Alcohol problems in patients can easily be missed in clinical practice. The categories and definitions of persons with alcohol problems established by federal and international agencies are noted in Table 1. Patients are generally classified on the basis of the amount of alcohol they consume or the alcohol-related social or physical consequences they experience. Hazardous drinking, defined as the level required to increase risk for various adverse health outcomes, occurs at quantities below those considered diagnostic for alcohol abuse or dependence. The prevalence of alcohol problems in primary care is estimated to range from 9 to 34 percent for hazardous drinking, 2 to 8 percent for lifetime alcohol dependence and 9 to 36 percent for a current or lifetime diagnosis of alcohol abuse or dependence. Fiellin and associates reviewed the outpatient diagnosis and management of patients with alcohol problems.

Formal screening instruments such as the CAGE questionnaire, the Alcohol Use Disorders Identification Test (AUDIT) and the Michigan Alcoholism Screening Test (MAST) are the most effective screening tools in primary care. These instruments focus on the social and behavioral aspects of alcohol problems. AUDIT seems to be the best tool for identifying hazardous drinking. The CAGE questionnaire is the best tool for identifying patients with alcohol abuse or dependence. Questions about quantity of intake and frequency of drinking can enhance the accuracy of screening tools. Biologic markers such as aspartate aminotransferase and alanine aminotrans-ferase levels, mean corpuscular volume and g-glutamyltransferase levels work poorly as screening tools for alcohol problems in primary care patients. Common clinical findings in patients who are drinking excessive alcohol include behavior-related social problems, psychiatric problems and medical problems.

Primary care treatment for hazardous drinkers includes short interventions with focused discussions promoting awareness of the negative effects of alcohol and motivating the patient to change (Table 2). Treatment for alcohol abuse or dependence may include outpatient detoxification. Withdrawal with mild or moderate symptoms can be controlled with supportive care and monitoring. More severe withdrawal symptoms may require treatment with benzodiazepines using a front-loading, fixed dose or a symptom-triggered regimen to decrease the incidence of seizures. Outpatient detoxification can be achieved by using chlordiazepoxide in a dosage of 50 mg; oxazepam in a dosage of 15 to 30 mg; diazepam in a dosage of 10 mg; or lorazepam in a dosage of 2 mg, every six hours for the first 24 hours.

Three specific psychotherapeutic techniques commonly used by treatment programs are motivational enhancement therapy, 12-step facilitation and therapy to develop cognitive behavioral coping skills. Self-help groups such as Alcoholics Anonymous can help prevent relapse. Pharmacotherapy with disulfiram or naltrexone can be useful as treatment or relapse prevention adjuncts, especially when combined with brief interventions.

The authors conclude that primary care physicians are well positioned to provide care for patients with alcohol problems. Close follow-up is essential during treatment and relapse prevention. Useful tools include counseling skills that build a supportive therapeutic relationship, maintaining a nonjudgmental attitude, communicating with empathy, reinforcing positive behavioral change and working with families. Collaboration with addiction specialists may be useful in select cases.

editor's note: Some patients may be able to manage alcohol withdrawal with counseling alone. When medication is necessary, short-and long-acting benzodiazepines are most often used. When the patient is elderly, a lower dosage of benzodiazepines should be started, with slower increases to reduce the risk of comorbidities and drug interactions. When possible, shorter-acting agents should be used because of their reduced liver toxicity. Longer-acting agents, however, may provide a more even level of serum drug levels, promoting an easier withdrawal. Phenobarbital is useful in patients undergoing multiple-drug withdrawal and when the risk of withdrawal seizures is high. Clonidine or atenolol, both of which reduce withdrawal symptoms, are useful if hypertension occurs during withdrawal. The dosage and duration of treatment should be guided by the severity of the withdrawal symptoms.—r.s.