adherence to recommended practices, but such bias would strengthen our findings about suboptimal levels of screening and intervention. Nonetheless, the lack of validation of our measures against actual barriers and practices renders our findings exploratory. In addition, although perceived waiting times for alcohol treatment did not enter our models, we have no information on the availability of treatment services. We also have no information on whether and how these physicians confirm the diagnosis of alcohol abuse or dependence in patients who screen positive, and thus cannot discern whether diagnostic uncertainty poses another barrier to treatment.
Although it is difficult to change physicians' practices regarding alcohol problems,50,51
the dissemination of brief interventions and the development of effective pharmacotherapies promise to bring these disorders into the mainstream. Our findings imply that initiatives to promote physician involvement with alcohol use disorders should include strategies to increase their confidence managing these problems,17
to improve their familiarity with expert recommendations, and to dispel concerns about patients' sensitivity around substance issues. These initiatives should examine different types of interventions such as education and training of physicians, chart reminders, and feedback regarding adherence to recommended practices,35
practice guidelines, and focused incentives. Multidisciplinary interventions, including greater access to behavioral health professionals and alcohol treatment services, and a structured office support system,52
might also improve the quality of diagnosis and intervention for alcohol problems in generalist settings.