2013 Update in addiction medicine for the generalist

Abstract

Increasingly, patients with unhealthy alcohol and other drug use are being seen in primary care and other non-specialty addiction settings. Primary care providers are well positioned to screen, assess, and treat patients with alcohol and other drug use because this use, and substance use disorders, may contribute to a host of medical and mental health harms. We sought to identify and examine important recent advances in addiction medicine in the medical literature that have implications for the care of patients in primary care or other generalist settings. To accomplish this aim, we selected articles in the field of addiction medicine, critically appraised and summarized the manuscripts, and highlighted their implications for generalist practice. During an initial review, we identified articles through an electronic Medline search (limited to human studies and in English) using search terms for alcohol and other drugs of abuse published from January 2010 to January 2012. After this initial review, we searched for other literature in web-based or journal resources for potential articles of interest. From the list of articles identified in these initial reviews, each of the six authors independently selected articles for more intensive review and identified the ones they found to have a potential impact on generalist practice. The identified articles were then ranked by the number of authors who selected each article. Through a consensus process over 4 meetings, the authors reached agreement on the articles with implications for practice for generalist clinicians that warranted inclusion for discussion. The authors then grouped the articles into five categories: 1) screening and brief interventions in outpatient settings, 2) identification and management of substance use among inpatients, 3) medical complications of substance use, 4) use of pharmacotherapy for addiction treatment in primary care and its complications, and 5) integration of addiction treatment and medical care. The authors discuss each selected articles’ merits, limitations, conclusions, and implication to advancing addiction screening, assessment, and treatment of addiction in generalist physician practice environments.

Use of Pharmacotherapies in the Treatment of Alcohol Use Disorders and Opioid Dependence in Primary Care

“…However, screening and brief intervention of adolescents, a time early in the use of illicit drugs such as cannabis, has shown some effectiveness [ 21 , 22 ]. Keeping in view the high prevalence and associated morbidity and mortality of chronic drug and alcohol dependence [ 16 ], the impact of unidentified substance-related and addictive disorders on the management of comorbid conditions such as diabetes, heart disease, and liver disease [ 23 ], the natural history of substance-related and addictive disorders [ 4 ], and the availability of effective pharmacotherapies, the primary care health professional may give serious consideration to applying the same or similar screening and brief intervention strategies to all substance-related and addictive disorders. It would be good clinical practice, from the point of view of efficiency and utility, to implement and maintain a screening and brief intervention process that is comprehensive addressing not only alcohol use disorders, but also tobacco and other substances use and misuse [ 17 ].…”

“…Primary care is an important entry point for all patients suffering from chronic conditions. Primary care health providers are the best positioned to address substance-related and addictive disorders in a comprehensive manner encompassing screening, prevention, diagnosis, disease management, and relapse prevention [ 3 , 4 ]. However, currently in primary care, there is poor adoption of pharmacotherapies that have demonstrated effectiveness for alcohol use disorders [ 5 , 6 ].…”

Screening accuracy of brief alcohol screening instruments in a general hospital setting

“…The method is strongly recommended by the World Health Organisation (WHO) [5], and many nations have established practical guidelines for its use. Still, implementation of SBI remains a challenge [6,7]. Time restraint is one of the main reported limiting factors, along with lack of training and support.…”