After 15 years of skepticism from other physicians, Dr. Michael F. Fleming now appears to have the last word on the issue of talking to patients about alcohol use. He is chief researcher of a study published in last week’s issue of the Journal of the American Medical Association that showed brief interventions by general internists and family physicians can significantly reduce alcohol use by problem drinkers.
“It took me 10 years to get this study into the research literature, from developing a pilot program to writing grants to conducting the experiment to convincing the journal editors it should be published,” said Fleming, associate professor of family medicine and director of the Center for Addiction Research and Education at the University of Wisconsin in Madison. “But now we have science to support our approach. It should be easier to convince doctors that saying something to patients can have a positive effect.”
In fact, Fleming said, many of the 64 Wisconsin physicians who participated in the study said they saw results after the first few months. Wisconsin ranks third in per-capita alcohol consumption.
The study looked at 482 men and 292 women who were classified as “at-risk drinkers” whose alcohol consumption was affecting their personal health but didn’t yet qualify them as alcoholics. About half of the patients consumed an average of more than three drinks every day of the week.
Fleming said hypertension or high blood pressure is perhaps the most common symptom related to problem drinking, though obesity, elevated cholesterol levels, diabetes, headaches and depression are other major problems. These at-risk drinkers also are involved more frequently in auto accidents and domestic violence.
The patients then were split between control and experimental groups. The experimental patients were scheduled for two 15-minute intervention sessions one month apart with their doctors. The control group was told simply that the study was a screening process to study health behaviors, including alcohol use.
The U. of W. Center for Addiction provided each doctor with a workbook with five components to the suggested intervention:
– The doctor would express concern about the patient’s alcohol use, outlining the ways in which it was affecting the patient’s health and could be adverse.
– The doctor would note the patient was drinking more than 90 percent of Americans.
– The doctor would discuss practical ways to cut down on alcohol use, such as alternating alcoholic and non-alcoholic drinks while out at a bar or pouring a less potent cocktail.
– The doctor and patient would negotiate a specific amount of reduction.
– The doctor would write a prescription sheet asking the patient to drink only the agreed number of drinks three or four times a week. The patient was provided a diary card to record alcohol use for the next visit.
A one-year followup found the average reported number of drinks per week decreased from 19.1 to 11.5 in the experimental group, plus 46 percent fewer episodes of binge drinking and nearly a 30 percent reduction in excessive drinking during the typical week. The percentage of more intense drinkers — more than three drinks per day — dropped from 50 to 20 percent in the experimental group.
The evidence “should be a strong motivator for including alcohol screening” in primary-care medical practices, Dr. David C. Parish of the Medical Center of Georgia at Macon wrote in the same issue of the journal.
The Wisconsin study did result in some reduction of drinking in the control group as well, which Fleming attributed in part to the fact that the issue of alcohol had been raised, however briefly, in a clinical setting.
When he trains physicians about alcohol intervention, Fleming encourages class participation, including role-playing.
“In some cases, the physician might even role-play with the patient to help anticipate pressure from friends or family members who are urging the patient to continue drinking,” Fleming said.
“Doctors don’t like to sit down with patients and tell them something they don’t want to hear, that the drinking is not good for personal health or the family. But those talks can go a long way toward solving the problem.”
