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INTRODUCTION

Picasso’s “Absinthe drinker.” Pablo Picasso: “L’Absinthe,” 1901.

Unhealthy alcohol and other substance use, defined as the spectrum of use that includes “at-risk” levels of use and substance use disorders, is common among patients presenting to primary care settings. The prevalence of substance use disorders exceeds 20% in ambulatory practices and is even higher in hospitalized patients. Those affected include everyone from adolescents to older adults, including clinicians themselves. Even though alcohol and other substance use have a major impact on health and function, they often go unaddressed in routine health care settings, as clinicians often lack the language, knowledge, and skills to identify unhealthy substance use and treat it.

Evidence from many sources provides reason for optimism, however, and shows that clinicians who take a few moments to thoughtfully structure their interventions with patients and offer indicated treatments can reduce harm, lower medical care costs, lessen morbidity and mortality, strengthen patients’ family and social relationships, and enhance patient self-esteem and emotional stability. Indeed, the rate of successful treatment (i.e., achievement of abstinence) is about 30–40% of treated patients, which exceeds that for most other chronic illnesses. These relationships can be very satisfying for patients and providers alike, akin to the treatment of other life-threatening medical conditions such as cancer.

Primary care medicine is increasing its role in addressing alcohol and other substance-related problems, since the majority of individuals with such problems may be reluctant to seek care from specialized addiction treatment programs. Several important developments are significant in this regard. One is a push for early identification and treatment of alcohol and other substance use before those problems become severe. The Screening, Brief Intervention and Referral to Treatment (SBIRT) model is a public health approach promoted by the National Institutes of Health (NIH) and the Substance Abuse and Mental Health Services Administration (SAMHSA) to encourage universal primary care screening and intervention when needed. This screening qualifies for Medicare reimbursement and has been further encouraged by changes in reimbursement structure associated with the Affordable Care Act. In addition, primary care is a natural place to address substance use because patients frequently present with medical and psychiatric conditions that are related to their use. Primary care providers are already trained in providing care for chronic conditions such as diabetes mellitus that involve referral to specialty care as needed. Specialty care capacity is also limited, and it is important both to build workforce skill in primary care and to de-stigmatize substance use interventions by integrating them into routine health services.

Physicians and other primary care clinicians, including nurse practitioners and physician assistants, have a key role to play in this process. In this chapter, we discuss identification and management of substance use problems, and how clinician interactions with patients can enhance patients’ coping with these problems. We note that this chapter ...

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