FRONTIERS OF PRIMARY CARE Series Editor: Mack Lipkin, Jr. FRONTIERS OF PRIMARY CARE Series Editor: Mack Lipkin. Jr. Editorial Board Charles Bridges-Webb Sydney. Australia Thomas Delbanco Boston. Massachusetts. USA Sheldon Greenfield Los Angeles. California. USA Henk Lamberts Amsterdam.The Netherlands Robert Pantel! San Francisco. California. USA Burton Sin~er New Haven. Lonnecticut. USA Robert Taylor Portland. Oregon. USA Kerr L. White Standardsville. Virginia. USA Maurice Wood Richmond. Virginia. USA Henrietta N. Barnes Mark D. Aronson Thomas L. Delbanco Editors Alcoholism A Guide for the Primary Care Physician Foreword by Julius B. Richmond With Contributions by A. Abrams, M.D. Aronson, H.N. Barnes, R.D. Bayog, M. Bean-Bayog, J. Bigby, B. Bush, M.G. Cyr, J. Daley, T.L. Delbanco, J. Ende, A.W. Fox, P.A. Friedman, M.E. Griner, P.F. Griner, M. Grodin, N.J. Guzman, A. Halliday, J.T. Harrington, K. Hesse, R.A. Hingson, A. Meyers, A.W. Moulton, S.F. O'Neill, J. Savitsky, W.A. Spickard, Jr., D.C. Walsh Springer-Verlag New York Berlin Heidelberg London Paris Tokyo Henriclta N. Barnes, M.D. Mark D. Aronson. M.D. Instructor in Medicine. Associate Professorof Medicine, Harvard Medical School. Harvard Medical School. Massachusclls General Hospital, Beth Israel Hospital, Chelsea Memorial Health Center. Boslon. MA 02215. USA Chelsea. MA 02150, USA Series Editor Mack Lipkin. Jr.. M.D. Thomas L Delbanco. M.D. Director, Primary Care; Associate Professor ofMedicine. Associate Professorof Medicine, Harvard Medical School, New York University Medical Beth Israel Hospital. Center, School ofMedicine. Boston, MA 02215. USA New York. NY 10016. USA With ftlur Figure~ LibraryorCongre~sCalaloging·in-Publkalion Data Alcoholism: a guide for Ihe primary care phy~ician. (Frol1licr~ofprimarycarc) Induues index. I. Aktlholism. 2. Family tllcuicillC. I. Barnes. Hcnriena N. II. Arunson. Mark D. III. Dclbanco. Thomas. IV. Abmms. A. (Alan). 1951- V. Scrics. IDNLM: I. Alcoholism. WM 274 A35419] RC565.A44518 1987 616.86'1 87·20652 II) 1<,I1l7 by Springer·Verlag New York Inc. SoftwarereprintoftheHardcover I$tedition 1987 All righlsre~erved. Thi.,work maynOIbelranslatcdorcopiedinwholeorinpan wilhoutlhewriuen permission of lhe publisher (Springer-Verlag. 175 Fifth Avenue. New Yurko New York 10010. U.S.A.).CX~"CpI for briefexcerpts inconneclion wilh reviewsorscoolarlyanalysis. Use in ~"()T1ncction withany form ofinformationsltlrage anu retrieval,ellX'tronicadaptatiun. compulersoftware.orby ~imilar ordis~imilarrnelhouology now known or hereafterdeveloped is forbidden. The useofgeneml descriplive names. mlde names, lrademarks.eiC. in thispublication, even iflhe furmer are nol especially idenlified. is nOI ttl be laken asa signlhal such names. as understood by lhe Trade Marks and Merchandise Marks Act. may acoordingly be used freely by anytlne. While lhe advice and informalion in this hook are believed tobe lrue andaccurate atlhedateofgoingIU press. neither the autoors nor the editors nor lhc publi~hcrcan accept any legal responsibility ror anyelTorsoromissions that may be made. The publisher makes no warranty. expressor implied, with respecl to lhe material contained herein. Typeset by Publishers Service. Bozeman. Monlana. ISBN-13:978-1-4612-9155-8 e-ISBN-13:978-1-4612-4786-9 DOl: 10,1007/978-1-4612-4786-9 911765432 To Our Families David, Jacob, and Rebecca Jean, Adam, Raney, Alexander, and Benjamin Jill, Steve, Suzanne, and Jennifer Series Preface Primary care is the new frontier in medicine. Every nation worldwide has recognized the necessity to deliver personal and primary care to its people. This includes flfst contact care; care based in apositive and caring personal relationship; care by a single person for the majority ofthe patient's problems; coordination of all care by the patient's personal provider, advocacy for the patient; the provision of preventive and psychosocial care as well as care for episodes of acute and chronic illness. These facets of care work most effectively when embedded in a coherent integrated approach. The support for primary care derives from several significant trends. First, technologically based care costs have rocketed beyond reason or availability. This has occurred in the face ofexploding populations and diminishing real resources in many partsofthe world,even in many partsofthe wealthiernations. Simultaneously, the primary care disciplines-general internal medicine and pediatrics and family medicine-have matured significantly. They have become viable alternatives to the specialty approach to care with its potential dehu manization, coordination problems, and increased cost. The primary care disci plines have begun to create new sets of intellectual tools and new educational approaches to support their new paradigm of biopsychosocial care. These new tools include clinical epidemiology which examines the efficacy, effectiveness and efficiency of everyday, real world care; clinical decision making which is beginning tofind ways to improve the rational basis for common clinical choice; the medical interview which is now coming under critical study as the major medium of care; problem based learning and community oriented medical education which enable efficient learning of the greatest relevance and with increased satisfaction for learner and teacher; and the philosophic and empiric study ofethical aspects ofcare. A number of major questions have emerged in the new disciplines. Who is to do primary care? What do they need to know? How can the needed content, skills, and attitudes be best taught? Who is to teach these new practitioners and what skills do they need? The persons interested in these sorts ofquestions include practitioners, teachers, and researchers in primary medicine. The Frontiers of Primary Care series plans to help meet the needs of these VIII Series Preface overlapping groups. It will report fundamental and applied