By: Paid Cline MA CAGS LMHC LADC, Dr. Nicholas Young, Ed.D, and Stephen Moltenbrey.

Physicians are becoming increasingly aware that alcoholism is a major problem in our society. There are an estimated 18 million Americans with alcohol problems, and less than 15 percent receive treatment (United States General Accounting Office, 1991). Many physicians would like to be more effective in helping their patients and families deal with alcohol abuse, but the question then becomes "what can we do about it?"

The following appeared in the New England Journal of Medicine (NEJM) in February 1998: "Alcohol use is associated with 100,000 deaths and an annual cost of $100 billion in the United States. Up to 40 percent of medical and surgical patients have alcohol problems, and alcohol use accounts for more than 15 percent of health-care costs. Generalist physicians who provide continuous care can have a major role in the care of patients with [current or future] alcohol problems by providing effective screening and assessment, patient education, office-based interventions, and referrals to specialty services. Generalist physicians should screen all patients for alcohol problems and should be able to assess patients for alcohol-related diagnoses."

Early detection and effective interventions greatly increase the prognosis for these patients. Doctors are often key motivators for the person who needs treatment, because of their professional standing and because addicts cannot emotionally manipulate them as they can family members and friends.

Many physicians are reluctant to address the problem because of its confrontational nature and their lack of training in this area. According to the NEJM, "In addition to (the) inadequate training about substance abuse, factors that may be associated with non-detection include physicians’ negative attitudes about patients with substance abuse, skepticism about the effectiveness of treatment, (and) the perception that alcohol problems are not in the realm of generalists."

According to the National center on Addiction & Substance abuse, " 9 out of 10 doctors fail to diagnose Alcoholism even when their patients have the classic symptoms. Only 3% of doctors surveyed said treatment for Alcoholism is effective, studies show that treatment is effective with half the patients who receive it.

Clearly this is not the doctor's fault - ABC News recently pointed out that "only 8% of medical schools require any courses in substance abuse or addiction. Most of our doctors lack the proper training necessary to make the diagnosis and provide help to the patient.

In our work with doctors we have found them to be kind, compassionate and willing to help, once they are aware of the problem. Physicians can be very effective in detecting and dealing with alcoholism if they follow a few guidelines.

First, always be aware that when a given treatment or medicine is not working as it should, alcohol (or street drugs) may be preventing it from working.

Second, ask. By including a few questions on the standard intake questionnaire and asking a few more in the office, you may find that a patient’s use of alcohol is not what it should be. Alcoholics do not fully understand what "normal drinking" is. They will often list an amount that is less than what they actually use, but is beyond normal drinking. An alcoholic might drink 8-24 beers a day and list on the questionnaire that he or she drinks four or five beers a day, thinking this is normal drinking. Actually, three or more drinks a day is a telltale sign that an addiction or abuse problem may be present and needs more investigation.

Third, use the four-item "CAGE" test:

A positive response to any of these questions can signal a drinking problem because a normal drinker will not have any of these problems.

Fourth, interview family members if you have any suspicions about a patient’s alcohol use. Family members are less likely to lie about the problem, or may not lie as well as a practiced alcoholic.

Fifth, do a urine, saliva or blood screen for alcohol (or other drugs). This is easy to obtain and likely to be interpreted by the patient as a routine health check. As stated in the NEJM, "Laboratory tests (such as liver-enzyme tests) may provide clues to the presence of a suspected alcohol problem."

Sixth, carefully observe all patients on any mood-altering prescriptions (especially pain medications and benzodiazopines). Did you ask if they are recovering alcoholics or drug addicts before you prescribed them? Are they on the medications longer than needed? Many addicts consider doctors to be their best dealers.

Seventh, pay extra attention to patients presented with problems typical of this population, such as traumatic injuries, depression, panic disorders, pancreatitis, hypertension or liver disease (Cooney, Zweben & Fleming, 1995).

Once the drinking problem is detected the doctor should not try to address the issue alone, but should have a list of treatment providers and help the patient to make an appointment with one of them. If the patient will not accept the referral, give a referral of the same providers to the family members so they can get help in dealing with this problem. It is also important that no matter what happens, family members be referred to counseling and Al-anon or other support groups to get the help they themselves need in this time of crisis.

"A practitioner can use a self-help pamphlet for purposes of increasing clients’ understanding of the negative consequences of their drinking and enhance their knowledge of various treatment approaches that might be helpful" (Cooney, Zweben & Fleming, 1995). Such a pamphlet might include information on local counseling services, area agencies and self-help support groups like AA/NA and SMART Recovery.

Finally, doctors can help by joining addiction counselors when they do interventions, a process in which addicted patients are confronted by a group and offered treatment. Doctors can also greatly help by attending seminars to learn more about the signs, symptoms and course of addiction. What they learn will definitely save lives.