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Picasso’s “Absinthe drinker”. Pablo Picasso: “L’Absinthe,” 1901. Accessed at: http:/


Physicians are well aware of the harm that the use of drugs and alcohol brings to their patients and families. The prevalence of substance use disorders exceeds 20% in ambulatory practices and is even higher in hospitalized patients. Those affected include everyone from adolescents, teachers, and shipyard workers to doctors themselves. Physicians report that conversations with patients about drinking can be stressful and conflict laden, and that many patients are unmotivated to change their behavior. Physicians’ negative feelings sometimes derive from their own family experiences or from encounters with intoxicated patients who can be hostile, uncooperative, and occasionally violent. These dynamics, combined with the sense that substance abuse may not really be a “medical” issue, tend to keep physicians from addressing alcohol and substance use disorders in their patients.

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 can reduce harm, lower medical care costs, lessen morbidity for patients and families, strengthen patients’ family and social relationships, and enhance patient self-esteem and emotional stability. Indeed the recovery rate from substance abuse, 30–40% of treated patients, exceeds that from most other chronic illnesses. Recovering patients often credit their clinicians with being a primary factor in their recovery and with literally saving their lives. For physicians, participating in the identification and treatment of substance abuse can be as gratifying as helping patients recover from leukemia or pneumonia.

Primary care medicine is increasing its role in addressing alcohol and drug problems, since the majority of individuals with alcohol or drug abuse usually avoid seeking care from specialized chemical dependence programs. Two important recent developments are significant in this regard. The first is a push for early identification and treatment of alcohol and drug abuse 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 to encourage universal primary care screening and intervention when needed. This screening now qualifies for Medicare reimbursement. The second important movement is the increasing recognition that alcohol and drug use problems are often chronic relapsing conditions and need to be managed medically, with ongoing monitoring in primary care settings and referral when needed to specialized chemical dependency services. Physicians have a key role to play in this process. In this chapter, we will discuss identification and management of substance use problems, and how physicians’ interactions with patients can enhance their coping with these problems.

Chemical dependence (nontobacco-related addictive disease) is a chronic, progressive illness affecting 24.8% of Americans at some time in their lives (lifetime prevalence) and approximately 6.5% of Americans at any given point in time. Heavy drug or alcohol abuse precipitates a ...

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