research findings in clinically relevant, readable ways. It will provide information to teachers of primary medicine about necessary content areas such as alcoholism or the medical interview. It will also infonn teachers about new teaching approaches and methods and will include some books teachers may choose to use as texts. Finally, it will publish new conceptual work about the basis ofthe field and the shifting paradigm ofcare. This first volume is an important guide to practicing health care personnel and those preparing for such roles concerningoneofthe most prevalentand complex problems in primary care: alcoholism. In highly readable short chapters, the authors have managed to convey concrete useful approaches to the detection, diagnosis and treatment of alcoholism and its complications. It masterfully integrates basic research, cIinical wisdom, and sound pedagogy. It is a fitting beginning for the series. Mack Lipkin, Jr. Series Editor Foreword This is an important book. It is no secretthat, fordecades, physicians and hospitals have tried to avoid caring for patients with problems related to alcohol con sumption. This book is a milestone in theeffortto reverse that trend. To become more effective, physicians and their colleagues need the kind of help provided in this volume. The significance of alcohol-related problems is well documented; the personal, social, and economic burdens are vast. The basic problems are complex and not amenable to easy solutions. The authors respect thiscomplexity but, on the basis oftheir experiences, strike an optimistic note. Without sounding overly simplistic, they relate how theirclinical experiences lead them tosuggest that most patients can be helped. The book offers full recognition of the multifactorial nature of the problem and illustratesthe interrelationshipbetweenthebiological, psychological, social, and cultural issues which require a comprehensive approach to diagnosis and management. The varioussupportservicesnecessaryforpropermanagementand the physician's role in utilizing them for betterpatientcare are presented in very practical ways. While the emphasis throughout is on the role of the primary physician, there is a general awareness of the need for an interdisciplinary ap proach. Thus, the need to collaborate with other health professionals and agencies, as well as with other medical specialties, is clearly shown. The authors have performed a most valuable service in summarizing the relevant knowledge from diverse fields and gathering together the alcohol-related problems scattered among the literatures ofthe various professions. The focus, however, is always on the relevance for the primary care physician. It is appropriate to note that this is not a cookbook for physicians, although it provides practical guidelines based on clinical experience ofthe authors. Rather, its objective is to improve the care ofindividual patients by enhancing the phy sician's understanding ofthe complex nature of alcoholism. The authors are to be congratulated on the lucidityofthe writing and editing. This volume demonstrates that medical writing can be readable without sacrificing x Foreword accuracy. As aconsequence, the book should be ofvalue to other health profes sionals concerned with the care of patients with alcohol-related problems. Its ultimate impact should be the reduction ofsuffering and the improvement ofthe quality of life for alcoholic patients and their families. Julius B. Richmond Preface This book is written by primary care physicians to enable other primary care practitioners to recognize and care for alcoholic patients. It is an outgrowth of the Commonwealth-Harvard Alcohol and Research Teaching Program (CHART). In 1981 this group ofgeneral internists began meeting to learn about alcoholism in order to teach their medical residents about the disease. The members ofthat initial group-Alan Abrams, JudyAnn Bigby, Booker Bush, Joan Savitsky, Marie Warburg, and Henrietta Barnes-have continued to care for and teach about alcoholic patients. The process ofself-education clarified for us the unique role of the primary care physician in the care of patients with alcoholism. We discovered that, although there was a wealth of information about the disease, there was no one to tell us how we, as primary care physicians, should care for alcoholic patients in our busy practices. We set out to teach ourselves by consulting experts, sharing ourexperiencescaring for alcoholic patients, and learning how to adapt the techniques used by alcoholism counsellors to the constraints of our practices. Most of us were surprised to learn how many undiagnosed alcoholics were in our practices, and we were excited and relieved to find that we had something to offer these patients. We came to understand that the interviewing skills and long-term perspective of the practicing primary care physician were well suited to the care of many alcoholic patients. Our initial perspective that alcoholism is "like a disease" gave way to the conviction that alcoholism is, in fact, a prototypical chronic disease. Like diabetes mellitus or multiple sclerosis, it is adisease marked by periods ofremission and exacerbation which has medical, psychological, and social sequelae. There is treatment but no cure. By using alcoholism as a model, we discovered that we could teach our residents about the psychosocial aspects ofa long-term illness, the importance of patient education and self-care, and the goal of improving function rather than striving for acure. We could also teach them about alcoholism in a primary care context. The main focus of this book is how to detect early alcoholism and how to care for patients with the disease, whether a first-time patient or one of long standing. Although the primary locus is the physician's office, a chapter on the hospitalized patient emphasizes the importance ofthe primary physician in that