How can alcoholism treatment be better integrated into primary care?

An estimated 20% to 25% of American adults drink at unhealthy levels, and 14% have an alcohol use disorder (AUD). Despite these alarming numbers, only about 10% of patients with unhealthy alcohol use receive recommended care. Bu results of a trial program show the possibility of better enabling primary care doctors to identify patients with AUD and begin treatment for them.

The program, known as Sustained Patient-Centered Alcohol-Related Care (SPARC) took place among about 334,000 patients at 22 primary care practices in Washington State between January 2015 and July 2018. Its results were summarized in a recent JAMA Internal Medicine article.

The article’s authors explain that SPARC consisted of three elements: practice facilitation, in the form of implementation teams embedded in participating practices for six month periods; electronic health record clinical decision support; and performance feedback, consisting of reports on the prevalence of screening and assessment of AUD symptoms among the practices’ patients.

They add that SPARC had both a prevention and treatment objective. The prevention objective was to test whether, compared with usual care, SPARC increased the proportion of primary care patients who screened positive for unhealthy alcohol use and had documented brief intervention. The treatment objective was to test whether the intervention increased the proportion of patients newly diagnosed with AUD who got treatment for the disorder.

The researchers found that the SPARC intervention resulted in brief patient interventions for unhealthy alcohol use—the primary outcome for prevention—at a rate of 57 per 10,000 patients, compared with a rate of 11 per 10,000 among patients not treated during the SPARC intervention.

In addition, SPARC quadrupled screening rates, from 20.8% to 83.2%, and increased treatment initiation from 6.2 to 7.8 per 10,000 patients. However, the proportion of patients engaging in three visits for AUD, the main treatment outcome, increased only minimally, from 1.4 to 1.8 per 10,000 patients.

Even so, the authors say, the increases in newly-documented AUD diagnoses and treatment initiation is important for the fact that they took place in primary care settings and without adding specialized staff. Moreover, experts generally recommend second AUD screens followed by referral if the initial screen shows unhealthy alcohol use.

“However, many patients don’t accept referral, and this approach has not been shown to increase AUD treatment,” they note. Consequently, “systematic assessment, diagnosis and initiation of treatment in primary care may be more effective.”

The article, “Integrating Alcohol-Related Prevention and Treatment Into Primary Care,” was published online February 27 in JAMA Internal Medicine.