BACKGROUND: Alcohol use disorders (AUDs) are prevalent in primary care patient populations. Many primary care patients with AUDs can remit without formal treatment. An understanding of the factors that predispose patients to remission may help primary care physicians provide effective brief counseling for those with mild to moderate disorders and more effectively recommend formal treatment for others.
METHODS: A total of 119 eligible and randomly selected primary care patients with alcohol abuse or dependence in remission (as defined in Diagnostic and Statistical Manual of Mental Disorders, third edition, revised) participated in a semistructured telephone interview.
RESULTS: Of the subjects, 59.7% were women; 50.4% had been alcohol dependent; 66.3% made a conscious decision to modify their drinking; and 62.1%, including 54.2% of the alcohol-dependent subjects, moderated their drinking without abstaining. Family, emotional, and medical issues most often prompted reduced drinking. Nearly one third of the subjects found specific strategies and rules helpful in reducing their drinking, and many cited circumstances that helped or hindered their efforts. Only 10.9% had formal alcohol treatment.
CONCLUSIONS: A significant proportion of patients with AUDs remitted without formal treatment. Abstinence may not be necessary for a subset of dependent patients. When counseling patients with active AUDs, primary care clinicians are advised to counsel patients about the psychosocial and medical reasons to control drinking, promote rule-setting about drinking, help patients avoid circumstances that trigger drinking, and support patients’ attempts at moderating drinking rather than abstaining. Motivational interviewing (motivational enhancement therapy) may provide a useful framework for such counseling.
Alcohol use disorders (AUDs) are prevalent in primary care settings.1,2 Research has shown that appropriately trained primary care clinicians can use screening and brief intervention to identify and assist many patients with risky and problematic drinking.3,4 Clinicians are advised to refer all alcohol-dependent patients for formal specialized treatment. The traditional teaching is that alcohol-dependent patients must receive formal treatment and must abstain.
Recent studies have suggested that some alcohol-dependent patients remit spontaneously.5-12 The generalizability of these findings to general populations is unknown, since most of the studies used convenience sampling. Also, the applicability of these findings is unclear with regard to specific AUDs, since many of these studies used screening questionnaires rather than diagnostic assessments to classify subjects.
Our goal was to describe the phenomenology of remission for a randomly selected sample of primary care patients who had been diagnosed with alcohol abuse or had alcohol dependence in remission for at least 1 year. Specifically, we assessed patients’ decisions and reasons for modifying their drinking, their decisions regarding whether to cut down or abstain from drinking, the strategies and circumstances that helped or hindered their efforts, and the roles played by professionals in their process of change. Our results are intended to guide the treatment of AUDs in primary care settings.
Methods
Subjects
A total of 702 English-speaking primary care patients aged 18 to 59 years who were not pregnant were randomly selected from 3 family practice clinics to participate in a previous study.13 For the earlier study, all participants responded to the Composite International Diagnostic Interview-Substance Abuse Module, which assesses current and lifetime alcohol and other drug disorders with excellent reliability and validity.14-17 The response rate was 90.4%.
Subjects were eligible to participate in our study if they met the Diagnostic and Statistical Manual of Mental Disorders, third edition, revised (DSM-III-R) criteria for alcohol abuse or alcohol dependence in remission. In the previous study, 217 (30.9%) of the 702 participants had these DSM-III-R diagnoses. Of those patients, 196 expressed a willingness to participate in further studies, and 179 could be reached. Of those 179, 3 were pregnant, 1 had died, 14 had relapsed, and 6 could not respond to many of the questions because they did not remember reducing their alcohol consumption. Of the 155 remaining eligible individuals, 119 (76.8%) agreed to participate. Demographic information is presented in Table 1.
Eligible subjects were invited to participate with a letter and a follow-up telephone call. Participants received $10 after completing a 30-minute telephone interview. The protocol was approved by the University of Wisconsin Center for Health Sciences human subjects committee.
Data Collection
Four research assistants were trained to administer semistructured telephone interviews. To enhance interrater reliability, the interviewers were trained together and frequently monitored; they also often listened to each other’s interviews. The interview protocol consisted of a sequence of closed-ended and open-ended questions. Initial questions assessed the subjects’ current quantity and frequency of alcohol use and alcohol-related diagnoses. They were asked whether they consciously decided to either quit or cut down on their drinking or if their level of drinking decreased without intention. Subjects were asked open-ended, somewhat redundant questions designed to elicit their reasons for quitting or cutting down. The remainder of the questions focused on how the subjects moderated their alcohol use Table 2.